Transcript Related Guidelines

Preventive Treatment for Chronic Migraine in Adults

Peter Goadsby, MD, PhD · University of California at San Francisco  


January 07, 2022

Editor’s Note: Data from the phase 4 HER-MES trial, the first head-to-head trial of its kind,  have been shared and show that erenumab, a calcitonin-gene related peptide receptor (CGRP) inhibitor, is more effective and tolerable compared to the anticonvulsant agent topiramate when used to treat patients with migraine.[1]

This transcript has been edited for clarity.

Patients with chronic migraine who have 15 days or more of headache due to migraine a month clearly need prevention; all of them need prevention.[2] We do the same sort of thing—give them lifestyle advice: regular sleep, regular meals, and regular exercise.[3,4] I think we emphasize a little bit more on the control or the judicious use of acute treatments and problems with medication overuse.[5] We’re particularly concerned about opioid use, frequent triptan use getting over 10 days a month, because that can make things more difficult in a number of ways, plus the side effects.[6] So, that’s an important piece of that discussion. We work through this, basically the same sorts of medicines that we use for episodic migraine. Now, admittedly, many of them don’t have a formal license for an indication for chronic migraine. But then in the old days, the studies were all done in migraine as opposed to chronic or episodic migraine. So, you might say it’s a little bit woolly. I certainly use AMY (amylin) modulators.[7] I think there’s a role for beta blockers and tricyclics.[8] Certainly, the anticonvulsant, topiramate, there are actually two studies in chronic migraine for topiramate so that’s clear.[9] Calcium channel blockers can be useful if you have access to appropriate ones. In chronic migraine, onabotulinumtoxinA, has two randomized placebo-controlled trials and a meta-analysis.[10] It’s clearly useful at reducing frequency and severity, and there’s an indication in chronic migraine specifically. Certainly use it in angiotensin-based therapies, like candesartan, and I think that chronic migraine patients in the second study, and again it’s off license, but it’s well-tolerated and useful to have more tools. It’s certainly true. Melatonin can be used; data are not nearly as clear. The nutraceuticals, one can talk about them, but I seldom find them terribly useful as the frequency goes up. 

A really important development has been the CGRP (calcitonin gene-related peptide) monoclonals, the calcitonin gene-related peptide monoclonal pathway. Monoclonal antibodies, erenumab, fremanezumab, and galcanezumab, all have an indication and all have efficacy data against placebo in chronic migraine, and they are very well-tolerated; so it has been quite a boon to patients with difficult migraine problems.[11] Neuromodulation approaches, again, can be useful, both single pulse transcranial magnetic stimulation and external trigeminal stimulations, as preventives.[12] Nerve blocks are widely used, although again the evidence bases are poor. The experiential base is broad, but the controlled trial evidence base for things like occipital nerve blocks or other blocks is widely accepted, if not firmly used. To bridge from chronic migraine, you might say to make a change, a big change, I think many of us would in hospital practice or where we have access to inpatients, would still revert to using from time to time, intravenous dihydroergotamine in the five-day infusion rate which is not indicated as it is, but there’s a very long history of doing this in chronic migraine. Chronic migraine is highly disabling, and there’s no apology having the list of things to do, because patients with this problem have a challenge in their life, and it’s a challenge to physicians to make sure we’re as equipped as we can be, to do the best that we can.[13]


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