Migraine 20 Sep, 2023 Read Time: 7 mins

Bringing episodic and chronic migraine under control

At an IHC 2023 symposium, Professor Dawn Buse, Dr Jonathan Ong and Professor Messoud Ashina highlighted how the impact of migraine goes beyond headache and can impair work, educational, social, and family life. When assessing migraine, it is important to understand the burdens of such on a patient’s life. This helps the healthcare professional and patient come to a shared decision as to the right treatment that can not only address migraine symptoms, but also reduce the impact of migraine on a patient’s health related quality of life, taking into account the patients’ needs and goals. Long-term treatment of episodic migraine should commence as soon as possible to try and mitigate progression to chronic migraine. One such treatment that may aid this are migraine-specific calcitonin gene-related peptide monoclonal antibodies (CGRP-mAbs). Studies of these treatments have shown significant decreases in migraine symptoms and frequency, as well as in migraine impact and burden.

Migraine burden and comorbidities

At currently around 1.1 billion,1,2 burgeoning migraine prevalence, discussed Dr Ong, “is an issue of public health concern.” Migraine prevalence, along with incidence and years lived with disability, are much higher in females than males, especially in young adult women.2,3

Migraine is more than just a headache. While this symptom may last 4−72 hours, prodromal symptoms can appear hours to days and aura symptoms 5−60 minutes prior to headache onset, and postdromal symptoms may last 24−48 hours.4 Migraine may be episodic (EM; 0−14 headache days/month), high-frequency episodic (8−14 headache days/month), or chronic (CM; ≥15 headache days/month),5-7 and, typically, the higher the frequency of migraine attacks, the lower a person’s health-related quality of life (HRQoL).5,8

Migraine symptoms can negatively impact a person’s quality of life9,10

For many people, a migraine attack can lead to ‘some’ or ‘severe’ impairment.9 However, while impacts can include those on work/school, social, and family life,9,10 there may be a lack of understanding of migraine symptoms and impact from work colleagues, friends, and family.11 Missing work, or being unable to properly carry out work duties, also contributes to the economic burden of migraine.12

As comorbidities associated with migraine include psychiatric, cardiovascular, respiratory, neurological, and metabolic conditions,13-16 Dr Ong recommended educating colleagues in other disciplines regarding proper treatment or referral for migraine. Lifestyle and external factors, such as diet, exercise, and stressful life events, can also contribute to migraine occurrence.13,14,17

Migraine assessment and treatment planning

“Assessing disability,” said Professor Buse, “can be as simple as asking ‘how is migraine affecting your life’?” When such a question can be answered, the patient feels ‘heard,’ rapport can be established, and the healthcare professional (HCP) can better understand migraine impact and burden.18 The SHARE model details five steps to help improve shared decision-making between HCP and patient.19 By assessing a patient’s values and preferences, comparing treatment options, determining goals, and defining treatment success, a shared treatment decision can be attained that can aid patient outcomes and medication adherence.20-22

Inadequate treatment of episodic migraine can lead to progression to chronic migraine

If EM attacks are not treated adequately in the acute setting, development of CM is more likely.23,24 Prevention of disease progression, discussed Prof Ashina, can be aided by early intervention and fast-active preventive treatment. This may help improve a patient’s HRQoL through reduction of migraine frequency, duration, and severity.25,26 This is especially important when treating young patients, stressed Prof Ashina, “imagine how their lives change if we start early treatment with migraine-specific medications.” However, one recent USA-based study showed that around three-quarters of people with high-frequency EM or CM who were eligible for preventive medication were not currently using it.27

CGRP-monoclonal antibodies

Migraine treatment has moved from non-specific therapies to migraine-targeted drugs including the calcitonin gene-related peptide monoclonal antibodies (CGRP-mAbs). 24,28,29 In a recent update to the 2021 European Academy of Neurology/European Headache Foundation consensus, CGRP-mAbs were moved from third-line to first-line therapy for preventive treatment and were recommended for acute treatment for EM or CM.24,29

CGRP-mAb use can decrease monthly migraine days and improve a patient’s quality of life

Results from Phase III studies of the mAbs showed that use can lead to significantly higher percentages of patients with EM or CM achieving ≥75% reduction in monthly migraine days (MMD) compared to placebo.30-33 Real-world evidence studies (3−6 months administration) show ≥75% response in 60−77% of patients with CM.34-37

Ratings on patient-reported outcome measures have also shown significant improvement following CGRP-mAb use versus placebo.30-32,38,39 Professor Buse hypothesised that one reason disability levels may continue to improve was that greater control of migraine may lead to a better ability to plan and engage in life again.

Systematic analyses of the mAbs have shown that these treatments are ‘generally more likely to help than harm,’40 and that they can significantly reduce migraine attack likelihood, weekly migraine days, or migraine frequency within 1−7 days of administration.41 Prof Ashina cautioned though, that he is “careful what I promise my patients, I say there is a chance we can achieve this effect within the first week but usually we have to wait at least 3 months.”

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References

  1. Global Burden of Disease. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020;396:1204−22.
  2. Safiri S, et al. Global, regional, and national burden of migraine in 204 countries and territories, 1990 to 2019. Pain 2022;163:e293−e309.
  3. Steiner TJ, et al. Migraine remains second among the world's causes of disability, and first among young women: findings from GBD2019. J Headache Pain 2020;21:137.
  4. American Migraine Foundation. The timeline of a migraine attack. https://americanmigrainefoundation.org/resource-library/timeline-migrai…. Published 2018. Accessed 16.09.2023.
  5. Blumenfeld AM, et al. Disability, HRQoL and resource use among chronic and episodic migraineurs: results from the International Burden of Migraine Study (IBMS). Cephalalgia 2011;31:301−15.
  6. Buse DC, et al. Demographics, headache features, and comorbidity profiles in relation to headache frequency in people with migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study. Headache 2020;60:2340−56.
  7. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38:1−211.
  8. Meletiche DM, et al. Quality-of-life differences between patients with episodic and transformed migraine. Headache 2001;41:573−8.
  9. Lipton RB, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007;68:343−9.
  10. Buse DC, et al. Life with migraine: Effects on relationships, career, and finances from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study. Headache 2019;59:1286−99.
  11. Lampl C, et al. Interictal burden attributable to episodic headache: findings from the Eurolight project. J Headache Pain 2016;17:9.
  12. Ong JJY, et al. Economic burden of migraine in Singapore Cephalalgia Reports. 2020;3:2515816320908241.
  13. Buse DC, et al. Sleep disorders among people with migraine: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study. Headache 2019;59:32−45.
  14. Bigal ME, Lipton RB. Obesity and chronic daily headache. Curr Pain Headache Rep 2008;12:56−61.
  15. Bigal ME, et al et al. Prevalence and characteristics of allodynia in headache sufferers: a population study. Neurology 2008;70:1525−33.
  16. Scher AI, et al. Comorbidity of migraine. Curr Opin Neurol 2005;18:305−10.
  17. Agbetou M, Adoukonou T. Lifestyle modifications for migraine management. Front Neurol 2022;13:719467.
  18. Hahn SR, et al. Healthcare provider-patient communication and migraine assessment: Results of the American Migraine Communication Study, phase II. Curr Med Res Opin 2008;24:1711−18.
  19. Agency for Healthcare Research and Quality. The SHARE approach. Essential steps of shared decision making. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/educatio…. Published 2020. Accessed 16.09.2023.
  20. Elwyn G, Vermunt N. Goal-based shared decision-making: Developing an integrated model. J Patient Exp 2020;7:688−96.
  21. Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making 2015;35:114−31.
  22. Náfrádi L, et al. Is patient empowerment the key to promote adherence? A systematic review of the relationship between self-efficacy, health locus of control and medication adherence. PLoS One 2017;12:e0186458.
  23. Lipton RB, et al. Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine. Neurology 2015;84:688−95.
  24. Sacco S, et al. European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention – 2022 update. J Headache Pain 2022;23:67.
  25. American Headace Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache 2019;59:1−18.
  26. Silberstein SD. Preventive migraine treatment. Continuum (Minneap Minn) 2015;21(4 Headache):973−89.
  27. Lipton RB, et al. Diagnosis, consultation, treatment, and impact of migraine in the US: Results of the OVERCOME (US) study. Headache 2022;62:122−40.
  28. Nissan GR, et al. Reducing the burden of migraine: Safety and efficacy of CGRP pathway-targeted preventive treatments. J Clin Med 2022;11(15).
  29. Eigenbrodt AK, et al. Diagnosis and management of migraine in ten steps. Nat Rev Neurol 2021;17:501−14.
  30. Ashina M, et al. Safety and efficacy of eptinezumab for migraine prevention in patients with two-to-four previous preventive treatment failures (DELIVER): a multi-arm, randomised, double-blind, placebo-controlled, phase 3b trial. Lancet Neurol 2022;21:597−607.
  31. Ferrari MD, et al. Fremanezumab versus placebo for migraine prevention in patients with documented failure to up to four migraine preventive medication classes (FOCUS): a randomised, double-blind, placebo-controlled, phase 3b trial. Lancet 2019;394(10203):1030−40.
  32. Mulleners WM, et al. Safety and efficacy of galcanezumab in patients for whom previous migraine preventive medication from two to four categories had failed (CONQUER): a multicentre, randomised, double-blind, placebo-controlled, phase 3b trial. Lancet Neurol 2020;19:814−25.
  33. Reuter U, et al. Efficacy and tolerability of erenumab in patients with episodic migraine in whom two-to-four previous preventive treatments were unsuccessful: a randomised, double-blind, placebo-controlled, phase 3b study. Lancet 2018;392(10161):2280−87.
  34. Ornello R, et al. Conversion from chronic to episodic migraine in patients treated with erenumab: real-life data from an Italian region. J Headache Pain 2020;21:102.
  35. Bader Y, et al. Effectiveness and safety of eptinezumab in episodic and chronic migraine headache in the UAE: A retrospective study. Neurol Ther 2023;12:1683−93.
  36. Barbanti P, et al. Fremanezumab in the prevention of high-frequency episodic and chronic migraine: a 12-week, multicenter, real-life, cohort study (the FRIEND study). J Headache Pain 2022;23:46.
  37. Vernieri F, et al. Galcanezumab for the prevention of high frequency episodic and chronic migraine in real life in Italy: a multicenter prospective cohort study (the GARLIT study). J Headache Pain. 2021;22:35.
  38. Lanteri-Minet M, et al. Effect of erenumab on functional outcomes in patients with episodic migraine in whom 2-4 preventives were not useful: results from the LIBERTY study. J Neurol Neurosurg Psychiatry 2021;92:466-472.
  39. Kudrow D, et al. Long-term safety and tolerability of eptinezumab in patients with chronic migraine: a 2-year, open-label, phase 3 trial. BMC Neurol 2021;21:126.
  40. Drellia K, et al. Anti-CGRP monoclonal antibodies for migraine prevention: A systematic review and likelihood to help or harm analysis. Cephalalgia 2021;41:851−64.
  41. Gottschalk C, et al. The importance of an early onset of migraine prevention: an evidence-based, hypothesis-driven scoping literature review. Ther Adv Neurol Disord 2022;15:17562864221095902.