The cost of delay: How missed opportunities derail migraine control
Industry Buzz
[Delayed treatment] is actually a huge contributor to disease progression and disease chronification.
—Amaal Starling, MD, neurologist at Mayo Clinic
It is also important to be upfront about potential side effects of any of the medications with patients. We reassure them that there are many options available, so if any side effects were to occur, we would have other options to consider.
—Leon Moskatel, MD, migraine expert and professor of neurology at Stanford
Despite the numerous benefits of migraine preventive therapy, gaps remain in the timely prescription of these treatments for patients.
Experts say delaying appropriate preventive migraine therapy can make things harder for patients in the long term.
Consequences can be significant
Delay in the use of preventive treatment “is actually a huge contributor to disease progression and disease chronification,” Amaal Starling, MD, a neurologist at Mayo Clinic, tells MDLinx.
In her work, Dr. Starling sees the consequences of delays in treatment all the time.
“The patient I worked with earlier today is someone who has had a delay in preventive treatment options for a variety of reasons," she says, noting that at the patient's initial visit in 2021, she was having one to two migraines per month—a year later, that had progressed to as many as five per month. "She's someone who [had] been hesitant about using preventive medication, and [...] now has daily headache, with every other day more severe migraine attacks, and so her disease has progressed."
It is an all too familiar pattern that Dr. Starling sees, that she argues could be avoided with more timely intervention.
“When individuals are in chronic migraine, we know that not only the disability is higher, the functional levels are lower, but also chronic migraine can be harder to treat than infrequent migraine. And so it can be harder to treat chronic migraine and disease that has progressed to more severe stages compared to when we can intervene early," she says. "If we can initiate prevention, hopefully that will reduce progression of disease."
Related: From last resort to first consideration: Reframing migraine preventionWhen to prescribe a preventive therapy
There are a number of factors that could indicate when a preventive medication is a good idea, according to Leon Moskatel, MD, a clinical assistant professor of adult neurology and an expert in migraine at Stanford.
“Medications for the prevention of migraine are one of the components of a comprehensive strategy for managing migraine that also includes lifestyle modifications and acute medications,” he says. "We will often consider starting a preventive medication when patients have at least 4-6 headache days per month, fewer but more severe attacks, or when the patient and their clinician agree that starting a preventive medication makes sense."
But he argues it’s crucial to have a positive conversation with patients in a clinical setting that set expectations for preventive options, including side effects.
“Positive conversations with patients about migraine center on listening carefully to the patient’s concerns with starting a daily medication, and then addressing these points in detail," Dr. Moskatel says. "It is also important to be upfront about potential side effects of any of the medications with patients. We reassure them that there are many options available, so if any side effects were to occur, we would have other options to consider."
Side effects can be a barrier
Dr. Starling says side effects are something patients will often cite as a reason for not trying preventive therapies. But newer therapeutic options may address this.
“Those are very valid concerns that patients have, but that is where our more novel treatment options have been much more beneficial than our older oral therapeutics because they are much better tolerated, have a much lower risk, and lower frequency of side effects. And so we're finding that a lot more patients are able to initiate and stay on prevention because they're tolerating it better.”