Preventive medications might be considered in patients with 4 or more migraine days per month.
Pharmacists can be a helpful resource in counseling patients with migraine. In part 1, Sara Crystal, MD, a neurologist and headache specialist and medical director of Cove discussed nonprescription measures that can help prevent migraine. In cases where nonprescription measures are not enough, preventive treatment with prescription medications may be necessary. Patients may have a lot of questions about these medications—especially when a new drug hits the market.
When choosing preventive treatment for her patients, Crystal explained, “The most important [goal] is to establish realistic expectations.” Crystal teachesher patients that complete elimination of headaches is unlikely. “The goal of preventive therapy is a 50% reduction in migraine/headache days per month, in addition to decreasing the severity and duration of attacks and overall disability,” she said. Crystal also cautions patients that it can take weeks to months to notice improvements from oral preventive drugs. “The migraine-specific anti-[calcitonin gene-related peptide]CGRP medications demonstrate faster onset, though,” she said.
Crystal considers turning to preventive medication in patients with 4 or more migraine days per month, or 2 or more migraine days if the headaches are disabling and don’t respond to acute treatments.
There are 3 classes of non-specific migraine preventives—medications developed for other conditions and found to be effective for migraine prevention: blood pressure medications, anti-seizure medications, and antidepressants.
“When choosing a preventive, we take into account the patient’s comorbidities and other medications, as well as side effects. A beta blocker may be a good choice for someone with hypertension and migraine, while a tricyclic antidepressant might be avoided in someone trying to lose weight,” Crystal explained.
Crystal’s rule of thumb in terms of dosing is to start low and go slow. She starts the patient on a low dose and titrates slowly to the dose that is effective for the patient with minimal side effects.
Both the American Headache Society and the American Academy of Neurology recommend drugs with the best evidence.1 Prescription drugs with the best evidence for migraine prevention include:
Parenteral CGRP inhibitors3
Parenteral CGRP inhibitors have established efficacy for migraine prevention. There are 4 parenteral CGRP inhibitors approved for use in the United States:
Oral CGRP inhibitors/gepants
Come back tomorrow for Part 3 of this series, a review of a preventive prescription therapy.