Migraine management conundrums—the data can help

What is the best management for patients with migraine if they have cardiovascular disease or if they have worsening episodic migraine with medication overuse and comorbid depression or anxiety? These two common migraine management conundrums were presented and discussed by three experts in a thought-provoking satellite symposium at EAN 2021.

Migraine and concomitant cardiovascular disease

Cardiovascular disease becomes increasingly common among patients with increasing age. This alters their options for migraine treatment because triptans are contraindicated in patients with cardiovascular disease.1 Such patients can then experience worsening of migraine despite using conventional preventive therapies, explained Professor Jessica Ailani, Washington, DC.

Anti-CGRP mAbs do not appear to worsen myocardial ischemia

A typical case history of a patient with migraine and cardiovascular disease was then discussed in the light of emerging evidence on the cardiovascular safety of anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (anti-CGRP mAbs).

Anti-CGRP mAbs appear to be a safe preventive therapy for patients with migraine and cardiovascular disease

Professor Ailani presented the following data suggesting that anti-CGRP mAbs are a safe preventive migraine therapy for patients with cardiovascular disease:

  • Three Phase 3 clinical trials have demonstrated that cardiovascular treatment-emergent adverse events (AEs) or serious AEs are low and similar for patients treated with an anti-CGRP mAb and placebo with few discontinuations2
  • A Phase 3 clinical trial has shown no difference in time to exercise-induced angina during treadmill testing between patients treated with an anti-CGRP mAb and placebo3


High-frequency migraine headache with anxiety and depression

Treatment decisions can be optimized through application of clinical evidence

A second commonly encountered management conundrum was introduced by Dr Patricia Pozo-Rosich, Barcelona, Spain.

A patient has worsening episodic migraine and is experiencing nine episodes per month and at risk of progressing to chronic migraine despite increasing use of medication. In addition, she has moderately severe anxiety and depression.

Anti-CGRP mAbs improve migraine associated with medication overuse

To assist in the management of this patient, Dr Pozo-Rosich presented data from two studies demonstrating the beneficial effects of an anti-CGRP mAb for patients with migraine and medication overuse, as follows:

  • A significant reduction in monthly average migraine days and monthly average headache days of at least moderate severity in patients with episodic or chronic migraine, a documented inadequate response to between two and four classes of migraine preventive medications, and medication overuse4
  • A reduction in migraine frequency and acute migraine-specific medication treatment days and conversion to non-medication overuse at 3 months among patients with chronic migraine and medication overuse5

Anti-CGRP mAbs improve chronic migraine associated with comorbid depression and/or anxiety

Dr Pozo-Rosich also presented data demonstrating anti-CGRP mAb efficacy in the preventive treatment of chronic migraine and reduced headache impact in patients with depression,6 and reducing migraine headaches days in patients with anxiety and/or depression.7


How do you measure improvement in the patient?

Finally, in a discussion on how to measure improvements in migraine and quality of life for patients, Professor Ailani and Professor Brössner, Innsbruck, Austria, highlighted the importance of asking patients if they feel they are improving and what they are doing. Can they now take part in everyday activities?

Treatment of episodic migraine with an anti-CGRP mAb improved MSQ scores across domains

Dr Patricia Pozo-Rosi also noted that scales may show an improvement before a patient reports improvement and highlighted the Migraine-Specific Quality of Life Questionnaire (MSQ)8 as particularly useful.

She described how the MSQ has been used to measure the efficacy of treatment with an anti-CGRP mAb in patients with episodic migraine. Significant improvement was demonstrated compared with placebo in MSQ scores across domains, reducing migraine disability and impact and improving patients’ health-related quality of life.9

This satellite symposium was funded by Eli Lilly.

  1. Dodick DW, et al. Migraine patients with cardiovascular disease and contraindications: an analysis of real-world claims data. J Primary Care Community Health 2020;11:1–10.
  2. Oakes TM, et al. Evaluation of cardiovascular outcomes in adult patients with episodic or chronic migraine treated with galcanezumab: data from three Phase 3, randomized, double-blind, placebo-controlled EVOLVE-1, EVOLVE-2, and REGAIN studies. Headache 2020;60:110–23.
  3. Depre C, et al. A randomized, double-blind, placebo-controlled study to evaluate the effect of erenumab on exercise time during a treadmill test in patients with stable angina. Headache 2018;58:715–23.
  4. Silberstein S, et al. Efficacy of fremanezumab in migraine patients with medication overuse and documented inadequate response to 2–4 classes of migraine preventive treatments: subgroup analysis of the randomized, placebo-controlled FOCUS study. Poster IHC-PO-156, presented at the International Headache Congress (IHC); 5–8 September 2019.
  5. Tepper SJ, et al. Erenumab in chronic migraine with medication overuse. Neurology  2019;92:e2309–20.
  6. Lipton RB, et al. Effects of fremanezumab in patients with chronic migraine and comorbid depression: Subgroup analysis of the randomized HALO CM study. Headache 2021;61:662–72.
  7. Smitherman TA, et al. Efficacy of galcanezumab for migraine prevention in patients with a medical history of anxiety and/or depression: a post hoc analysis of the Phase 3, randomized, double-blind, placebo-controlled REGAIN, and Pooled EVOLVE-1 and EVOLVE-2 studies. Headache 2020;60:2202–19.
  8. Jhingran P, et al. Development and validation of the migraine-specific quality of life questionnaire. Headache 1998;38:295–302.
  9. Buse D, et al. Migraine-related disability, impact, and health-related quality of life among patients with episodic migraine receiving preventive treatment with erenumab. Cephalalgia 2018;38:1622–31.


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