A Chief of Neurology's top 4 tips for managing chronic migraine—are you following this protocol?

Migraine is one of the top causes of disability worldwide—especially in young women—and when it becomes chronic, the toll is even heavier, from missed workdays to strained family life.^[]

1. Have patients maintain a headache diary and follow-up regularly

Only a quarter of patients with chronic migraine are given an accurate diagnosis, and less than half of those patients are provided with acute and preventive migraine treatment.^[]

When managing a patient with headache, it is helpful to ask them to maintain a headache diary, in which they record all days of headache pain, even if mild. Patients often are unable to recall how many headache days they have had over the previous months and may report only the more severe headache days, ignoring mild or moderate days of headache pain. Inquire about both days with headache as well as days in which the patient is completely headache- and symptom-free.

By getting an accurate assessment of monthly headache days, one can not only arrive at the proper diagnosis, but can more effectively monitor response to treatment at regular follow-up visits.

2. Evaluate and address the patient’s risk factors for migraine progression

Once the diagnosis of chronic migraine is made, a treatment plan must include the assessment and management of risk factors for progression from episodic to chronic migraine.

These modifiable risk factors should be assessed at each visit to ensure that treatments and management strategies are optimized appropriately.

In addition to pharmacologic management to reduce headache frequency and manage acute attacks, patients should be encouraged to maintain a normal weight, avoid medication overuse, treat comorbid depression and anxiety, minimize caffeine use, and manage any sleep disorders.

3. Initiate evidence-based migraine preventive therapy when indicated

The advent of the first class of migraine-specific preventive treatments targeting calcitonin gene-related peptide (CGRP) has led to an increase in awareness of available migraine therapeutics.

The main driver of preventive medication use, however, is headache frequency. Treatment guidelines recommend the use of preventive treatment in patients with at least 4 headache days monthly.^[]

Of patients with migraine, 40% are eligible for preventive treatment, but only around 17% are using it.^[] There are several evidence-based treatments for both episodic and chronic migraine available, and it is important to remain up to date on treatment guidelines.

Currently, topiramate, onabotulinumtoxin A, erenumab, galcanezumab, fremanezumab, eptinizumab, and atogepant have evidence for the treatment of chronic migraine. Many others, including valproate, amitriptyline, venlafaxine, candesartan, and propranolol are considered to have level A or B evidence of the treatment of episodic migraine and are routinely used in clinical practice for patients with chronic migraine.^[]

4. Offer migraine-specific acute treatments early

The goal of acute migraine treatment is to quickly and consistently resolve pain and associated symptoms and return the patient to normal function without recurrence.

Only around a quarter of patients with migraine are using migraine-specific prescription acute medications.^[] Acute treatments are either migraine-specific or non-specific agents, such as non-steroidal anti-inflammatory drugs (NSAIDs) or simple/combination analgesics.

The triptan class of medications, 5-hydroxytryptamine (5-HT) 1B/1D receptor agonists, has been available since the 1990s and is considered first line, both in terms of efficacy and cost considerations.

There are seven different triptan medications and all are available in generic formulations. Unfortunately, 48% of patients describe inadequate 2-hour pain freedom, and 38% report 24-hour pain recurrence.^[] Combination treatment (with NSAIDs or anti-emetics) can be helpful in improving response rates at times. Common side effects to triptans include paresthesia, chest/throat/jaw tightness, flushing/warmth, nausea, and dizziness.

Action on the 5-HT1B receptor can lead to some vasoconstrictive effects and triptans are thus contraindicated in patients with known cardiovascular and cerebrovascular disease.^[]

Tolerability for the gepant family of medication is overall favorable with nausea, constipation, and dyspepsia as the most common side effects. The ditan class has higher rates of central nervous system side effects, such as dizziness, nausea, and fatigue.^[]

All patients who present with migraine should be offered acute treatment. Migraine-specific medication should be the first line option in most cases, and there are currently several different classes available. Ineffective acute treatment is considered a risk factor for migraine progression, and it is essential to offer effective and evidence-based options at a patient’s initial appointment.