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Migraine Prophylaxis
The 2021 American Headache Society Guidelines on the Principles of Preventive Migraine Treatment include:
- using evidence-based treatments
- titrating until clinical benefits are achieved
- giving each treatment a trial of at least 2–3 months
- avoiding overuse of acute treatments
Titration is not necessary with injectable preventive treatments, which are initiated at therapeutic doses and have a relatively rapid onset of action. Furthermore, it states that patients who have severe, disabling, or frequent migraine attacks, as well as those who cannot tolerate or are nonresponsive to acute treatment, should be considered for preventive treatment.
The decision to initiate preventive treatment should be based on:
- the frequency of migraine attacks
- average number of days with migraine
- moderate/severe headache
- degree of disability
What are the key factors that lead you to initiate migraine prophylaxis?
How do CGRPs fit into your treatment algorithm?
Reference:
- Ailani J, et al. (2021) The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache: The Journal of Head and Face Pain 61:1021-1039.
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Katherine Moyer3yrIt may be difficult to trial each treatment for 2-3 months in patients with severe, disabling migraines. Do you give a trial of a preventative treatment and ask patients to come back in a month?
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Huma Sheikh, CEO, NY Neurology Medicine, PC3yrThe key factors in deciding on starting a preventing are number of days of headache and patient disability.
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Migraine Connect3yrWhat are the alternatives to CGRPs? How do they compare?
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Liang Lu3yrThe intensity, frequency and impact on quality of life are key factors to initiate preventive treatment for migraine. Given its superior safety and efficacy, the new CGRPs are mostly used for 2nd or 3rd line prophylaxis in my practice.
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Huma Sheikh, CEO, NY Neurology Medicine, PC3yrWith the new cGRP inhibitors, the titration is not as much of an issue. Insurances can hinder picking a cGRP sooner.
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Anonymous User4yrI use preventative medications as soon as a patient tells me that they have more than 3 migraines/month, or if their abortive medications aren't working well and their migraines, though few, will last a couple days. If insurance allows, I try to initiate CGRPs immediately not only for abortive therapy but also for preventative therapy. They have a fantastic safety profile, work quickly and decrease the number of migraines by over 60%.
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Michelle Santiago4yrInitiating migraine prophylaxis therapy is based on a couple factors. My biggest factors are probably the frequency, severity, and level of disability. For example if the patient has 2 migraine headaches but they are severe and have potentially a very disabling feature, I would initiate preventative therapy much earlier than in another patient with easily aborted migraines 1 to 2 times a month. My typical benchmark is for migraines a month and the degree of disability the I also will utilize patient experience and patient desire in to migration. I will assess the patient's readiness to start a regular medications such as an injectable or oral medication. CGRP are very much a part of the equation and are great option for many patients. I used these often.
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Anonymous User4yrDefinitely need for use with patients experiencing chronic migraine who have failed on existing prophylactic modalities
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Anonymous User4yrInitiating prophylactic medications should be considered for patients with more than 1-2 episodes per month or 3 days of symptoms per month. Anti-CGRP may be considered for patients with chronic migraine, have intense headache pain for most days of the month and have failed other treatments. Documentation such as use of headache diary and medications used in the past is also beneficial. This may help in obtaining insurance coverage. Also important are to discuss potential side effects of the anti CGRP with patients and ruling out other serious medical conditions as the etiology of the severe headache.
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MOHAMMAD ZEIBO, MD4yri have very successful results with CGrp antagonists
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Jigisha Thakkar, LOYOLA UNIVERSITY MEDICAL CENTER4yrChronic migraine and status migrainosus. CGrp antagonists used when they fail 2 or more traditional prophylactic meds.