American Headache Society Releases Statement on Integrating New Treatments for Migraine Into Practice

 

To provide health care professionals with updated guidance on the use of novel preventive and acute treatments for migraine in adults, the American Headache Society (AHS) published a position statement in the journal Headache. Noting that the principles of preventive and acute pharmacotherapy that have been previously outlined by the AHS remain in place, the position paper specifically addresses a need for updated guidance on new therapies recently made available, erenumab (Aimovig; Novartis, East Hanover, NJ), fremanezumab (Ajovy; Teva, North Wales, PA), and galcanezumab (Emgality; Lilly, Indianapolis, IN) as well as the previously available onabotulinumtoxinA (Botox; Allergan, Madison, NJ). All 4 of these treatments are injectable. 

The position statement addresses that for oral medications for prevention of migraine, the dose should start low and be titrated up slowly but that, in contrast, injectables do not require titration and each have a standardized starting dose that does not require titration. The AHS position statement also addresses that efficacy for an individual patient in clinical practice may vary from the measures of efficacy used in clinical trials. 

Recommendations for when to initiate preventive treatment are unchanged and state that patients should be considered for preventive treatment if they have migraine more than 4 days per month; attacks that interfere with activities of daily living despite acute treatment; failure or overuse of, contraindications to, or adverse events with acute treatments. New indications for initiating treatment with the 3 newly approved therapies was provided. For adult patients with migraine 4 to 14 days per month, those with migraine 4 to 7 days per month must have moderate disability and all must be unable to use or achieve relief from at least 2 previously existing treatments after 6-week long trials of each.  For adults with migraine 8 to 14 days per month, they must be unable to tolerate or achieve relief from onabotulinumtoxinA after a minimum of 2 quarterly injections or have been unable to tolerate or achieve relief after 6-week trials of previously existing treatments. 

The 18-page position statement was developed through surveys of stakeholders including clinicians, patient advocates, and insurance providers to produce a balanced and evidence-based approach.  

President of the AHS, Kathleen Digre, MD, FAHS said, “The Society’s mission is to improve the care and lives of people living with headache disorders. As a headache society that represents neurologists and primary care providers, it was important for us to play an active role in this process. Ultimately, we advocate for our patients and want them to get the best possible treatment.” 

 

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