The CGRP playbook migraine experts actually use
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“At each visit, I work with my patients to plan out not only the next step but also the backup step that we will consider after that, if needed.” — Leon Moskatel, MD, clinical assistant professor and expert in headache medicine at Stanford
“Migraine treatment is not a one-size-fits-all treatment, but rather the treatment has to be personalized for each patient based on their disease characteristics, treatment response, and, of course, their treatment preferences. The treatment algorithm is not a linear flow chart, but rather a complex web of propositional logic questions.” — Amaal J. Starling, MD, associate professor of neurology, Program Director of the Headache Medicine Fellowship at Mayo Clinic
Effectively treating migraine can be challenging. Variability in treatment response, side effects, and insurance hurdles are just some of the difficulties facing physicians and patients alike.
MDLinx spoke with two experts in the field of migraine medicine who shared their strategies for treating patients with migraine.
“The main challenge in treating patients with migraine is the disease heterogeneity and thus treatment response variability,” Amaal J. Starling, MD, an associate professor of neurology and Program Director of the Headache Medicine Fellowship at Mayo Clinic, tells MDLinx.
"Migraine treatment is not a one-size-fits-all treatment, but rather the treatment has to be personalized for each patient based on their disease characteristics, treatment response, and, of course, their treatment preferences. The treatment algorithm is not a linear flow chart, but rather a complex web of propositional logic questions,” she explains.
Personalizing treatments
Dr. Starling argues that although there has been a significant increase in disease-specific treatment options for patients, there are still challenges in personalizing treatment to the individual. “Our clinical trials tell us that a specific treatment option works in a cohort of patients with migraine, let’s say 50%," she says. "The remaining question is, which 50% does the patient sitting in front of me fall into?”
Related: Oral, injectable, or IV? Experts break down CGRP options“In the absence of treatment personalization, the treatment of migraine is a trial-and-error process with treatment options that have been successful in cohorts of patients in clinical trials. Trial and error is frustrating for patients and does lengthen the journey to effective care, which can lead to complications including chronification, central sensitization, and medication-overuse headache,” Dr. Starling explains.
Improving patient outcomes
Amidst the challenges in treating a complex patient population is the overall goal of improving patient outcomes.
The experts who spoke with MDLinx say there are numerous steps physicians can take to help their patients.
“Physicians can help improve outcomes for patients with migraine by working with them to develop a comprehensive migraine treatment strategy, including lifestyle modifications, preventive medications and strategies, and acute therapies to best treat their migraine attacks when they happen,” Leon Moskatel, MD, clinical assistant professor of adult neurology, and an expert in headache medicine at Stanford, tells MDLinx.
“It can take two to three months of consistent use of medications to see the full benefit of a treatment option. Additionally, at each visit, I work with my patients to plan out not only the next step but also the backup step that we will consider after that, if needed,” Dr. Moskatel says.
Migraine freedom
Experts emphasize that having a comprehensive discussion about treatment goals with patients is critical.
Setting higher treatment goals—including the goal of migraine freedom—is also something physicians can aim for with their patients.
“Discuss clear goals with the patient for the acute and preventive treatment of migraine,” Dr. Starling says. “Be robust in working towards those goals. Goals for acute therapy include that within 2 hours of taking the acute treatment, the patient should be back to function and near baseline. This goal incorporates both efficacy and side effects as well as head pain and the non-headache symptoms of migraine-like sensory sensitivities, nausea, [and] brain fog,” she says.
Dr. Starling says her goal for preventive therapy is to see less than four headache/migraine days per month. "In addition, those 0-3 days with headache/migraine have to be effectively treated with acute treatment. Do I get there with every patient? No, but that is the goal, and I can continue to work with patients until we get as close to [that] goal and migraine freedom as possible."
Goals like these are supported by the recent International Headache Society (IHS) position statement advocating for setting higher treatment goals, Dr. Starling says.[][]
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