Who should have migraine preventive treatment and how effective are these therapies?

What is migraine preventive eligibility?

Many people think migraine preventive eligibility is at least four migraine headache days/month, said Professor Nahas. However, it has been shown that:

Many people with migraine are not receiving appropriate preventive therapy

• ∼40% of people with at least four migraine headache days/month experience have little to no disability
• 15–25% of people with less than four migraine headache days/month experience have moderate-to-severe disability²

Many people with migraine are therefore missing out on appropriate preventive therapy, said Professor Nahas.

Some people may argue that people with less than four migraine headache days/month need better acute therapy, she added.

But perhaps management of migraine should not be dichotomized into acute and preventive like two sides of a coin. Maybe management of migraine should be considered as two constantly spinning hemispheres of a globe, Professor Nahas said.

Management of migraine should not be dichotomized into acute and preventive

Are migraine preventive therapies reducing the frequency of migraine attacks?

Professor Nahas described a retrospective review of 2800 patients treated with migraine preventive therapies between 2009 and 2019.³

The preventive drugs used were beta blockers, calcium channel blockers, antidepressants, magnesium, antiepileptics, and angiotensin II antagonists. 550 patients withdrew from treatment due to adverse events and many others (1000) were lost to follow-up.³

The study demonstrated that only one-third of patients who completed the study experienced a reduction of migraine frequency of at least 50%.³

More needs to be done achieve better migraine reduction

Devices and other therapies are gaining in popularity and have shown preventive efficacy, but they may not be more effective than standard medications, said Professor Nahas. They include:

• adherence to the healthy eating plate⁴
• multiple chronic nerve blocks⁵
• the Percutaneous Mastoid Electrical Stimulator (PMES) and Supraorbital Transcutaneous Stimulator (STS)⁶
• onabotulinum toxin A^7,8

Professor Nahas concluded by highlighting that rapid migraine reduction is a goal worth striving for but more needs to be done to identify when patients need better migraine reduction and how to achieve it.