American Headache Society December 11, 2018

Objective

To provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults.

Background

The principles of preventive and acute pharmacotherapy for patients with migraine have been outlined previously, but the emergence of new technologies and treatments, as well as new formulations of previously established treatments, has created a need for an updated guidance on the preventive and acute treatment of migraine.

Methods

This statement is based on a review of existing guidelines and principles for preventive and acute treatment of migraine, as well as the results of recent clinical trials of drugs and devices for these indications. Input was sought from health insurance providers, employers, pharmacy benefit service companies, device manufacturers, pharmaceutical and biotechnology companies, patients, and patient advocates. Expert clinicians and researchers in the field of headache medicine from across North America and the European Union provided input and feedback.

Results

The principles of pharmacologic preventive treatment of migraine with oral treatments have been as follows: use evidence‐based treatments when possible and appropriate; start with a low dose and titrate slowly; reach a therapeutic dose if possible; allow for an adequate treatment trial duration; establish expectations of therapeutic response and adverse events; and maximize adherence. Newer injectable treatments may work faster and may not need titration. The principles of acute treatment include: use evidence‐based treatments when possible and appropriate; treat early after the onset of a migraine attack; choose a nonoral route of administration for selected patients; account for tolerability and safety issues; consider self‐administered rescue treatments; and avoid overuse of acute medications. Neuromodulation and biobehavioral therapy may be appropriate for preventive and acute treatment, depending on the needs of individual patients. Neuromodulation may be useful for patients who prefer nondrug therapies or who respond poorly, cannot tolerate, or have contraindications to pharmacotherapy.

Conclusions

This statement updates prior recommendations and outlines the indications for initiating, continuing, combining, and switching preventive and acute treatments of migraine.

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