Thanks for this wonderful contribution [~Huma--Sheikh--huma927@ ]! What insights can others provide regarding the prevention of migraines? In which patients is such intervention particularly effective? Are there some patients who are refractory to prevention based on your clinical experiences? Please share your insights.

Primarily insurance driven with Nurtec or Ubrelvy.

Have to do thorough evaluation for any comorbid conditions and insurance coverage before prescribed

I concur with our colleague above that the recent approval of Nurtec ODT for preventive treatment of episodic migraines, as well as for acute therapy, can help to simplify a patient's treatment regimen. Despite the clinical benefits of the injectable CGRP-active therapies, some patients with migraines report having a needle phobia. Having another oral medication option for migraine care is good news for our patients who are needle-averse.

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If one medication is not effective at all or having intolerable side effects then I tend to switch medication classes. If patient reports partial efficacy but no remission then I try to augment the efficacy by adding another medication on. I prefer brand names unless there are reimbursement concerns. Migraines are chronic so long term adherence is important and often challenging

Determining a preventive for a patient can be difficult. It is important to follow the guidelines that are presented by the American Headache Society but insurance coverage also plays a role. Sometimes, the best option for a patient might not be covered and you have to try other things first, this is mainly dictated by cost which is unfortunate.

Determining a preventive for a patient can be difficult. It is important to follow the guidelines that are presented by the American Headache Society but insurance coverage also plays a role. Sometimes, the best option for a patient might not be covered and you have to try other things first, this is mainly dictated by cost which is unfortunate.

Thanks, All, for the wonderful input! How do you advise your patients on the treatment of resistant migraine? Your input is appreciated.

How do you advise patients on the treatment of resistant migraine?

Also need to consider insurance coverage & comorbid conditions in patients with Aimovig prescription.

I always try conservative rx first to minimize costs but for resistant migraine to triptsns etc
migraine
Aimivig worth a try
Prior authorization an issue
Karl Brot

Definitely depends on the patient’s other medical issues such as hypertension. Would make a switch if cGRP is not preventing migraines.

Aimovig works but choice ends up being insurance driven for Medicare patients as well as commercial since patients tend to want to avoid the hassle of coupons, vouchers, and patient assistance programs.

Nurtec and Ubrelvy are good options as well.

Now that Nurtec odt is approved for acute treatment and prevention , It is a simple way to treat migraine , especially in patients reluctant to injections

The specific CGRP is insurance driven and even more difficult with the Medicare patients as they cannot have patient assistance. A specific issue is the denial if the patient is on either Ubrevley or Nurtec for prn use.

These drugs should be a big game changer and I think consider first line but I have never gotten them approved by insurance companies

I usually use Aimovig as first line, it came out first so I was more used to it. Sometimes it's about formulary or Ajovy which is q 3 months. Just depends

I have used ajovy more than the the others in this class due to not worrying about the risk of HTN. If a patient fails this then I may go to aimovig

These are not on our formulary so have not used these yet.

The clinical trial data for all cGRPs are largely comparable, no particular cGRP seems clinically superior to its peers. I am not sure there is an universal algorithm to decide the hierarchy of cGRPs. Therefore, my recommendation of cGRPs is more related to other factors, such as personal real-world experience, length on the market of the cGRPs, and patients' comorbidities, etc. When switching a patient for efficacy reasons, I tend to consider preventive therapies with distinctive mechanisms of action.

Depending on severity and if the pt is ok to have IV fusion treatments, I would offer Vyepti.

I usually use Aimovig, unless the pt has blood pressure and constipation issues. If they do I will use Emgality.

for me it seems the first paradigm in treatment is ajovy or emgality, given aimovig has possible constipation and HTN and the first two don't. Bascially I let insurance approval hash this out. if you fail ajovy or emgality, then I move to aimovig. If you fail that, then try vyepti which is though to be higher efficacy

Some of the side effects observed with Aimovig are allergic reactions, rash, angioedema, anaphylaxis high blood pressure, and constipation. Must closely Monitor patients treated with Aimovig for new-onset hypertension, or worsening of pre-existing hypertension

At this point i do not have any strategy for deciding which cGRP to use for patients aside from insurance coverage and comorbid conditions with Aimovig. I tend to avoid aimovig in patients with known constipation and elevated blood pressure. I will typically hold off on using Vyepti due to the requirement involved for the patient.

HI. I am a big proponent of using the CGRPi infusion therapies rather than gepants for isolated occasional therapies. Although more costly and time consuming, I feel that providing a steady state level of blocking the molecule at the receptor site promotes better migraine diaries as per the patient and gives them confidence to use rescue medications or other therapies only as needed with less frequency. I am not using Vyepti currently due to the pandemic as infusion chairs are at a premium, and for a while were not available, leading to a VNA program, at least for my MS patients. For Migraine, that does not seem cost effective. I really have confidence in Aimovig more than the others, and rarely switch.