Managing Migraine: Abortive and Preventive Therapies Have Advanced

AUGUST 11, 2019
Migraine is a neurologic condition associated with headache (HA) attacks described as throbbing, pulsatile pain with associated symptoms including photophobia, phonophobia, nausea, vomiting, and cutaneous allodynia (sensitivity to innocuous stimuli), with an attack duration ranging from 4 to 72 hours.

Managing migraine HA involves nonpharmacologic and pharmacologic approaches. In addition, the identification of triggers and HA patterns and their documentation with patient diaries are also useful. At the 9th annual Directions in Pharmacy conference, George DeMaagd, PharmD, BCPS, Professor of Pharmacy, Associate Dean of Academic Administration from Union University College of Pharmacy, in Jackson, Tennessee, covered this topic comprehensively.

Migraine HA is one of the most common types of HA and considered one of the most disabling neurologic conditions. Approximately 14% of Americans experience migraine HA. Migraine HA has a strong genetic component, with 70% of patients having a first-degree relative with the disease. Women are affected 3 times more than men, with initial HA attacks occurring in childhood and peaking in the 30- to 40-year age group. When patients with migraine experience 15 or more migraine HA days per month, they are classified as having chronic migraine. Patients with fewer than 15 HA days per month are classified as having episodic migraine. It is important to remember that migraine is not just a headache, and a single attack can disable a patient for 3-4 days.

Dr. DeMaagd stressed that patients with migraine experience problems with routine physical activities, including activities of daily living. Migraine can also impact their social/family activities, including parenting. The financial consequences of migraine are also significant and include the direct medical costs of care, along with the indirect costs, including absenteeism and loss of productivity.

After reviewing the most recent theories of migraine pathophysiology, Dr. DeMaagd covered the diagnostic criteria for migraine, including migraine with and without aura, along with episodic and chronic migraine. In addition, he covered the clinical course and timeline associated with migraine including the HA and non-HA phases.

Numerous nonpharmacologic approaches are available for patients with migraine. These interventions can range from simple applications of cold pressure packs, cognitive behavioral therapies, along with identifying and avoiding triggers including dietary influences. In addition, numerous neuromodulation devices are now available, including transcranial magnetic and transcutaneous supraorbital neural stimulation and other devices. Complementary treatments, including acupuncture, and some natural products may be useful for some patients.

Pharmacologic management of migraine includes abortive/ acute therapy (eg, treating the HA during premonitory or HA phases), and prevention therapy (eg, treatments for preventing migraine attacks).

Dr. DeMaagd issued a brief warning about medication-overuse HA, which occurs when patients become tolerant to the painrelieving effects of some acute migraine therapies. This pure withdrawal phenomenon occurs when patients overuse various analgesic combinations (eg, opioid, barbiturates, or migraine-specific therapies including ergots and triptans). The overuse of these agents can magnify the patient’s HA intensity and frequency, and require detoxification protocols as a component of management. He also reviewed the American Headache Society’s “Choosing Wisely” recommendations, emphasizing that opioids or butalbital-containing medications are never treatments of choice. This task force report also emphasizes the avoidance of frequent and prolonged use of OTC analgesic medications.

The abortive/acute and preventive/prophylaxis HA treatment guidelines include levels of evidence supporting the role of the various agents. First-line acute therapies include the nonsteroidal anti-inflammatory drugs and triptans, although other agents were discussed as having potential roles as well, including the antiemetics, magnesium, and others. A novel serotonin agonist, lasmiditan, is under development for the acute treatment of migraine and may offer a more favorable vascular adverse effect profile, offering an additional treatment option.

Preventive or prophylactic therapies are recommended in patients who continue to have recurring HAs (>8 HA days per month), cannot tolerate abortive therapies, experience severe attacks, or have certain types of migraine. Just one-third of patients who are eligible for preventive migraine treatments actually receive them, and discontinuation rates are quite high, especially with the nonmigraine-specific preventives (eg, betablockers, anticonvulsants, and antidepressants). The preventive medications with the strongest evidence supporting their use are divalproex sodium, topiramate, propranolol, timolol, the tricyclic antidepressants, and the recently approved calcitonin gene receptor peptide (CGRP) antagonists. Triptans including frovatriptan can be used for short-term prophylaxis of menstrual migraine.

More recently approved agents include onabotulinumtoxinA and the CGRP antagonists. OnabotulinumtoxinA is approved for prevention of chronic migraine and may be an option for some patients, although complicated administration and tolerability may preclude its use in some patients. The 3 CGRP antagonists, erenumab, fremanezumab, and galcanezumab, were FDAapproved in 2018. These agents are monoclonal antibodies that bind to the neuropeptide CGRP or block its receptor. They have demonstrated clinical efficacy in patients who have not responded to or were unable to tolerate older preventive medications. The role of these agents continues to evolve and criteria for their appropriate use are being developed.

Dr. DeMaagd concluded his presentation with discussion on the role of the pharmacist in the management of migraine. He acknowledged that many pharmacists may find it challenging to counsel their patients with migraine due to their busy practices. Pharmacists are the health care providers to whom patients may turn to first and the importance of engaging patients in conversations related to the potential role of abortive and preventive therapies may have a significant impact on migraine outcomes. In addition, pharmacists should be knowledgeable regarding red flags for referral and the appropriate use of OTC medications, and proactively address patients’ fears and concerns about self-injections. He shared some simple tools and questionnaires that can be used to conduct basic screening with their patients with HA. He also discussed options for more extensive collaboration with provider colleagues, utilizing tools that evaluate disability and the impact of HAs on daily life.