What are the most important unmet needs in the management of migraine?

Most Important Unmet Needs in Migraine Management

Patient Education and Realistic Expectations

The most critical unmet need in migraine management is inadequate patient education, with most patients reporting at least one perceived unmet treatment need, primarily driven by unrealistic expectations that effective treatment means cure rather than disease control. 1

• Patients commonly misconceive that migraine treatment should eliminate attacks entirely, when the realistic objective is returning control from the disease to the patient by reducing attack frequency, duration, and pain intensity to minimize life disruption 1
• Non-adherence remains a major obstacle requiring time-intensive education about correct medication use, potential adverse effects, and the critical importance of avoiding medication overuse 1
• Time constraints in clinical practice prevent adequate patient education, though freely available patient information leaflets can partially address this gap 1

Limited Access to Specialized Care and Optimal Therapy

• General practitioners often lack adequate education about migraine management, while specialists remain few and difficult to access 2
• No a priori basis exists for selecting optimal acute therapy for individual patients, forcing reliance on trial-and-error stepped care approaches 1
• Prescription accessibility issues prevent patients from receiving the best available therapies due to insurance restrictions and cost barriers 2

Medication Overuse Headache Epidemic

Medication overuse headache represents a devastating unmet need, with patients using acute medications more than twice weekly developing increasing headache frequency that can progress to daily headaches. 1

• Polytherapy remains common practice because treatment is not optimized, despite being strongly not recommended 2
• Opioids continue to be inappropriately overprescribed despite lack of efficacy and high risk of dependency and rebound headaches 2
• Detoxification requiring withdrawal of overused drugs and management of withdrawal symptoms (including transient headache worsening) becomes necessary but is poorly implemented 3

Inadequate Preventive Therapy Implementation

• Preventive therapy is underutilized despite clear indications: two or more attacks per month producing disability lasting 3+ days, use of abortive medication more than twice weekly, or failure of acute treatments 1
• Only onabotulinumtoxinA is FDA-approved for chronic migraine prevention, leaving limited evidence-based options for this severely disabled population 4, 5
• Clinical benefit from preventive medications requires 2-3 months to manifest, yet patients and clinicians often discontinue therapy prematurely before adequate trials 1

Treatment Efficacy and Safety Limitations

• Triptans and NSAIDs have remained the cornerstones of acute treatment for over 30 years despite well-known adverse effects and cardiovascular contraindications 2, 6
• Cardiovascular safety concerns with triptans exclude many patients with comorbid conditions from receiving effective acute treatment 3, 6
• Tolerance issues and frequent side effects impede prescription of available therapies, leaving patients undertreated 2

Chronic Migraine Management Gap

Chronic migraine (≥15 headache days per month) remains underdiagnosed and poorly treated, with substantially greater personal and societal burden than episodic migraine. 4, 5

• Randomized controlled trials supporting preventive medications for chronic migraine are sparse, with only onabotulinumtoxinA having FDA approval for this indication 4, 5
• Many chronic migraine patients are poorly responsive to or noncompliant with conventional preventive therapies 5
• No definitive guidelines exist for identifying which episodic migraine patients would benefit from preventive therapy to prevent progression to chronic migraine 5

Emerging Therapies Not Yet Widely Accessible

• CGRP-targeted monoclonal antibodies and gepants demonstrate superior efficacy and safety profiles but remain inaccessible to many patients due to cost and insurance restrictions 2, 6
• Ditans (5-HT1F receptor agonists) offer promise without cardiovascular contraindications but require confirmation of long-term safety and medication overuse headache risk 2
• Neuromodulation devices have approval for acute and preventive treatment but lack widespread availability and insurance coverage 6

Lack of Mechanism-Based Treatment Selection

• Treatment selection remains empirical rather than mechanism-based, with no biomarkers or clinical features reliably predicting individual treatment response 1, 7
• Patients must undergo multiple failed treatment trials before finding effective therapy, prolonging disability and suffering 7

Comorbidity Management Integration

• Depression, epilepsy, stroke, and myocardial infarction are comorbid with migraine but are rarely addressed in integrated treatment plans 6
• Coexisting conditions limit treatment choices but systematic approaches to managing these constraints are lacking 8