Welcome to the WCN 2023 Interactive Program
PREVENTIVE TREATMENT OF MIGRAINE MADE EASIER
Abstract
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Migraine is a neurological disease characterized by recurrent attacks of intense headache associated to a multitude of neurological and systemic symptoms. These altogether contribute to the great disability associated to the disease, which can be further worsened by the comorbidity with depression, epilepsy, stroke and myocardial infarction. Trigeminal sensory activation is considered the neurobiological mechanism underlying cephalic pain, as a consequence of dysfuntional areas in the central nervous systemc. Vasodilation is only a secondary phenomenon and vasoconstriction is not essential for antimigraine efficacy. Traditionally, the management of migraine is subdivided into acute and preventive treatment of attacks, although recent developments have led to the availability of migraine-specific drugs that are active in both approaches. The acute treatment is aimed at aborting ongoing attacks, ideally within 2 hours from the onset, and is based on analgesics or NSAIDs for mild attacks, triptans for more intense attacks or for patients who do not benefit from or bear controindications to analgesics or FANS. Because of cardiovascular safety concerns, unreliable efficacy and tolerability issues, use of ergots to abort attacks has nearly vanished in most countries. Opioids are not considered effective in the abortive treatment of migraine and bear the risk of inducing dependence. CGRP receptor antagonists (gepants) and lasmiditan, a selective 5HT1F receptor agonist, have emerged as effective acute treatments. Preventive treatment should be considered in patients with at least two migraine days per month that do not benefit from acute treatment and are highly disabled during the attacks. Several non specific oral preventive drugs have shown an efficacy superior to placebo, although their poor tolerability profile makes them unfit for long-lasting courses of treatment. Intramuscular onabotulinumtoxinA is an option for chronic migraine (migraine on ≥15 days per month) and monoclonal antibodies targeting CGRP or its receptor, as well as gepants, have proven effective and well tolerated for the preventive treatment of migraine with at least 4 monthly migraine days. Real world studies show that these drugs are effective in a large percentage of patients, with a very low discontinuation rate. For these reasons, onabotulinumtoxinA in chronic migraine, and monoclonal antibodies targeting CGRP and gepants (atogepant, rimegepant) in patients with at least 4 migraine days/month might represent the first-choice treatment for migraine prevention. However, their relatively high cost has inspired restrictive regulations in several high-income countries and very limited circulation in medium-to-low income countries. The benchmark for efficacy of preventive drugs for migraine is conventionally set to the "at-least-50% reduction" in monthly migraine days, which can be attained in 40-60% of patients treated with approved drug options. For poor responders of to achieve higher response rates, preventive drugs may be used in combination and, where available and approved, some neuromodulation modalities can also be added in.
MIGRAINE IN THE EMERGENCY DEPARTMENT
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Migraine is a common cause of emergency department (ED) visits, particularly among young women. Although most ED patients with headaches suffer from migraine, it's crucial for ED specialists to identify patients with acute headaches caused by secondary etiologies, which can be fatal and require urgent intervention. Rapid resolution of migraine pain is the primary goal of ED treatment. Antidopaminergic agents such as prochlorperazine and metoclopramide are effective for migraine pain and accompanying symptoms, and NSAIDs are also proven to be effective. Corticosteroids and greater occipital nerve block may be beneficial for some patients, and novel treatment options such as gepants and lasmiditan may have some effects on acute abortive treatment. Overall, the effective management of migraines in the ED can help optimize outpatient care and avoid unnecessary hospitalizations and medical costs. In general, migraine patients presenting to the ED are underdiagnosed and undertreated, making their management more challenging than general migraine patients seen in outpatient clinics.
LOW-COST EFFECTIVE APPROACHES
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Patients living with migraine and headache disorders should access care worldwide, but some treatments are not accessible in many countries. This lecture will review affordable treatment options for headache management including trigger prevention, lifestyle adaptations, natural supplements, first line oral medications, and nerve blocks.