From the Guidelines
Chronic migraine-related pain should be treated with a combination of preventive and acute therapies, with topiramate being the first-line preventive medication due to its effectiveness and lower cost, as supported by the most recent evidence 1. The treatment of chronic migraine-related pain involves a multifaceted approach, including lifestyle modifications, acute treatments, and preventive therapies.
Preventive Therapies
Preventive medications are crucial in reducing migraine frequency and include:
- Topiramate, which is the drug of first choice due to its lower cost and proven effectiveness 1
- OnabotulinumtoxinA, which is limited by regulatory restrictions but effective for patients who have failed other preventive medications 1
- CGRP monoclonal antibodies, such as erenumab, fremanezumab, and galcanezumab, which have been proven beneficial for patients who have failed at least two other preventive medications 1
Acute Therapies
For acute treatment, the following options are available:
- Triptans, such as sumatriptan and rizatriptan, which can abort attacks if taken early 1
- NSAIDs, like ibuprofen and naproxen, which help manage pain 1
- Newer gepants, such as ubrogepant and rimegepant, and ditans, like lasmiditan, which offer alternatives for those who cannot take triptans 1
Lifestyle Modifications
Non-pharmacological approaches are also essential and include:
- Lifestyle modifications, such as regular sleep, meals, and exercise 1
- Stress management, biofeedback, cognitive behavioral therapy, and neuromodulation devices 1 Treatment typically begins with lifestyle changes and acute medications, adding preventive therapies if migraines occur more than 4 days monthly or significantly impact quality of life. It is crucial to counsel patients on the importance of beginning treatment as soon as possible after migraine onset and to be aware of medication overuse headache, a potential complication of migraine treatment 1.
From the FDA Drug Label
to prevent headaches in adults with chronic migraine who have 15 or more days each month with headache lasting 4 or more hours each day.
The treatment option for chronic migraine-related pain is onabotulinumtoxinA (IM), which is used to prevent headaches in adults with chronic migraine.
- Key points:
- OnabotulinumtoxinA is used for chronic migraine prevention.
- It is indicated for adults with 15 or more days of headache per month, lasting 4 or more hours per day.
- This treatment option is specifically mentioned in the drug label for onabotulinumtoxinA 2.
Another option is eletriptan (PO), however the label does not explicitly state it is for chronic migraine, but rather for migraine attacks.
- Key points:
- Eletriptan is used for the treatment of migraine attacks.
- It is not explicitly indicated for chronic migraine prevention in the provided drug label 3.
From the Research
Treatment Options for Chronic Migraine-Related Pain
- The treatment of chronic migraine-related pain involves a combination of preventive and acute therapies 4, 5, 6, 7, 8.
- Preventive treatments are essential for managing chronic migraine, and several options are available, including:
- Topiramate: an antiepileptic drug that has been shown to be effective in reducing the frequency of migraine days 4, 6, 7, 8.
- Beta-blockers: such as metoprolol and propranolol, which have been proven to be effective in migraine prophylaxis 5.
- Calcium channel blockers: such as flunarizine, which has been shown to be effective in migraine prophylaxis 5.
- 5-HT antagonists: which have been proven to be effective in migraine prophylaxis 5.
- Amitriptyline: an antidepressant that has been shown to be effective in migraine prophylaxis 5.
- Acute therapies for chronic migraine-related pain include:
- Triptans: such as sumatriptan and zolmitriptan, which are highly effective in treating migraine attacks 5.
- Ergotamine and dihydroergotamine: which have been shown to be effective in treating migraine attacks, although with inferior efficacy compared to triptans 5.
- Analgesics: such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), which are effective in treating migraine attacks 5.
- OnabotulinumtoxinA (BOTOX) has also been shown to be effective in the prophylactic treatment of chronic migraine, with similar efficacy to topiramate and fewer adverse events 8.
Efficacy and Safety of Topiramate
- Topiramate has been shown to be effective in reducing the frequency of migraine days in patients with chronic migraine 4, 6, 7.
- The efficacy of topiramate has been demonstrated in patients with and without acute medication overuse 7.
- Topiramate has been shown to be generally well tolerated, with common adverse events including paraesthesia, nausea, dizziness, and fatigue 6, 8.
Comparison of Topiramate and OnabotulinumtoxinA
- A pilot study comparing the efficacy and safety of topiramate and onabotulinumtoxinA (BOTOX) for the prophylactic treatment of chronic migraine found similar efficacy between the two treatments 8.
- OnabotulinumtoxinA was found to have fewer adverse events and discontinuations compared to topiramate 8.