When prevention fails: Why migraine patients deserve a rethink
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What we are currently doing is not working, and what we're currently doing is we're not initiating prevention on enough people, and that is why there is disease progression that occurs.
—Amaal Starling, MD, neurologist at Mayo Clinic
It can often feel like trial and error to the patient and leave them feeling frustrated.
—Leon Moskatel, MD, migraine expert and professor of neurology at Stanford
Despite significant advances in the field of preventive migraine treatments, for some patients, these therapies are still ineffective.
Some studies suggest up to 78% of patients experience failure of treatments, and that is even higher among those who had previously found preventive migraine treatment options ineffective. []
“We do not yet have a strong way to match patients with the preventive medication to which they will best respond, so it can often feel like trial and error to the patient and leave them feeling frustrated,” Leon Moskatel, MD, clinical assistant professor of adult neurology and an expert in migraine at Stanford, tells MDLinx.
Related: Interactive case study: This migraine patient is frustrated and in pain—would your consult rebuild trust?A preventive therapy hasn’t worked: What now?
So, what can physicians do when preventive treatments aren’t working? Dr. Moskatel says it starts with a thorough evaluation.
“When patients do not respond to a preventive option, it is helpful to think through the potential reasons. One reason is often that the trial was not long enough; a full trial of a migraine preventive is 2-3 months. Beyond this, it is often helpful to consider a medication from a different class of therapeutics," he says.
Experts say part of the reason some patients may find preventive options ineffective is that treatment is initiated late.
“In general, what we are currently doing is not working, and what we're currently doing is we're not initiating prevention on enough people, and that is why there is disease progression that occurs and people developing chronic migraine or more severe forms of migraine,” Amaal Starling, MD, a neurologist at Mayo Clinic, tells MDLinx.
There can be a variety of reasons for such a delay, and both patients and healthcare providers can contribute to this.
According to Dr. Moskatel, “Delays in treatment are often related to three factors: stigma, underdiagnosis, and undertraining in headache treatments. Many still consider migraine to be ‘just a headache.’ This means that it may not be seen as a priority, and this can underplay the intense impact it can have on patients’ lives.”
“Additionally, migraine can be underdiagnosed and then not be felt to warrant treatment, when in fact that patient has migraine and would benefit greatly from a preventive medication," he says. "Moreover, headache medicine is undertaught in medical school and residencies, so non-specialized clinicians are often uncomfortable with starting and managing these preventive medications."
Fortunately, Dr. Moskatel says, the American Headache Society is currently working to expand the teaching of headache medicine—in medical schools, during residency, and among doctors who treat patients with migraine.
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Finding the right preventive therapy can be a frustrating process of trial and error. The experts who spoke with MDLinx emphasize that communication with patients during this process is critical.
“Talking with patients about why a certain medication was selected and what the future options could be can help patients feel more like there is a road map,” Dr. Moskatel says.
Managing patient expectations can also mean being ready to adjust treatments when necessary.
“Patients never want to be put on a medication that they're now going to be stuck with for the rest of their life. And interestingly, in migraine, I always tell patients that nothing I ever give you in migraine is a life sentence,” Dr. Starling says.
“Migraine fluctuates throughout a lifetime," she continues. "There will be periods of time where people with migraine, people living with migraine, may go into remission, and in that setting, we can back off of medications. There may be times where people will have worsening of disease, and we need to amp up or ramp up their medications and their treatment options, but it's always a bit of a moving target.”