Raising the bar for successful migraine prevention

A 75% reduction in migraine days can be achieved in up to one-third of patients with chronic migraine treated with anti-calcitonin gene-related peptide monoclonal antibodies, which also show long-term effectiveness and a rapid onset of action. In contrast, traditional oral migraine preventive therapies are considered effective if they reduce migraine days by 50%. Should the bar for successful migraine prevention be raised? asked an expert at EAN 2022.

Goals for migraine preventive therapy

The ultimate goal for preventive therapy is to prevent migraine progression into chronic migraine

A patient-centric, joint decision-making approach is essential for deciding upon realistic preventive treatment goals for a patient with high-frequency disabling episodic migraine, explained Professor Cristina Tassorelli, Pavia, Italy. She highlighted the case history of one her patients throughout to demonstrate factors to take into account in terms of treatment goals.

Treatment goals and their priority will vary for different patients at different stages of their life, Professor Tassorelli said, but include:

Preventive treatment goals and their priority vary for different patients

  • Reduced attack frequency, severity, and duration
  • Improved response to acute therapies and avoidance of medication overuse
  • Improved functioning and quality of life
  • Long-term efficacy and prevention of progression to chronic migraine1,2
  • A rapid onset of action3
  • A favorable tolerability profile4

 

Efficacy of migraine preventive therapies

The efficacy of migraine treatments is traditionally assessed in terms of their effect on monthly migraine days, said Professor Tassorelli. The benchmark for efficacy for traditional oral migraine preventive therapies has been a 50% reduction in monthly migraine days.1

Patients with a 75% response rate report better daily function than those with a 50% response

Up to one-third of patients with chronic migraine treated with anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) can achieve at least 75% reduction in monthly migraine days.5–8

The 6-item Headache Impact Test (HIT-6), which assesses pain, social functioning, role functioning, vitality, cognitive functioning, and psychological distress, reveals that these patients with a 75% response have better daily functioning than those who achieve a 50% response,3,9,10 added Professor Tassorelli.

 

Long-term efficacy of anti-CGRP mAbs

Long-term studies of anti-CGRPS demonstrate sustained efficacy with improved functioning

Studies have also demonstrated long-term efficacy of anti-CGRPs mAbs over 1–2 years in patients with chronic migraine, with sustained improvements in patient-reported outcome measures, including the Migraine Disability Assessment (MIDAS) score,11,12 said Professor Tassorelli.  

The MIDAS score measures headache-related disability as lost time from paid work or school, household work, and nonwork activities due to headache and provides a better evaluation of disease burden than monthly migraine days (MMDs).13

 

Onset of action of anti-CGRP mAbs

Preventive efficacy can be observed from day 1

Early onset of effect is important for improving adherence and outcome, said Professor Tassorelli, and enables a rapid return to normal daily life. Preventive efficacy can be observed from Day 1,14,15 and is evident for all anti-CGRP mAbs within 1 week.14–17

Professor Tassorelli concluded by referring back to her patient case history. She commented that although patients with migraine should be encouraged to have realistic expectations, the advent of anti-CGRP mAbs means that it may now be possible to raise the bar when deciding with the patient upon preventive treatment goals.

 

Educational financial support for this symposium is provided by H. Lundbeck A/S.

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References
  1. American Headache Society. The American Headache Society Position Statement on Integrating New Migraine Treatments into Clinical Practice. Headache. 2019;59(1):1–18.
  2. May A, Schulte LH. Chronic migraine: risk factors, mechanisms and treatment. Nat Rev Neurol. 2016;12(8):455–64.
  3. Ailani J, Winner P, Hartry A, et al. Patient preference for early onset of efficacy of preventive migraine treatments. Headache. 2022;62(3):374–82.
  4. Mansfield C, Gebben DJ, Sutphin J, et al. Patient preferences for preventive migraine treatments: A discrete-choice experiment. Headache. 2019;59(5):715–26.
  5. Brandes JL, Diener HC, Dolezil D, et al. The spectrum of response to erenumab in patients with chronic migraine and subgroup analysis of patients achieving ≥50%, ≥75%, and 100% response. Cephalalgia. 2020;40(1):28–38.
  6. Halker Singh RB, Aycardi E, et al. Sustained reductions in migraine days, moderate-to-severe headache days and days with acute medication use for HFEM and CM patients taking fremanezumab: Post-hoc analyses from phase 2 trials. Cephalalgia. 2019;39(1):52–60.
  7. Detke HC, Goadsby PJ, Wang S, Friedman DI, Selzler KJ, Aurora SK. Galcanezumab in chronic migraine: The randomized, double-blind, placebo-controlled REGAIN study. Neurology. 2018;91(24):e2211–21.
  8. Lipton RB, Goadsby PJ, Smith J, et al. Efficacy and safety of eptinezumab in patients with chronic migraine: PROMISE-2. Neurology. 2020;94(13):e1365–77.
  9. Lipton RB, Charleston L 4th, Tassorelli C, Brevig T, Hirman J, Cady R. Patient-reported outcomes, health-related quality of life, and acute medication use in patients with a ≥ 75% response to eptinezumab: subgroup pooled analysis of the PROMISE trials. J Headache Pain. 2022;23(1):23.
  10. Shin HE, Park JW, Kim YI, Lee KS. Headache Impact Test-6 (HIT-6) scores for migraine patients: Their relation to disability as measured from a headache diary. J Clin Neurol. 2008;4(4):158–63.
  11. Kudrow D, Cady RK, Allan B, et al. Long-term safety and tolerability of eptinezumab in patients with chronic migraine: a 2-year, open-label, phase 3 trial. BMC Neurol. 2021;21(1):126.
  12. Iannone LF, Fattori D, Benemei S, Chiarugi A, Geppetti P, De Cesaris F. Long-term effectiveness of three anti-CGRP monoclonal antibodies in resistant chronic migraine patients based on the MIDAS score. CNS Drugs. 2022;36(2):191–202.
  13. Lipton RB, Stewart WF, Sawyer J, Edmeads JG. Clinical utility of an instrument assessing migraine disability: the Migraine Disability Assessment (MIDAS) questionnaire. Headache. 2001;41(9):854–61.
  14. Dodick DW, Gottschalk C, Tassorelli C, Cady R, Hirman J. Eptinezumab demonstrated efficacy in sustained prevention of episodic and chronic migraine beginning on day 1 afterdosing. J Headache Pain. 2020;60:2220–31.
  15. Detke HC, Millen BA, Zhang Q, et al. Rapid onset of effect of galcanezumab for the prevention of episodic migraine: Analysis of the EVOLVE studies. Headache. 2020;60(2):348–59.
  16. Schwedt T, Reuter U, Tepper S, et al. Early onset of efficacy with erenumab in patients with episodic and chronic migraine. J Headache Pain. 2018;19(1):92.
  17. Winner PK, Spierings ELH, Yeung PP, et al. Early onset of efficacy with fremanezumab for the preventive treatment of chronic migraine. Headache. 2019;59(10):1743–52.

 

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