From the Guidelines
Chronic migraine management should prioritize preventive treatment with beta blockers, topiramate, or candesartan as first-line medications, considering the patient's frequency of migraine attacks and impact on daily life, as recommended by the most recent guidelines 1.
Key Considerations
- Preventive treatment should be considered in patients who experience migraine on ≥2 days per month despite optimized acute treatment, to reduce the frequency and severity of attacks.
- First-line medications for prevention include beta blockers (atenolol, bisoprolol, metoprolol, or propranolol), topiramate, or candesartan, which have been shown to be effective in reducing migraine frequency and severity 1.
- Second-line medications, such as flunarizine, amitriptyline, or sodium valproate, can be considered if first-line treatments are not effective or tolerated, as suggested by recent guidelines 1.
- CGRP monoclonal antibodies can be considered as third-line medications for patients who have not responded to first- and second-line treatments, due to their efficacy in reducing migraine frequency and severity 1.
Lifestyle Modifications and Acute Treatment
- Lifestyle modifications, such as maintaining regular sleep patterns, staying hydrated, eating regular meals, exercising regularly, and managing stress, are crucial in managing chronic migraine, as they can help reduce trigger frequency and severity.
- Acute treatments, such as triptans, NSAIDs, gepants, and ditans, can be effective in managing individual migraine attacks, but should be limited to 2-3 days per week to avoid medication overuse headache, as recommended by recent guidelines 1.
Multimodal Approach
- A multimodal approach, combining preventive medications, acute treatments, and lifestyle modifications, is essential in managing chronic migraine, as it addresses both symptom management and underlying mechanisms of migraine, including neuronal hyperexcitability and trigeminovascular activation.
- Keeping a headache diary can help track patterns and trigger identification, allowing for more targeted treatment and lifestyle modifications, as suggested by recent guidelines 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. Chronic Migraine Headache Management: OnabotulinumtoxinA (IM) is used 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 2.
- Key Points:
- OnabotulinumtoxinA (IM) is indicated for chronic migraine prevention
- Sumatriptan (PO) is not indicated for chronic migraine prevention, but rather for acute treatment of migraine attacks 3
- OnabotulinumtoxinA (IM) has a specific dosing regimen and administration guidelines that should be followed to minimize risks and optimize efficacy 2.
From the Research
Chronic Migraine Headache Management
- Chronic migraine headache management involves a combination of acute and preventive treatments 4, 5, 6, 7, 8
- Acute treatments for migraine include acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine, as well as migraine-specific treatments such as triptans and gepants 4
- Preventive treatments for migraine include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, which can reduce migraine frequency by 1 to 3 days per month relative to placebo 4, 5, 6, 7, 8
Treatment Options
- Beta-blockers, such as propranolol, are considered first-line agents for migraine prevention 5, 7
- Antiepileptics, such as topiramate, have been shown to be effective in reducing headache frequency and improving quality of life in patients with episodic migraine 8
- Calcitonin gene-related peptide monoclonal antibodies have been shown to be effective in preventing migraine and are recommended for use if two traditional preventive therapies have proven inadequate 6
- Non-pharmacologic treatments, such as relaxation techniques, bio-feedback, and cognitive behavioral therapy, may also be effective in preventing migraine 7, 8
Considerations for Treatment
- The choice of prophylactic drug should depend on efficacy, co-morbidity, side effects, availability, and cost 7
- Patients with cardiovascular risk factors should avoid triptans due to their vasoconstrictive properties 4
- Emerging real-world studies have found higher rates of adverse events with monoclonal antibodies targeting calcitonin gene-related peptide or its receptor than were seen in clinical trials 6