Is precision medicine possible in migraine?

Healthcare tailored to an individual patient takes account of the individual’s unique characteristics including their genome, microbiome, environment, health, lifestyle, and diet, said Professor Fumihiko Sakai, Saitama, Japan, chair of the debate.

Precision medicine has the potential to revolutionize healthcare

The potential of such precision medicine to revolutionize healthcare has been recognized and promoted by the Precision Medicine Initiative in the USA, which was launched by President Obama in 2015.¹

Precision medicine is possible in migraine

Combining precision medicine and artificial intelligence will improve diagnosis and treatment

Precision medicine and artificial intelligence have synergistic roles in improving personalized care, said Professor Tassorelli, Pavia, Italy. Together they can be used to improve pathophysiologic understanding, risk prediction, diagnosis, treatment plans, and future therapeutic interventions.²

In presenting the case for the motion “Is precision medicine possible in migraine?” she highlighted that the tools and options are now available to make it a reality — for example, genome sequencing, easier identification of gene-bearing mutations that cause disease, and wearable devices for monitoring.

The phenotypic variability of migraine lends itself to precision medicine

Professor Tassorelli explained that migraine lends itself to analysis using these tools due to its association with many comorbidities,³ its phenotypic variability⁴ and its polythetic diagnostic criteria,⁵ for example:

• Headache may be unilateral, pulsating, moderate or severe, with different aggravating factors and accompanying symptoms
• Auras may be visual, sensory, motor, brainstem, retinal, or involve speech or language

Professor Tassorelli concluded her case by highlighting a genetic risk score model that has shown potential for predicting headache response to triptans.⁶

Precision medicine is not possible in migraine

In presenting the difficult case against the motion “Is precision medicine possible in migraine?” Professor Diener, Essen, Germany, highlighted data showing that treatment of migraine based on biomarkers or deep attack phenotyping is currently a hypothetical construct.

Precision medicine in migraine is a hypothetical construct

Professor Diener accepted the benefit of precision medicine for patients with migraine and comorbidities,³ but argued that:

• Although unilateral pain, phonophobia, cranial autonomic symptoms and premonitory symptoms have been associated with response to a triptan,⁷ it is not possible to know that these features will occur before an attack
• Identification of triptan nonresponders⁸ is restricted to trial and error
• Identification of genetic⁹ and molecular biomarkers¹⁰ is challenging and not currently able to identify patients with migraine, except those with familial hemiplegic migraine¹¹
• Reliable and robust neuroimaging biomarkers are still lacking for migraine¹²

85% of the audience voted that precision medicine is possible in migraine

The result

The debate concluded with voting, which secured a clear majority for the motion. 85% of the audience agreed with Professor Tassorelli that precision medicine is possible in migraine.