Bringing episodic and chronic migraine under control

Migraine burden and comorbidities

At currently around 1.1 billion,^1,2 burgeoning migraine prevalence, discussed Dr Ong, “is an issue of public health concern.” Migraine prevalence, along with incidence and years lived with disability, are much higher in females than males, especially in young adult women.^2,3

Migraine is more than just a headache. While this symptom may last 4−72 hours, prodromal symptoms can appear hours to days and aura symptoms 5−60 minutes prior to headache onset, and postdromal symptoms may last 24−48 hours.⁴ Migraine may be episodic (EM; 0−14 headache days/month), high-frequency episodic (8−14 headache days/month), or chronic (CM; ≥15 headache days/month),^5-7 and, typically, the higher the frequency of migraine attacks, the lower a person’s health-related quality of life (HRQoL).^5,8

Migraine symptoms can negatively impact a person’s quality of life^9,10

For many people, a migraine attack can lead to ‘some’ or ‘severe’ impairment.⁹ However, while impacts can include those on work/school, social, and family life,^9,10 there may be a lack of understanding of migraine symptoms and impact from work colleagues, friends, and family.¹¹ Missing work, or being unable to properly carry out work duties, also contributes to the economic burden of migraine.¹²

As comorbidities associated with migraine include psychiatric, cardiovascular, respiratory, neurological, and metabolic conditions,^13-16 Dr Ong recommended educating colleagues in other disciplines regarding proper treatment or referral for migraine. Lifestyle and external factors, such as diet, exercise, and stressful life events, can also contribute to migraine occurrence.^13,14,17

Migraine assessment and treatment planning

“Assessing disability,” said Professor Buse, “can be as simple as asking ‘how is migraine affecting your life’?” When such a question can be answered, the patient feels ‘heard,’ rapport can be established, and the healthcare professional (HCP) can better understand migraine impact and burden.¹⁸ The SHARE model details five steps to help improve shared decision-making between HCP and patient.¹⁹ By assessing a patient’s values and preferences, comparing treatment options, determining goals, and defining treatment success, a shared treatment decision can be attained that can aid patient outcomes and medication adherence.^20-22

Inadequate treatment of episodic migraine can lead to progression to chronic migraine

If EM attacks are not treated adequately in the acute setting, development of CM is more likely.^23,24 Prevention of disease progression, discussed Prof Ashina, can be aided by early intervention and fast-active preventive treatment. This may help improve a patient’s HRQoL through reduction of migraine frequency, duration, and severity.^25,26 This is especially important when treating young patients, stressed Prof Ashina, “imagine how their lives change if we start early treatment with migraine-specific medications.” However, one recent USA-based study showed that around three-quarters of people with high-frequency EM or CM who were eligible for preventive medication were not currently using it.²⁷

CGRP-monoclonal antibodies

Migraine treatment has moved from non-specific therapies to migraine-targeted drugs including the calcitonin gene-related peptide monoclonal antibodies (CGRP-mAbs). ^24,28,29 In a recent update to the 2021 European Academy of Neurology/European Headache Foundation consensus, CGRP-mAbs were moved from third-line to first-line therapy for preventive treatment and were recommended for acute treatment for EM or CM.^24,29

CGRP-mAb use can decrease monthly migraine days and improve a patient’s quality of life

Results from Phase III studies of the mAbs showed that use can lead to significantly higher percentages of patients with EM or CM achieving ≥75% reduction in monthly migraine days (MMD) compared to placebo.^30-33 Real-world evidence studies (3−6 months administration) show ≥75% response in 60−77% of patients with CM.^34-37

Ratings on patient-reported outcome measures have also shown significant improvement following CGRP-mAb use versus placebo.^30-32,38,39 Professor Buse hypothesised that one reason disability levels may continue to improve was that greater control of migraine may lead to a better ability to plan and engage in life again.

Systematic analyses of the mAbs have shown that these treatments are ‘generally more likely to help than harm,’⁴⁰ and that they can significantly reduce migraine attack likelihood, weekly migraine days, or migraine frequency within 1−7 days of administration.⁴¹ Prof Ashina cautioned though, that he is “careful what I promise my patients, I say there is a chance we can achieve this effect within the first week but usually we have to wait at least 3 months.”