Medical Management of Migraines: Comparing Novel & Established Treatments

Issue

Only 4.5% of patients in the United States with chronic migraine are receiving the appropriate standard of care. 

Outcomes

As a result of participating in this activity, learners will be better able to:

• Evaluate migraines
• Differentiate Migraine vs Sinus vs Cluster Headache
• Discuss pathophysiology therapeutic options with patients
• Establish care for each patient's unique needs

Session Outline

1. Review migraine diagnosis
2. Migraine pathophysiology
3. Understand available treatment options: Mechanisms, Contraindications, Pharmacology
   1. NSAIDS
   2. ERGOTAMINES
   3. TRIPTANS
   4. GEPANTS
   5. DITANS
   6. ANTIHYPERTENSIVES
   7. ANTICONVULSANTS
   8. ANTIDEPRESSANTS
   9. ONABOTULINUMTOXIN-A
4. Acute treatment follow-up
5. Differentiating treatments for episodic vs. chronic migraine
   1. Acute therapy vs. prophylactic therapy

Desirable Physician Attributes

• Patient Care [ACGME/ABMS] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
• Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
• Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • Describes the complex, multidimensional, and individual-specific nature of pain
  • Demonstrates knowledge of the theories and science for understanding the physiology of pain and pain transmission
  • Demonstrates knowledge of the terminology for describing pain, including acute pain, chronic pain, and pain at the end of life

• 2. Pain assessment and measurement: How is pain recognized?
  • Describes patient, clinician, and system factors that can facilitate or interfere with effective pain assessment and management
  • Uses valid and reliable tools for measuring pain, function, and associated symptoms to assess and reassess related outcomes appropriate to the clinical context and population
  • Evaluates a patient’s pain using culturally appropriate, evidence-based methodologies considering age and gender

• 3. Treatment: How is pain safely and effectively treated?
  • Demonstrates knowledge of risk stratification, patient selection, and ongoing monitoring for pharmacological pain treatment
  • Identifies appropriate multimodal pain treatment options as part of a comprehensive pain management plan
  • Identifies and describes potential pharmacological and nonpharmacological treatment options
  • Develops a pain treatment plan based on benefits and risks of available treatments
  • Monitors the effects of pain management approaches to adjust the plan of care as needed with respect to functional outcomes

Accreditation & Designation

Release date: This activity was released 8/19/2022.

Termination date: The content of this activity remains eligible for CME Credit until 8/18/2025, unless reviewed or amended prior to this date.

Claiming Credit: Watch the entire presentation and complete the Improvement Plan/Evaluation

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

California Required CME on Pain Management and the Appropriate Treatment of the Terminally Ill
AB487 requires physicians licensed in California to complete a one-time CME activity for 12 hours of credits that addresses both pain management and the appropriate care and treatment of the terminally ill. This activity contributes to achievement of requirements with AB487.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Presenter] Alexander Feoktistov discloses the following financial relationships within the past 24 months: Speaking: AbbVie, Amgen, Lundbeck, Biohaven, Eli Lilly, Impel, Teva (ended); Consulting: Amgen, Lundbeck, Eli Lilly

No other person with control of, or responsibility for, the planning, delivery, or evaluation of accredited continuing education has, or has had within the past 24 months, financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships have been mitigated. Materials were reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. In some cases, content may have been modified as part of the review and mitigation process. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

• Stovner, L. J., Nichols, E., Steiner, T. J., Abd-Allah, F., Abdelalim, A., Al-Raddadi, R. M., ... & Murray, C. J. (2018). Global, regional, and national burden of migraine and tension-type headache, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 17(11), 954-976.
• Lipton, R. B., Bigal, M. E., Diamond, M., Freitag, F., Reed, M. L., & Stewart, W. F. (2007). Migraine prevalence, disease burden, and the need for preventive therapy. Neurology, 68(5), 343-349.
• Blumenfeld, A. M., Varon, S. F., Wilcox, T. K., Buse, D. C., Kawata, A. K., Manack, A., ... & Lipton, R. B. (2011). Disability, HRQoL and resource use among chronic and episodic migraineurs: results from the International Burden of Migraine Study (IBMS). Cephalalgia, 31(3), 301-315.
• Arnold, M. (2018). Headache classification committee of the international headache society (IHS) the international classification of headache disorders. Cephalalgia, 38(1), 1-211.
• Serrano, D., Lipton, R. B., Scher, A. I., Reed, M. L., Stewart, W. B. F., Adams, A. M., & Buse, D. C. (2017). Fluctuations in episodic and chronic migraine status over the course of 1 year: implications for diagnosis, treatment and clinical trial design. The journal of headache and pain, 18(1), 1-12.
• Dodick, D. W., Loder, E. W., Manack Adams, A., Buse, D. C., Fanning, K. M., Reed, M. L., & Lipton, R. B. (2016). Assessing barriers to chronic migraine consultation, diagnosis, and treatment: results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study. Headache: The Journal of Head and Face Pain, 56(5), 821-834.
• Martin, V. T., Feoktistov, A., & Solomon, G. D. (2021). A rational approach to migraine diagnosis and management in primary care. Annals of Medicine, 53(1), 1969-1980.
• Dodick, D. W. (2021). Diagnosing secondary and primary headache disorders. CONTINUUM: Lifelong Learning in Neurology, 27(3), 572-585.
• Blumenfeld, A., Durham, P. L., Feoktistov, A., Hay, D. L., Russo, A. F., & Turner, I. (2021). Hypervigilance, allostatic load, and migraine prevention: antibodies to CGRP or receptor. Neurology and therapy, 10(2), 469-497.
• Goadsby, P. J., Edvinsson, L., & Ekman, R. (1990). Vasoactive peptide release in the extracerebral circulation of humans during migraine headache. Annals of Neurology: Official Journal of the American Neurological Association and the Child Neurology Society, 28(2), 183-187.
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• Lipton, R. B., Fanning, K. M., Serrano, D., Reed, M. L., Cady, R., & Buse, D. C. (2015). Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine. Neurology, 84(7), 688-695.
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• American Headache Society. (2019). The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache: The Journal of Head and Face Pain, 59(1), 1-18.
• McCulloch, J., Uddman, R., Kingman, T. A., & Edvinsson, L. (1986). Calcitonin gene-related peptide: functional role in cerebrovascular regulation. Proceedings of the National Academy of Sciences, 83(15), 5731-5735.
• Wimalawansa, S. J., & El-Kholy, A. A. (1993). Comparative study of distribution and biochemical characterization of brain calcitonin gene-related peptide receptors in five different species. Neuroscience, 54(2), 513-519.
• Khalil, Z., & Helme, R. (1996). Sensory peptides as neuromodulators of wound healing in aged rats. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 51(5), B354-B361.
• Chaitman, B. R., Ho, A. P., Behm, M. O., Rowe, J. F., Palcza, J. S., Laethem, T., ... & Blanchard, R. L. (2012). A randomized, placebo‐controlled study of the effects of telcagepant on exercise time in patients with stable angina. Clinical Pharmacology & Therapeutics, 91(3), 459-466.
• Zhou, H., & Mascelli, M. A. (2011). Mechanisms of monoclonal antibody–drug interactions. Annual review of pharmacology and toxicology, 51, 359-372.
• Ashina, M., Goadsby, P. J., Reuter, U., Silberstein, S., Dodick, D. W., Xue, F., ... & Mikol, D. D. (2021). Long‐term efficacy and safety of erenumab in migraine prevention: results from a 5‐year, open‐label treatment phase of a randomized clinical trial. European journal of neurology, 28(5), 1716-1725.
• Kudrow, D., Pascual, J., Winner, P. K., Dodick, D. W., Tepper, S. J., Reuter, U., ... & Mikol, D. D. (2020). Vascular safety of erenumab for migraine prevention. Neurology, 94(5), e497-e510.
• Goadsby, P. J., Silberstein, S. D., Yeung, P. P., Cohen, J. M., Ning, X., Yang, R., & Dodick, D. W. (2020). Long-term safety, tolerability, and efficacy of fremanezumab in migraine: a randomized study. Neurology, 95(18), e2487-e2499.
• Oakes, T. M., Kovacs, R., Rosen, N., Doty, E., Kemmer, P., Aurora, S. K., & Camporeale, A. (2020). Evaluation of cardiovascular outcomes in adult patients with episodic or chronic migraine treated with galcanezumab: data from three phase 3, randomized, double‐blind, placebo‐controlled EVOLVE‐1, EVOLVE‐2, and REGAIN studies. Headache: The Journal of Head and Face Pain, 60(1), 110-123.
• Ashina, M., Saper, J., Cady, R., Schaeffler, B. A., Biondi, D. M., Hirman, J., ... & Smith, J. (2020). Eptinezumab in episodic migraine: a randomized, double-blind, placebo-controlled study (PROMISE-1). Cephalalgia, 40(3), 241-254.
• Smith, T. R., Spierings, E. L., Cady, R., Hirman, J., Schaeffler, B., Shen, V., ... & Mehta, L. (2021). Safety and tolerability of eptinezumab in patients with migraine: a pooled analysis of 5 clinical trials. The journal of headache and pain, 22(1), 1-11.
• Reuter, U., Ehrlich, M., Gendolla, A., Heinze, A., Klatt, J., Wen, S., ... & Maier-Peuschel, M. (2022). Erenumab versus topiramate for the prevention of migraine–a randomised, double-blind, active-controlled phase 4 trial. Cephalalgia, 42(2), 108-118.