A Historic Perspective on Preventive Therapy for Migraine

Stephen Silberstein, MD: Hello, and thank you for joining this NeurologyLive^® Peer Exchange discussion entitled, “New Paradigms: Preventive Treatment for Chronic Migraine.” I’d like to talk about recent understanding of migraine pathophysiology, which has led us to the development of new novel-treatment approaches for chronic migraine. In this NeurologyLive^® Peer Exchange, I’m joined by a panel of experts in headache medicine. We’ll discuss the latest information available on preventive therapies for migraines, including practical strategies for using CGRP [calcitonin gene-related peptide]-targeted monoclonal antibodies. I am Dr Stephen Silberstein, professor of neurology and director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia. I am also editor-in-chief of NeurologyLive^®.

Participating today are friends and colleagues, all experts in headache medicine, which include Dr Andrew Blumenfeld, director of the Headache Center of Southern California, San Diego, California;

Dr Deborah Friedman, professor in the Department of Neurology and Neurotherapeutics and the Department of Ophthalmology at the University of Texas Southwestern Medical Center in Dallas, Texas; Dr Stephanie J. Nahas, associate professor at the Department of Neurology at Thomas Jefferson University in Philadelphia, Pennsylvania, and director of the Headache Medicine Fellowship Program at Jefferson Headache Center. She’s also assistant director of the Neurology Residency Program at Thomas Jefferson University. And Dr Stewart Tepper, professor of neurology at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

Thank you for joining us and let’s begin. In the first segment we’re going to be talking about treatment algorithms for migraine-preventive therapy. Let’s talk historically about it and all chime in. How long have we been treating migraine preventively? We’ve been doing it for ages. You can read Shakespeare, you can read Plato, you can read about the pirates in ancient Egypt, but the modern treatment of headaches began in this century. Most of the drugs we use for the treatment of migraines have been discovered by accident to be effective for migraines.

For example, beta blockers were given to patients with hypertension and their migraines went away. Antidepressants were given to patients with depression and their migraines went away. Almost all of the drugs we’ve had until recently were developed for another reason, another cause, and were found by accident to be effective with treatment of migraines. Do you have any comments or questions, or discussion?

Andrew Blumenfeld, MD: I think this serendipitous approach is true, because there’s a lot of comorbidity with migraine. Migraine patients often have epilepsy, so they might have been on an anticonvulsant to treat their seizures, and inadvertently found that their migraines improved. Similarly, migraine patients often have hypertension, a lot of vascular risk factors, that’s where the blood pressure medicines stem from. We also know that depression and anxiety are very common in migraine, particularly chronic migraine. This overlap led to the serendipitous discovery that you were talking about.

Stephen Silberstein, MD: Stephanie, what have you seen in your own patients in terms of how preventive medication reduces frequency, duration, or severity?

Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: Well, certainly that’s what we’re going for, reduce the disease burden, reduce the disability associated with attacks, make them fewer and farther between, and less intense. Unfortunately, that doesn’t always happen. I might say, it’s more common than not, that the first thing I start on someone, they have to try something else. You have to be patient and have a high tolerance for frustration for this reason. This is something I think is important to say upfront when you’re taking care of patients with migraine.

Stewart J. Tepper, MD: I think it’s important to state how futile the old preventive medicines have been in terms of usage. There was a study by Zsolt Hepp, PharmD, MS, in 2015, in which a very large database was evaluated for chronic migraine in patients placed on conventional oral prophylaxis at the beginning of a year. Over 83% of those patients had discontinued the use of those preventive medicines by the end of the year. And in Andy’s ”The International Burden of Migraine Study,” the 2 most common reasons, not surprisingly, that they discontinued were adverse effects and lack of efficacy. So for the responder rates to our old preventive medicines, in the best of situations, 45% of patients would get at least a 50% reduction in their migraine frequency. I think that was the place from which we began to see the change in the last year. I think that was where we were.

Stephen Silberstein, MD: What have you seen in your own patients regarding health care and preventive effect, frequency, intensity, and duration of attacks?

Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: Certainly that’s the goal, the preventive treatment to reduce the burden of disease, make the attacks fewer and farther between, less intense, and more responsive to acute treatment. But that doesn’t always happen. Unfortunately, more often than not, the first medication that I might try on somebody doesn’t work and you need time to establish whether it’s effective. For that matter, most patients seeing me have tried many things already. So it can be very frustrating. To achieve success, you have to have perseverance and patience, knowing that it can take weeks or even months to establish whether the treatment is effective. And you may have to move on to something else, so having a high frustration tolerance is important. And stating that upfront so the patient understands, that this is what we’re in for, is also important.