Individualizing migraine therapy — the right treatment at the right time for the right patient

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 burden^2,3
• 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 discontinued^8–10
• 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.