Preventive Migraine Treatment

Rebecca Burch, MD, FAHS Headache p. 613-632 June 2021, Vol.27, No.3 doi: 10.1212/CON.0000000000000957
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PURPOSE OF REVIEW This article provides an overview of preventive interventions for migraine, including when to start and how to choose a treatment, pharmacologic options (both older oral treatments and new monoclonal antibodies to calcitonin gene-related peptide [CGRP] or its receptor), nonpharmacologic treatment such as neuromodulation, and preventive treatment of refractory migraine.

RECENT FINDINGS The migraine preventive treatment landscape has been transformed by the development of monoclonal antibodies targeting CGRP or its receptor. These treatments, which are given subcutaneously or intravenously monthly or quarterly, have high efficacy and were well tolerated in clinical trials. Emerging real-world studies have found higher rates of adverse events than were seen in clinical trials. They are currently recommended for use if two traditional preventive therapies have proven inadequate. Since the commonly cited 2012 American Headache Society/American Academy of Neurology migraine prevention guidelines were released, clinical trials supporting the preventive use of lisinopril, candesartan, and memantine have been published. Neuromodulation devices, including external trigeminal nerve stimulation and single-pulse transcranial magnetic stimulation devices, have modest evidence to support preventive use. The American Headache Society/American Academy of Neurology guidelines for the preventive treatment of migraine are currently being updated. A new class of oral CGRP receptor antagonists (gepants) is being tested for migraine prevention.

SUMMARY Successful preventive treatment of migraine reduces disease burden and improves quality of life. Many pharmacologic and nonpharmacologic treatment options are available for the prevention of migraine, including newer therapies aimed at the CGRP pathway as well as older treatments with good evidence for efficacy. Multiple treatment trials may be required to find the best preventive for an individual patient.

Address correspondence to Dr Rebecca Burch, 1153 Centre St, Ste 4H, Jamaica Plain, MA 02130, [email protected].

RELATIONSHIP DISCLOSURE: Dr Burch serves on the board of directors of the American Headache Society and the Headache Cooperative of New England, and as an associate editor for Neurology.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Burch discusses the unlabeled/investigational use of amitriptyline and other tricyclic antidepressants, candesartan, cyproheptadine, gabapentin, lisinopril, memantine, metoprolol, venlafaxine and other serotonin norepinephrine reuptake inhibitors, and herbs and nutritional supplements for the preventive treatment of migraine.

© 2021 American Academy of Neurology.