New delivery methods of older therapies—including
patches, inhalers, nasal sprays, and a variety of devices—are allowing
for faster medication delivery. These delivery methods offer some
advantages over older treatments in that they offer a way to bypass the
gastrointestinal system, which is advantageous for patients with chronic
headaches who also have stomach issues.
There are also newer molecular entities in development that have advantages over existing treatments.
On the topic of headache and migraine diagnosis, Dr. Robbins explained that it is important to diagnose disorders in the syndromic group, identify primary headache syndrome, and also exclude secondary headache.
Dr. Robbins noted that the mnemonic SNOOP can be used to guide physicians during the examination.
He cited new diagnostic criteria that defined medication overuse headache as “headache at least 15 days per month in a patient with pre-existing headache disorder,” and “regular overuse for more than 3 months of at least one acute/symptomatic treatment:
1. Ergotamine, triptans, opioids, or combination analgesic medications on at least 10 days per month
2. Simple analgesics or any combination of ergotamine, triptans, analgesics, or opioids on at least 15 days per month on a regular basis without overuse of any single class alone.”
Distinguishing primary from secondary headache disorders should be a
top priority, Dr. Robbins explained. He urged clinicians in attendance
to remain aware of “red flags.” He further noted that the “majority of
primary chronic headaches are chronic migraine.”
It is important that clinicians warn patients about risk factors for progression and systemic risks associated with medication overuse, and discuss with patients the fact that about one-half of all chronic migraine is associated with acute medication overuse.
On the topic of migraine prevention, the greatest development is the current research into monoclonal antibodies, according to Dr. Aurora. It is hoped that monoclonal antibodies will target the calcitonin gene-related peptide (CGRP) pathway to prevent migraines by blocking CGRP activity.
Dr. Aurora cited data that noted nearly 40% of patients should receive or could be considered for migraine preventive therapy, yet only 13% of those people who have migraine take daily preventive medication.
The goals of prevention are to decrease migraine and headache days,
decrease symptom intensity, and improve response to acute medications
and functional ability.
“Consider prevention when [the migraine] significantly interferes with routine activities despite use of acute treatment, attack frequency exceeds one per week, and/or when there is an elevated risk of medication overuse and chronic daily headache, “ Dr. Aurora noted in her slides. Other situations when prevention should be considered include when acute medications are ineffective or overused; when uncommon migraine symptoms are present, including prolonged aura; and in the setting of migrainous infarction.
She explained that several medications are being used for chronic migraine. OnabotulinumtoxinA is approved by the US Food and Drug Administration for treatment of chronic migraine and has been evaluated in double-blind, placebo-controlled studies. She cited data that prophylactic treatment significantly improved quality of life, in terms of emotional functioning and other measures, at 24 weeks compared with placebo.
Elaborating on CGRP monoclonal antibodies, Dr. Aurora explained that they have been shown to inhibit neurogenic vasodilation and are characterized by a long duration of action. She described advantages to this area of research, specifically that monoclonal antibodies can be used as a chronic treatment with no detectable effects on heart rate or blood pressure. Several monoclonal antibodies currently in development include Amgen’s AMG 334; Alder Biopharmaceuticals’ ALD 403; and Arteaus Therapeutics, Labrys/Teva, and Eli Lilly’s LY2951742.
Although it is likely to be a few years before the CGRP monoclonal antibody agents are approved, the panel members agreed that the fact that they are being studied represents an exciting era ahead for clinicians treating patients with migraine. Currently, patients are treated with a range of therapies from blood pressure agents to epilepsy medications. Discussing these options with patients also opens the door for communicating about how their current treatments are working and what may be on the horizon for them in the future.
Dr. Lipton encouraged clinicians in attendance to visit these websites for additional resources and information: www.AmericanHeadacheSociety.org ; www.AmericanMigraineFoundation.org ; and www.EaseHeadacheMigraine.com