Continuing challenges for optimal migraine care

Preventive therapy is indicated in approximately 40% of people with migraine, but only a minority of such patients are using preventive treatments, partly because of the limited efficacy and tolerability of the older preventive therapies, such as antihypertensive agents and antiseizure medications, which were not developed for migraine.¹ 

Adherence to these therapies is poor due to unsatisfactory tolerability or lack of efficacy, and patients may give up on preventive therapy instead of switching to a different treatment after a first treatment has failed.¹ Discontinuation rates as high as 50% at 60 days and 80% at one year have been reported.²

Growing evidence shows that anti-CGRP therapies are more effective and better tolerated than older preventive therapies, with lower treatment discontinuation rates.^3-5 There is also evidence that CGRP-targeting therapies have the potential to reduce both health economic expenditures and the socioeconomic burden of migraine.⁶

Although regulators and payers may require that patients fail on 2-3 older preventive therapies before initiating anti-CGRP treatment, international guidelines now support first line use of CGRP-targeting agents.^1,7

The American Migraine Foundation (AMF) identified four main barriers to accessing newer preventive therapies for migraine:⁸

1. Restrictive prior authorisation requirements
2. A perceived lack of real-world evidence and treatment guidelines
3. The need for clinician education
4. The need for patient education.

The AMF urged decision makers to make better use of newer evidence to evaluate policies that restrict the selection of first-line therapies, greater collaboration among stakeholders, improved sharing of data and best practices, and expanded clinician and patient education and training.

The International Headache Society (IHS) has urged earlier initiation of preventive treatment before migraine becomes refractory and the disease burden increases, and proposed a migraine preventive strategy aimed at moving from reactive treatment once disability is established (prevention of attacks), to proactive, individualised prevention initiated early with safe, effective and tolerable therapies (prevention of disease progression).⁹ This approach is based on:

1. Promoting early initiation of effective and tolerable preventive therapies, starting in patients with two to four monthly migraine days, in line with the majority of current guidelines
2. Fostering longitudinal studies to gather more evidence on the potential benefit of early prevention, with the goal of improving patient outcomes, promoting excellent migraine care, enhancing individual and social well-being, and, ultimately, preventing migraine progression and preserving brain health

In summary, the continuing challenges for migraine prevention include:

• Delays in initiation of preventive therapies in appropriate patients
• Regulator/payer requirements to start patients on older less effective and less well tolerated preventive medication
• A lack of awareness of guideline recommendations to include anti-CGRP therapies as a first line option for migraine prevention
• The need for more evidence of the benefits of early prevention with effective, well tolerated medication on migraine progression and brain health