The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice

Abstract

Objective To incorporate recent research findings, expert consensus, and patient perspectives into updated guidance on the use of new acute and preventive treatments for migraine in adults. Background The American Headache Society previously published a Consensus Statement on the use of newly introduced treatments for adults with migraine. This update, which is based on the expanded evidence base and emerging expert consensus concerning postapproval usage, provides practical recommendations in the absence of a formal guideline. Methods This update involved four steps: (1) review of data about the efficacy, safety, and clinical use of migraine treatments introduced since the previous Statement was published; (2) incorporation of these data into a proposed update; (3) review and commentary by the Board of Directors of the American Headache Society and patients and advocates associated with the American Migraine Foundation; (4) consideration of these collective insights and integration into an updated Consensus Statement. Results Since the last Consensus Statement, no evidence has emerged to alter the established principles of either acute or preventive treatment. Newly introduced acute treatments include two small‐molecule calcitonin gene‐related peptide (CGRP) receptor antagonists (ubrogepant, rimegepant); a serotonin (5‐HT1F) agonist (lasmiditan); a nonsteroidal anti‐inflammatory drug (celecoxib oral solution); and a neuromodulatory device (remote electrical neuromodulation). New preventive treatments include an intravenous anti‐CGRP ligand monoclonal antibody (eptinezumab). Several modalities, including neuromodulation (electrical trigeminal nerve stimulation, noninvasive vagus nerve stimulation, single‐pulse transcranial magnetic stimulation) and biobehavioral therapy (cognitive behavioral therapy, biofeedback, relaxation therapies, mindfulness‐based therapies, acceptance and commitment therapy) may be appropriate for either acute and/or preventive treatment; a neuromodulation device may be appropriate for acute migraine treatment only (remote electrical neuromodulation). Conclusions The integration of new treatments into clinical practice should be informed by the potential for benefit relative to established therapies, as well as by the characteristics and preferences of individual patients.

A rational approach to migraine diagnosis and management in primary care

“…Identifying an optimal therapy to reach this goal can be an iterative process for many patients, so it is crucial for providers to help patients set realistic expectations for what successful treatment will look like (i.e. attacks are unlikely to completely cease) and the timeline it may take to reach that end [ 42 ]. A thorough understanding of, and accounting for, patient preferences can help providers ensure adherence and treatment continuation [ 42 ].…”

“…attacks are unlikely to completely cease) and the timeline it may take to reach that end [ 42 ]. A thorough understanding of, and accounting for, patient preferences can help providers ensure adherence and treatment continuation [ 42 ]. Here, as outlined in Figure 4 , we provide a stepwise approach to selecting an appropriate treatment based on the latest American Headache Society (AHS) guidance and our clinical experience.…”

“…For acute treatment, the aims include rapid and consistent freedom from pain and other symptoms, return to normal function, minimal need for repeat dosing, and minimal adverse events [ 42 ]. According to the AHS guidance and as shown in Figure 4 , all patients with migraine should be offered acute therapy; an overview of evidence-based acute treatment options is provided in Table 2 .…”

“…According to the AHS guidance and as shown in Figure 4 , all patients with migraine should be offered acute therapy; an overview of evidence-based acute treatment options is provided in Table 2 . Over-the-counter or prescription NSAIDs and other non-opioid analgesics should be considered first for patients with mild-to-moderate migraine, followed by oral triptans and ergotamines for those who do not get adequate relief, or who have more severe attacks [ 42 ]. Of note, while NSAIDs can be appropriate therapy, many individuals will already have tried over-the-counter NSAIDS prior to consulting a provider about headaches.…”

Kynurenine Pathway of Tryptophan Metabolism in Migraine and Functional Gastrointestinal Disorders

“…The involvement of the serotonin pathway of L-Trp metabolism in migraine and other neuropsychiatric diseases is reported in much research (reviewed in [103]) and is not subjected to this review. The role of the gut microbiome metabolism of L-Trp in migraine is an emerging issue addressed in several studies (reviewed in [27]).…”