The American Headache Society Position Statement on Integrating New Migraine Treatments Into Clinical Practice

American Headache Society



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Patients with migraine featuring severe, disabling, or frequent attacks, as well as those who cannot tolerate or are nonresponsive to acute treatment, are candidates for preventive treatment. The decision to initiate preventive treatment should be based on the frequency of individual attacks, average number of days with migraine or moderate or severe headache, and degree of disability. The choice of treatment should be based on evidence of efficacy, provider experience, tolerability, patient preference, headache subtype, comorbid and coexistent disease, concomitant medications, and the potential for childbearing. The principles of preventive treatment with oral treatments include initiating treatment with evidence-based treatments at a low dose, titrating until clinical benefits are achieved, giving each treatment a trial of 2 to 3 months, avoiding overuse of acute treatments. Measuring the overall efficacy and tolerability of preventive treatment is a patient-driven decision made in partnership and after consultation with their healthcare provider. Validated patient-centric outcome measures that evaluate the effect of treatment on functional capacity, disability, and quality of life are important for guiding clinical treatment decisions to continue, add, combine, or switch preventive treatments.

Many evidence-based acute treatments are available, including triptans, ergotamine derivatives, NSAIDs (including aspirin), nonopioid analgesics, and analgesic combinations. As with preventive pharmacologic treatment, to individualize the choice of medication(s), evidence of efficacy, potential medication side effects, patient-specific contraindications, and drug interactions should be considered. Noninvasive vagus nerve stimulation is approved for the acute treatment of migraine pain, and single-pulse transcranial magnetic stimulation, supraorbital nerve stimulation are nonpharmacologic options that may be effective for the acute and preventive treatment of migraine, especially in those for whom pharmacologic treatment is contraindicated, poorly tolerated, ineffective, or not preferred. Empirically validated behavioral treatments with Grade A evidence for the prevention of migraine, including CBT, biofeedback, and relaxation therapies, should be considered in the management of migraine. These modalities may also be used alone or in addition to pharmacologic treatment, particularly in those with a partial therapeutic response and are excellent options for pregnant/lactating women as well as people with contraindications to certain treatments. In addition, all people with migraine will benefit from education and migraine-related lifestyle guidance.

It is the intent of the American Headache Society that this position statement will be reviewed annually and updated, if appropriate, based on the emergence of new evidence.