2020 Symposia Series 1 · Lipton RB, et al. Headache. 2001;41:646-657; Lipton RB, et al. Neurology....
Transcript of 2020 Symposia Series 1 · Lipton RB, et al. Headache. 2001;41:646-657; Lipton RB, et al. Neurology....
2020 Symposia Series 1
Embracing New Treatment Options in the Management of Migraine Headache
3
• Apply current diagnostic criteria for differential diagnosis of migraine to
increase early recognition and treatment
• Employ current migraine guideline recommendations and management
strategies to establish improved patient treatment plans
• Identify the appropriate use of established and emerging treatment options
for migraine and related monitoring and safety options
Learning Objectives
4
Migraine Is Common
Lipton RB, et al. Headache. 2001;41:646-657; Lipton RB, et al. Neurology. 2007;68:343-349.
0 20 30 40 50 60 70 80 100
0
5
10
15
20
25
30
Age (years)
Mig
rain
e P
reva
len
ce
(%
)
Female
Male
US Prevalence (%)
Female Male
Sex 17 6
Race
White
Black
17
14
6
4
Highest prevalence
Age 30 to 39 years 24 7
5
200 40 60 80
Migraine Is Debilitating
Feigin VL et al. Lancet Neurol. 2019, 18:459-480; Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease
Study 2017. Seattle, WA: IHME, 2018; Linde M, et al. Cephalalgia. 2004;24:455-465.
Percentage of Migraineurs (N = 423)
Very negative influence
Quite negative influence
Some negative influence
7Sexual life 8 28
3Love 6 22
2Finding friends 8
3Social position 10 24
8Leisure time 14 37
4 6Finances 20
4Family situation 23 38
8Pursuing studies 12 27
3Pursuing career 8 16
Attendance at work 8 18 47 • 2nd most disabling episodic
condition after lower back pain
• Migraine is a chronic disease
with episodic manifestations
6
Throbbing
pain
Release of CGRP
• Multiple potential sources or sites of action
• Headache and other symptoms
• Target for small-molecule antagonists and antibodies
Thalamus
• Sensitization of alteration of thalamocortical circuits
• Sensory sensitivity and allodynia
• Target for neuromodulation
Hypothalamus
• Activation in premonitory phase
• Premonitory symptoms
• Target for hypothalamic
peptides and modulators
Cortex
• Cortical spreading depolarization, altered connectivity
• Migraine aura and cognitive symptoms
• Target for neuromodulation
Trigeminocervical Complex
• Pain transmission or sensitization
• Headache and neck pain
• Target for medications and neuromodulation
Pathophysiology of Migraine—Implications for Management
Charles A. Lancet Neurol. 2018;17:174-182.
Pain perception
Upper Cervical Nerves
• Pain transmission or
sensitization
• Neck and head pain
• Target for local injections and
neuromodulation
7
Prodrome
• Fatigue
• Food craving
• Muscle pain
• Cognitive change
• Mood change
• Sensory disruption
Aura (if present)
• Visual
– Scintillating
scotoma
• Sensory
• Motor
Headache
• Localization
• Throbbing
• Nausea
• Vomiting
• Photophobia
• Phonophobia
Postdrome
• Fatigue
• GI upset
• Cognitive
change
• Muscle pain
• Mood change
What Happens During a Migraine Attack?
Adapted from: American Migraine Foundation. americanmigrainefoundation.org/understanding-migraine/timeline-migraine-attack/.
Accessed Apr 13, 2020.
≤1 hour~4 to 72 hours
Clinical Phases of Migraine
8
Case Study: Colleen, a 42-Year-Old Call Center Operator
Presenting Complaint
• “Tension headaches” that have become
more frequent and debilitating in the past
10 years
• Current headaches not relieved by
nonprescription NSAIDs
• Recurrent insomnia, occasional
constipation
NSAID = nonsteroidal anti-inflammatory drug.
History
• Minor headaches since she was in her teens
• No history of trauma or unusual stresses
• Bilateral tubal ligation
• Works from home most days
Physical Exam and Medications
• Height: 5 ft 6 in; weight: 186 lb; BMI: 30.0 kg/m2
• Hypertension controlled with amlodipine 5 mg/d
9
• Frequency and patterns
‒ Any significant changes
• Location
• Duration
• Quality and intensity
• Time to peak intensity
• Preceding symptoms (eg, how the headache begins; triggers)
• Warning symptoms and aura
• Associated symptoms and level of disability
• Aggravating or relieving factors
What to Ask About When Taking a Thorough Headache History
Weatherall MW. Ther Adv Chronic Dis. 2015;6:115-123.
10
Case Study (cont’d): Colleen’s History
• Unilateral pattern of pain, sometimes behind browbone
• Headaches often worse around menses
• Headaches 4 to 6 times a month for the last 2 years, lasting from a few
hours to up to a day
• Severity varies but is usually moderate or severe
• Interfere with work and household needs about 1 or 2 days a week
• Loud noises and bright lights make headaches worse; sometimes her
neck becomes sore
• Sometimes feels congested and has a runny nose
• Headaches often accompanied by nausea
• Neurologic exam within normal limits
11
Typical Presentations of Common Forms of Headache
TENSION TYPE• Pain “like a band”
squeezing the head
• Primary headache
per ICHD-3
MIGRAINE• Unilateral pain
• Often with nausea and
visual changes
• Primary headache
per ICHD-3
CLUSTER• Pain in and around one
eye
• Primary headache
per ICHD-3
“SINUS”• Pain behind browbone
and/or cheekbones
• Secondary headache per
ICHD-3
• Unless clear signs of active
infection, often is a migraine
headacheICHD-3 = International Classification of Headache Disorders, 3rd edition.
Cady RK, Schreiber CP. Otolaryngol Clin North Am. 2004;37:267-288; Headache Classification Committee of the International Headache Society
(IHS). Cephalalgia. 2018;38:1-211; brgeneral.org www.brgeneral.org/healthy-lifestyle-blog/2018/november/4-major-types-of-headaches-and-where-
they-hurt/. Accessed Apr 22, 2020.
12
Typical Presentations of Common Forms of Headache
ICHD-3 = International Classification of Headache Disorders, 3rd edition.
Cady RK, Schreiber CP. Otolaryngol Clin North Am. 2004;37:267-288; Headache Classification Committee of the International Headache Society
(IHS). Cephalalgia. 2018;38:1-211; brgeneral.org www.brgeneral.org/healthy-lifestyle-blog/2018/november/4-major-types-of-headaches-and-where-
they-hurt/. Accessed Apr 22, 2020.
TENSION TYPE• Pain “like a band”
squeezing the head
• Primary headache
per ICHD-3
MIGRAINE• Unilateral pain
• Often with nausea and
visual changes
• Primary headache
per ICHD-3
CLUSTER• Pain in and around one
eye
• Primary headache
per ICHD-3
“SINUS”• Pain behind browbone
and/or cheekbones
• Secondary headache per
ICHD-3
• Unless clear signs of active
infection, often is a migraine
headache
13
Migraine Tension-type
≥2 of the following
• Unilateral (59% of migraines)
• Pulsating (85% of migraines)
• Moderate to severe intensity lasting between 4 and
72 hours
• Aggravation by routine physical activity
≥2 of the following
• Bilateral
• Not pulsating
• Mild to moderate intensity
• Not aggravated by routine physical activity
≥1 of the following
• Nausea/vomiting (73% of migraines)
• Photophobia/phonophobia (~80% of migraines)
• No nausea/vomiting
• One or neither: photophobia/phonophobia
Not attributable to another disorder Not attributable to another disorder
Migraine vs Tension-type Headache: A Common Misdiagnosis
Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2018;38:1-211; Lipton RB, et al. Headache.
2001;41:646-657.
14
Landmark Study: How Likely Is it That an Episodic Headache
Is Migraine?
• Prospective, open-label study of patients with
episodic headache (N = 1203)
• >90% seen in primary care
• Self-report or physician diagnosis of migraine
almost always correct
• Self-report or physician diagnosis of
nonmigraine almost always later found
out to be migraine
Tepper SJ, et al. Headache. 2004;44:856-864.
Migraine(n = 288) 76%
Unclassifiable(n = 11) 3%
Episodic tension-type (n = 11) 3%
Probable
migraine (n = 67) 18%
15
Symptoms in the last 3 months:
❑ Light sensitivity with headache
❑ Nausea with headache
❑ Decreased ability to function with headache
ID Migraine™: Simplified Diagnostic Criteria for Migraine
Lipton RB, et al. Neurology. 2003;12:375-382.
Any 2 of the 3 above symptoms = migraine
16
S Systemic involvement (fever, myalgias, weight loss)
Systemic disease (cancer, AIDS)
N Neurologic symptoms or signs
O Onset sudden (thunderclap headache)
O Onset after age 50 years
PPattern of change: progressive headache/fewer headache-free periods; change in
type of headache; headache associated with pregnancy; headache related to body
position
Red Flags: SNOOP
Dodick DW. Adv Stud Med. 2003;3:87-92; Dodick DW. N Engl J Med. 2006;354:158-165.
Be alert to signs/symptoms of secondary headache.
17
HIT-6
• Measures the impact headaches have
on job, school, home and social
situations
• Total score ≥50 suggests significant
impact
MIDAS
• Measures how migraines affect everyday
functioning
Headache Impact Test (HIT)-6 and
Migraine Disability Assessment (MIDAS) Test
Kosinski M, et al. Qual Life Res. 2003;12:963-974.
18
Case Study (cont’d)
• Clinical findings are consistent with migraine without aura
• Colleen is surprised because she thought migraines were always
associated with an aura
• Says that she is “just happy to know what is going on”
• Headaches have a significant impact on her daily activity
19
Importance of a Headache Diary
• Helps identify
– Triggers
– Location
– Warning signals
– Length
– Stress, exercise, other related events
DateTime
(start/finish)
Intensity
(rate 1-10: most severe being 10)
Preceding
SymptomsTriggers
Medication
(and dosage)
Relief (complete/
moderate/none)
‒ Records intensity of pain
‒ Monitors treatment progress
‒ Sometimes required for prior
authorization for certain
medication coverage by insurers
20
• Irregular meals, dehydration
• Irregular caffeine
• Chocolate, nuts, bananas, etc
• Irregular sleep (particularly
excessive sleep)
• Weather, changes in weather
Common Migraine Triggers
Hoffmann J, et al. Curr Pain Headache Rep. 2013;17:370.
• Light, sunlight exposure
• Sensitivity to odors (osmophobia)
• Stress or “let-down” from stress
• Air travel, change in barometric
pressure
• Menstrual period
21
Six 8-oz glasses
of water per day
Lifestyle Modification: Consistency Is Key
Robbins L. www.practicalpainmanagement.com/patient/conditions/headache/7-lifestyle-tips-help-prevent-migraines-headaches.
Accessed Apr 13, 2020.
Don’t skip
mealsCaffeine
<200 mg/d
Sleep Exercise
22
• Oral contraceptives
• Hormone replacement
• SSRIs
• Steroids (tapering)
• Decongestants
• Short-acting sedatives
Medications That May Exacerbate Migraines
SSRI = selective serotonin reuptake inhibitor.
Allais G, et al. Neurol Sci. 2009;30(suppl 1):S15-S17; MacGregor EA. Curr Pain Headache Rep. 2009;13:399-403; Nierenburg Hdel C, et al.
Headache. 2015;55:1052-1071.
23
Acute Treatment Principles
• Establish what the patient’s goals are
• Treat at least two attacks with the same medication
• If medication is ineffective:
⎻ Ensure that no other medications are interfering with response
⎻ Ensure patient is taking the drug at the correct time
⎻ Maximize dose
⎻ Change formulation/route of administration
⎻ Change drug
⎻ Add drug
⎻ Try combination therapy (eg, sumatriptan + naproxen)
Goal: quickly
restore patient to normal
function in a safe and
effective manner that
minimizes additional
medication exposure and
resource use
24
Case Study (cont’d): Colleen’s Regimen for Acute Attacks
• Colleen begins lifestyle modifications of drinking more water, reducing
caffeine to <200 mg/day, and getting more sleep and exercise
• You counsel her on keeping a headache diary
• You prescribe sumatriptan, 100 mg as needed, with instructions to take at
onset of headache and repeat once in 24 hours if needed
‒ After 6 weeks on sumatriptan, Colleen’s headaches have not improved
• You discontinue sumatriptan, and prescribe rizatriptan oral disintegrating
tablet, 10 mg as needed, with instructions to take at onset of headache and
repeat once in 24 hours as needed
‒ After 6 weeks on rizatriptan, Colleen’s headaches have not improved
25
Triptans Ergots Nonspecific treatments Gepants
Serotonin 5-HT1F
Receptor Agonist
Almotriptan
Eletriptan
Frovatriptan
Naratriptan
Rizatriptan
Sumatriptan
Sumatriptan + naproxen
Zolmitriptan
Dihydroergotamine
Ergotamine + caffeine
Antiemetics
Aspirin +/‒ acetaminophen +/‒ caffeine
Diclofenac, ketorolac, other NSAIDs
Corticosteroids (IV; rescue therapy)
Rimegepant
Ubrogepant
Lasmiditan
Treatment of Acute Migraine: Medications
Med Lett Drugs Ther. 2017;59:27-32.
• A variety of routes of administration (oral, nasal spray, suppository, etc) and combinations are available
• Products containing butalbital are sometimes used despite evidence that butalbital is not effective for
migraine pain and can cause rebound headache
• Reserve opiates only for limited use in very severe migraine
26
Lasmiditan Rimegepant Ubrogepant
Mechanism
of Action
Serotonin 5-HT1F receptor agonist CGRP receptor
antagonist
CGRP receptor antagonist
Indication Acute treatment of migraine with or without aura in adults
Dosing 50 mg, 100 mg, or 200 mg orally,
as needed (not to exceed 1 dose
in 24 hrs)
75 mg orally or
sublingual, as needed
(not to exceed 1 dose
in 24 hrs)
50 mg or 100 mg orally, as
needed; may take 2nd dose
≥2 hours later; not to exceed
200 mg in 24 hrs
Adverse
Events
Dizziness, fatigue, paresthesia,
sedation, driving or machinery
impairment for 8 hrs after
taking
Nausea Nausea and somnolence
Lasmiditan, Rimegepant, and Ubrogepant:
New Options for Acute Migraine Treatment
Lasmiditan [prescribing information]. Eli Lilly and Company; 2019; Rimegepant [prescribing information]. Biohaven Pharmaceuticals, Inc; 2020;
Ubrogepant [prescribing information]. Allergan; 2019..
27
Case Study (cont’d)
• Colleen appears to be following lifestyle modifications
• You prescribe lasmiditan, 100 mg as needed
• Colleen reports success “sometimes,” but headaches worsening and still
missing work
• Review of headache diary:
‒ Headaches are more frequent than Colleen initially described, occurring
at least twice a week
‒ Headaches still cause impairment and often require bedrest
28
When Should Preventive Treatment for Episodic
Migraine Be Considered/Offered?
Lipton RB, et al. Headache. 2015;55(suppl 2):103-122; Lipton RB, et al. Neurology. 2007;68:343-349; Silberstein SD, et al. Neurology.
2012;78:1337-1345.
• When patients have severe or frequent migraines: 3 or more days per month
• After failure or overuse of acute therapies
• When patients want to pursue another option
• Epidemiologic studies suggest that:
‒ ~38% of migraineurs would benefit from preventive therapy, but…
‒ Only 11% currently receive them
29
Episodic vs Chronic Migraine: Definitions
Lipton RB, et al. Headache. 2015;55(suppl 2):103-122.
Episodic migraine:
• Headache <15 days/month
Chronic migraine:
• Headache ≥15 days/month
for >3 months
• Features of migraine headache
present for ≥8 days/month
30
Principles of Preventive Pharmacotherapy
• Establish what the patient’s goals are
• Give each treatment an adequate trial
• Continue for at least several months
• Avoid interfering, overused, and contraindicated drugs
• Re-evaluate therapy
• Women of childbearing potential should understand risks
• Involve patients in their care to maximize adherence
• Consider comorbidities and choose medications to treat coexisting disorders when
possible
• Choose drugs based on efficacy, patient preferences, headache profile, adverse effects
D’Amico D, et al. Neuropsychiatr Dis Treat. 2008;4:1155-1167.
Goal: reduce
frequency, duration,
and severity of
individual events and
possibly reduce disease
progression
31
Considerations
• Check for teratogenicity
• Topiramate for patients
with obesity?
• β-blocker for hypertensive
nonsmokers ≤60 years of
age?
• Triptan for MRM?
• Amitriptyline for patients
with insomnia, mood
disorder, or depression?
• Anti-CGRP monoclonal
antibodies now also an
option
AAN/AHS Classification of Preventive Therapies for Episodic Migraine
Yellow = FDA approved for migraine prophylaxis.
*For short-term prophylaxis of MRM.
AAN/AHS = American Academy of Neurology/American Headache Society; ACE = angiotensin-converting enzyme; MRM = menstrual-related migraine;
SSNRI = selective serotonin norepinephrine reuptake inhibitor; TCA = tricyclic antidepressant.
Silberstein SD, et al. Neurology. 2012;78:1337-1345.
Level A: Medications With
Established Efficacy
(≥2 class I studies)
Level B: Medications That Are
Probably Effective
(1 class I or 2 class II studies)
Level C: Medications That Are
Possibly Effective
(1 class II study)
Antiepileptic drugs
Divalproex sodium
Valproate sodium
Topiramate
Antidepressants/SSRI/SSNRI/TCA
Amitriptyline
Venlafaxine
ACE inhibitors
Lisinopril
Angiotensin receptor blockers
Candesartan
-Blockers
Atenolol
Nadolol
-Agonists
Clonidine
Guanfacine-Blockers
Metoprololl
Propranolol
TimololTriptans (MRM)
Naratriptan*
Zolmitriptan*Antiepileptic drugs
CarbamazepineTriptans (MRM)
Frovatriptan*-Blockers
Nebivolol, pindolol
Antihistamines
Cyproheptadine
32
• Anti-CGRP monoclonal antibodies*
‒ Eptinezumab
‒ Erenumab
‒ Fremanezumab
‒ Galcanezumab
• OnabotulinumtoxinA
FDA-Approved Preventive Therapies for Chronic Migraine
*Also FDA approved for prevention of episodic migraine.
Med Lett Drugs Ther. 2017;59:27-32.
33
Behavioral Interventions
• Relaxation training
• Biofeedback combined with
relaxation training
• Electromyography
biofeedback
• Cognitive behavioral therapy
• Combination treatment
Other Interventions for Prevention
Silberstein SD et al. Neurology Sep 2000, 55 (6) 754-762; American Migraine Foundation. americanmigrainefoundation.org/understanding-
migraine/spotlight-neuromodulation-devices-headache/. Accessed Apr 13, 2020; Gaul et al. J Headache Pain. 2015;16:516.
Neuromodulation
• Single pulse transcranial
magnetic stimulation
(sTMS)
• Noninvasive vagal nerve
stimulation (nVNS)
• External trigeminal nerve
stimulation (eTNS)
Other
• Acupuncture
• Physical therapy with
massage and exercise
• Nutritional supplements
– Magnesium, riboflavin,
CoQ10
34
Collaborative Care of Migraine
• Migraine is a chronic disease and requires patients and clinicians to work
together toward common therapeutic goals
• Help patients understand and address all migraine-related health issues
and comorbidities
• Integrate assessment tools and relevant patient education into
management
• Recognize “stages” in the evolution of migraine so as to personalize care
on the basis of disease progression
35
Case Study (cont’d)
• Colleen is prescribed topiramate 25 mg once a day, then over
1 month gradually increased to 50 mg twice a day
• She continues to follow lifestyle modifications
• Review of headache diary after 1 month:
‒ Headaches continue to occur at least twice a week
‒ Headaches still cause impairment and often require bedrest
• Switched from amlodipine to propranolol 40 mg twice a day, gradually
increased to 60 mg twice a day
• Cognitive behavioral therapy prescribed
36
• Landmark 1990 study showed that
CGRP—a potent vasoactive
peptide—is released during
migraine headache
• In 1993-1994, sumatriptan was
shown to inhibit CGRP release at
the same time that it aborts a
headache attack
• Led to development of drugs
specifically designed to block the
actions of CGRP
CGRP-Targeted Therapies Were Specifically Designed for the
Trigeminal Pain System and Headache
Control refers to headache-free period, while attack refers to headache period.
Edvinsson L, et al. Nat Rev Neurol. 2018;14:338-350; Goadsby PJ, et al. Ann Neurol. 1990;28:183-187; Goadsby PJ, et al. Ann Neurol. 1993;33:48-56.
0
20
40
60
80
100
With Aura Without Aura With Sumatriptan
CGRP Release During Migraine Inhibited by Sumatriptan
Control Attack
Co
nce
ntr
ation
of C
GR
P (
pm
ol/L
)
37
Newer Therapies for Headache Disorders: Different Targets of Action
Onabot-A = onabotulinumtoxinA.
Edvinsson L, et al. Nat Rev Neurol. 2018;14:338-350.
38
Drug Indication(s) Dosing Examples of Common Adverse Events
Eptinezumab EM, CM IV, quarterly URI, nasopharyngitis, fatigue, diarrhea,
oropharyngeal pain
Erenumab EM, CM SC, monthly Injection site reactions, constipation
Fremanezumab* EM, CM SC, monthly
or quarterly
Injection site reactions
Galcanezumab* EM, CM SC, monthly Injection site reactions
Newer FDA-Approved Therapies for Headache Disorders:
Monoclonal Antibodies
*Has also been studied for cluster headache.
CM = chronic migraine; EM = episodic migraine; SC = subcutaneous; URI = upper respiratory infection; UTI = urinary tract infection.
ClinicalTrials.gov. clinicaltrials.gov/ct2/show/NCT03855137. Accessed Apr 13, 2020; ClinicalTrials.gov. clinicaltrials.gov/ct2/show/NCT02605174.
Accessed Apr 13, 2020; ClinicalTrials.gov. clinicaltrials.gov/ct2/show/NCT03732638. Accessed Apr 13, 2020; Edvinsson L, et al. Nat Rev Neurol.
2018;14:338-350.
39
Drug Indication(s) Dosing Examples of Common Adverse Events Status
Serotonin 5-HT1F Receptor Agonist
Lasmiditan Migraine relief Oral, PRN Dizziness, paresthesia, somnolence FDA approved
CGRP Receptor Antagonists
Atogepant EM, CMOral, once or
twice dailyNausea, fatigue, constipation, nasopharyngitis, UTI Phase 3
RimegepantMigraine
relief, EM, CMOral, PRN Nausea, dizziness, UTI
FDA approved
for relief
Phase 3 EM,
CM
Ubrogepant Migraine relief Oral, PRN Nausea, dizziness FDA approved
Newer Therapies for Headache Disorders:
Other Agents Approved and in Development
ClinicalTrials.gov. clinicaltrials.gov/ct2/show/NCT03855137. Accessed Apr 13, 2020; ClinicalTrials.gov. clinicaltrials.gov/ct2/show/NCT02605174.
Accessed Apr 13, 2020; ClinicalTrials.gov. clinicaltrials.gov/ct2/show/NCT03732638. Accessed Apr 13, 2020; Edvinsson L, et al. Nat Rev Neurol.
2018;14:338-350.
40
CGRP/CGRP-R mAbs: Phase 3 Trials
-4.3
-8.2
-3.7
-6.6
-3.7
-4.6 -4.7 -4.8
-3.2
-5.6
-1.8
-4.2
-2.2-2.5
-2.8 -2.7
-9
-8
-7
-6
-5
-4
-3
-2
-1
0Eptinezumab: EM Eptinezumab: CM Erenumab: EM Erenumab: CM Fremanezumab: EM Fremanezumab: CM Galcanezumab: EM Galcanezumab: CM
Most effective dose Placebo
Holland C et al, Neurology. 2018;91:e2211-e2221; Stauffer VL. JAMA Neurol. 2018;75:1080-1088; Dodick DW et al, JAMA 2018;319:5-14;
VanderPluym J et al. Neurology. 2018;91:e1152-e1165; Goadsby PJ et al, N Engl J Med. 2017;377:2123-2132; Lipton et al. Neurology. 2019;92:
e2250-e2260; Ashina M et al. Cephalalgia. 2020;40: 241-254; Silberstein SD, et al. N Engl J Med. 2017;377:2113-2122; Stauffer VL et al, JAMA
Neurol. 2018;75:1080-1088; Sklijarveski V et al, Cephalagia 2018;38:1442-1454.
Re
du
ctio
n in
Mo
nth
ly M
igra
ine
He
ad
ach
e D
ays
All statistically significant
41
Case Conclusion
• Colleen is prescribed fremanezumab, a CGRP-targeted monoclonal
antibody for prevention of her episodic migraine because she prefers
quarterly SC injection regimen
• At 6 months, she reports that her headaches occur no more than once or
twice a month; when they do occur, she uses lasmiditan
• She hasn’t missed a day of work in several months
• You recommend that she continue keeping her headache diary and taking
preventive therapy
42
PCE Action Plan
✓ Consider migraine as the default diagnosis for recurring and disruptive headache
✓ Emphasize the importance of keeping a headache diary to identify triggers and the nature of
headache and to assess treatment progress
✓ Provide patient education and encourage use of nonpharmacologic interventions for
treatment/prevention
✓ Treat at least 2 acute migraines with same medication; consider alternatives if medication
remains ineffective
✓ When starting preventive pharmacotherapy, consider comorbidities and respect patient
preferences
✓ Participate in a collaborative care model of migraine treatment to improve communication and
involve patients in decision-making
PCE Promotes Practice Change
2020 Symposia Series 1