Preventative Pharmacotherapy for Chronic Migraine--One Step at a Time

Approximately 1 billion people in the world are affected with migraine and the thought is that about 40% of them that are candidates for some type of preventative therapy. A sizable proportion of that 40% doesn’t actually receive the kind of preventative therapy that they need, and so that equates to a very large burden that is exerted on a population that can’t function normally because they have headache of a very high frequency. So we need to not only identify those people and recognize who is a candidate for therapy, but then also make sure that they’re receiving the right kind of therapy. One of the things that we look to do is set up some reasonable goals, especially when you have an individual who has headache on most days or every day. I think if you ask a patient what they want, the overwhelming response is going to be that they want to be pain free. And, we know that that is just not possible in certain populations. There’s a lot of neurobiochemical reasons why that may occur; changes that make someone a little bit more prone to having pain for an indefinite period of time.  Those are the people where you really need to focus on functionality, where maybe the goal is not going to be pain freedom but to be able to learn how to function and how to cope with the pain that they experience on a daily basis.

There is a pretty large body of evidence-based treatments that we use for migraine prevention. The list is actually several years old and doesn’t reflect some of the newer agents that are coming out, or even some new more contemporary studies on agents that didn’t make the previous guidelines. So no doubt, especially now that CGRP medications and monoclonal antibody therapies are coming out, there will be a very large new armamentarium that we will have available to treat headache patients. It seems like the early studies on those medications are very promising, that not only are they efficacious, but they’re also very well tolerated. It seems like they’re going to be appropriate medications for populations of people that perhaps some other medications that we use frequently are just not appropriate for. The issue of course is going to be cost and what is that going to mean for the accessibility of these medications. Beyond medications we have a number of other things that studies indicate are effective, and are becoming more popular, including single-pulse transcranial magnetic stimulation, noninvasive vagal nerve stimulation, and peripheral stimulation through devices that stimulate supraorbital nerves or even implanted devices that can stimulate greater occipital nerves. When choosing among treatment options, we look for co-morbid conditions, and for other issues that result from their chronic pain. These could be cardiovascular risk factors or cerebrovascular risk factors, depression, anxiety, GI issues. We pick medications that may not only work for treating their chronic migraine issue, but also may treat some of their other co-morbid conditions. So we can frequently titrate antiepileptic medications, antidepressant medications, antihypertensives to get more than one treatment effect out of them.