Miller School Neurologist Co-Authors Guidelines for Treating Migraine
Summary
- Dr. Teshamae Monteith contributed to the Italian Society for the Study of Headache and the International Headache Society guidelines for the pharmacological treatment of migraine.
- The guidelines represent the most comprehensive, up-to-date guidance for migraine treatment based on clinical trials.
- Dr. Monteith was one of only a few Americans invited to contribute to the migraine guidelines.
The Italian Society for the Study of Headache (SISC) and the International Headache Society (IHS) released guidelines in April for the pharmacological treatment of migraine. The guidelines incorporate evidence-based recommendations from randomized controlled trials and expert-based opinions.
“These guidelines were the first collaborative effort of its kind between SISC and IHS, resulting in a high-level, global collaboration aimed at raising the standards of care,” said co-author Teshamae Monteith, M.D., professor of clinical neurology and chief of the Headache Division in the Department of Neurology at the University of Miami Miller School of Medicine. “These guidelines for migraine are data driven.”
Rigorous Review of Migraine Treatment
The guidelines represent the most comprehensive, up-to-date guidance for treatment based on clinical trials.
“This was a rigorous process,” said Dr. Monteith, one of a handful of Americans on the research team. “It took three years to get published. Our team alone, which evaluated triptans, reviewed over 100 papers.”
The project involved a systematic review of literature across multiple databases. The guidelines for acute and preventive treatment provide a foundation for migraine care while also underscoring gaps in research, such as a scarcity of head-to-head drug comparisons, said Dr. Monteith.
Migraine is among the most disabling conditions worldwide. It affects more than 40 million people in the U.S. and is ranked as the second leading cause of disability in people 50 and younger.
Before beginning the literature review, the research team developed population, intervention, comparators and outcomes (PICO) questions according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.
The population was patients with migraine, the intervention any drug used to treat or prevent the disease. Comparators included active drugs and placebo. For treating acute migraine attack, the outcomes included being pain free and pain relief rates two hours after intake. For prevention, the outcomes were persisting monthly headache/migraine days, changes in monthly headache/migraine days and the number of subjects reporting greater than a 50% reduction in monthly migraine days.
Established Treatments and Newer Migraine Therapies
For acute treatment, the research team looked at several classes of drugs, such as:
• Calcitonin gene-related peptide (CGRP) pathway inhibitors, known as the gepants and ditans
• Mainstay medications such as the triptans
• Non-specific drugs such as ibuprofen
Originally developed in the 1990s for the acute treatment of migraine, the recommendations for the triptans were strong and based on quality evidence. Similarly favorable recommendations were made for paracetamol, lasmiditan and all the available gepants indicated for acute attacks.
“The gepants tend to be better tolerated than the triptans but are more expensive,” said Dr. Monteith.
The evaluation of migraine preventive agents included a thorough review of older, non-specific migraine preventive drugs including anti-depressants, anti-hypertensive medications and anti-seizure drugs. The research team also looked at the gepant class and injectable, monoclonal antibodies to CGRP or its receptor, CGRP monoclonal antibodies.
For episodic migraine, recommendations were strongly in favor for atogepant, erenumab, fremanazumab, galcanezumab, topiramate and eptinezumab. For chronic migraine, the research team recommended onabotulinumtoxinA, all of the CGRP monoclonal antibodies and atogepant. Eptinezumab and rimegepant were strongly favored for studies that included episodic and chronic migraine.
Newer clinical trials and real-world studies show that significant reductions in migraine frequency and even complete freedom from migraine is achievable.
Improving Migraine Care and Education
The guidelines are being disseminated widely to assist patient advocacy groups, insurers, clinicians and researchers.
“For practicing physicians, it can be used as a tool to reduce disability and get patients on higher quality, evidence-based treatment faster,” said Dr. Monteith.
They will also help modernize medical school curricula where, according to Dr. Monteith, there is not a lot of time spent on headache disorders.
The guidelines are largely in alignment with the American Headache Society’s position statement on using CGRP therapy first, said Dr. Monteith. Some of the guidelines offered by the American College of Physicians, including rating CGRP targets as secondary, may have been driven by cost.
“I believe these guidelines will be valuable to the practicing physician and other health care providers treating migraine,” said Dr. Monteith. “It’s an honor to be part of the process of combing through the data to make things easier for colleagues, to support patients and to improve access to treatment.”
Tags: cluster headache, Department of Neurology, Dr. Teshamae Monteith, headache medicine, migraine, neurology