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Individualizing migraine therapy — the right treatment at the right time for the right patient
Migraine is a heterogeneous disease, and many patient-specific factors need to be taken into account when managing patients to provide each individual patient with the right treatment at the right time, explained experts at the Migraine Trust International Symposium 2022.
The importance of patient-specific factors and real-world evidence
An individualized approach when managing patients with migraine means taking into account a range of patient-specific factors, said Professor Christoph Schankin, Bern, Switzerland. These factors include:
Patient-specific factors facilitate an individualized approach to migraine management
- The heterogeneity of migraine1 and the patient’s history and disease burden2,3
- Any comorbidities and concomitant medications4
- Treatment failures and medication overuse5
- The use of any synergistic combination therapy6
- The patient’s preferences2
Real-world data help inform individualized migraine patient management
Real-world evidence (RWE) can then be used to provide guidance on how to manage different subgroups of patients and address the needs of the full spectrum of individuals with migraine.
In contrast to randomized controlled trials (RCTs), RWE studies reflect clinical practice, explained Professor Schankin. Like RCTs, they may be interventional and prospective, but they may also be observational and prospective or retrospective. In addition, unlike RCTs, the patient populations in real-world studies are diverse and unrestricted, and monitoring may not be required.7
Real-world evidence on the use of calcitonin gene-related peptide pathway monoclonal antibodies
The evidence for the use of CGRP pathway mAbs for episodic and chronic migraine is moderate to high quality2
Professor Schankin presented the results of real-world studies evaluating the use of calcitonin gene-related peptide (CGRP) pathway monoclonal antibodies (mAbs) in specific migraine patient populations and clinical scenarios.
These studies have shown:
- Sustained effectiveness of CGRP pathway mAbs in everyday patient populations2
- Increased migraine frequency when CGRP pathway mAbs are discontinued8–10
- Switching CGRP pathway mAbs may be an option for some patients2
As a result of these data, the European Headache Federation (EHF) has updated its guideline on the use of mAbs targeting the CGRP pathway for migraine prevention, said Professor Schankin.
Efficacy of a CGRP pathway mAb should be evaluated after a minimum of 3 consecutive months on treatment2
The EHF guideline now highlights that the evidence for using CGRP pathway mAbs for episodic and chronic migraine is moderate to high quality2 using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.11
The guideline also provides statements on first-line use of CGRP pathway mAbs, response evaluation, duration of treatment, and switching CGRP pathway mAbs as follows:2
CGRP pathway mAb treatment should be paused after 12–18 months but restarted if migraine worsens after treatment withdrawal2
- Include as a first line treatment option for preventive migraine treatment, but avoid in pregnant or nursing women, and use caution and make a case-by-case decision for patients with vascular disease or risk factors and Raynaud phenomenon
- Evaluate efficacy after a minimum of 3 consecutive months on treatment
- Pause treatment after 12–18 months but restart if migraine worsens after treatment withdrawal
- Although there is insufficient evidence on the benefits of switching to another CGRP pathway mAb if the patient has an inadequate response, switching may be an option
This satellite symposium was sponsored by Teva.
Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.
References
- Ashina M, Terwindt GM, Al-Karagholi MA, et al. Migraine: disease characterisation, biomarkers, and precision medicine. Lancet. 2021;397(10283):1496–1504.
- Sacco S, Amin FM, Ashina M, Bendtsen L, et al. European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention – 2022 update. J Headache Pain. 2022;23(1):67.
- Lipton RB, Seng EK, Chu MK, et al. The effect of psychiatric comorbidities on headache-related disability in migraine: results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study. Headache. 2020;60(8):1683–96.
- Pomes LM, Gentile G, Simmaco M, et al. Tailoring treatment in polymorbid migraine patients through personalized medicine. CNS Drugs. 2018;32(6):559–65.
- Schwedt TJ, Alam A, Reed ML, et al. Factors associated with acute medication overuse in people with migraine: results from the 2017 migraine in America symptoms and treatment (MAST) study. J Headache Pain. 2018;19(1):38.
- Mullin K, Kudrow D, Croop R, et al. Potential for treatment benefit of small molecule CGRP receptor antagonist plus monoclonal antibody in migraine therapy. Neurology. 2020;94(20):e2121–5.
- Blonde L, Khunti K, Harris SB, et al. Interpretation and impact of real-world clinical data for the practicing clinician. Adv Ther. 2018;35(11):1763–74.
- Raffaelli B, Terhart M, Overeem LH, et al. Migraine evolution after the cessation of CGRP(-receptor) antibody prophylaxis: a prospective, longitudinal cohort study. Cephalalgia. 2022;42(4-5):326–34.
- Gantenbein AR, Agosti R, Gobbi C, et al. Impact on monthly migraine days of discontinuing anti-CGRP antibodies after one year of treatment - a real-life cohort study. Cephalalgia. 2021;41(11–12):1181–6.
- Vernieri F, Brunelli N, Messina R, et al. Discontinuing monoclonal antibodies targeting CGRP pathway after one-year treatment: an observational longitudinal cohort study. J Headache Pain. 2021;22(1):154.
- The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Available from: http://gdt.guide linedevelopment.org/app/handb ook/handbook.html. Accessed 21 Sep 2022.