Optimizing Migraine Treatment

Описание: Dawn C. Buse, PhD
Psychologist & Clinical Professor of Neurology, Albert Einstein College of Medicine

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Dr. Buse: Sometimes when migraine is more severe, more frequent, you need to think about more optimized treatment. People get referred to neurology, so he's already in neurology—it's a great first step. We may want to think about migraine-specific treatments. All of our migraine-specific treatments — be they acute, taken at the time of an attack, or preventive, taken in advance to try to avoid attacks altogether — all of them are by prescription. That means you need to have that diagnosis and see a healthcare professional for the prescription. So, for this young man, we're going to want to think about optimizing his acute treatment and his preventive treatment. We want to think about prevention in all the ways: For prevention, we have a range of
medications. We also have neuromodulation; we have behavioral therapies; we have lifestyle enhancements; and we have nutraceuticals — vitamins, herbs, and minerals — which have been shown to be beneficial.
Dr. Buse: So, for this patient, he had tried a preventive it before, didn't like the side effects, couldn't tolerate them — it wasn't working for him. So we're going to revisit that, see if there's a different preventive approach. It may be a different type of medication. For some people, the traditional oral preventives were very hard to tolerate because of the side effects, and he may
need to move on to a CGRP-blocker preventive medication, which is calcitonin gene-related peptide. It's a specific peptide involved in migraine, and both the monoclonal antibodies and the gepants block CGRP. So we might think about a specific, like a CGRP blocker. His doctor may think about a toxin, onabotulinumtoxinA, which is given for people with chronic migraine
preventatively. Listeners probably already know this, but it's given once every 12 weeks preventatively in a series of injections around the head, and that's a preventive option. We may also, after we try those or before we try those, think about some of our nonmedication approaches. Neuromodulation — we have a series of neuromodulation devices which target different nerves that are involved in migraine. They're external; you wear them or hold them for
some period of time; some work acutely, some work preventatively, and some work in both.
Dr. Buse: We also — because he's feeling anxiety, he's feeling depression, he's feeling stigma — our behavioral therapies are going to give him a double bang for his buck. They will help reduce migraine-associated disability, as well as work on some of the depression/anxiety symptoms. And then later, as that improves, stigma tends to improve, as well. So we're going to
think about maybe cognitive behavioral therapy, maybe one of the mindfulness therapies, maybe some relaxation therapies. So we're going to start to put all of this together. Now this of course doesn't happen in one visit. Migraine management is an art and a science and will often take
multiple visits. It could take months. It could take a year of following up with that healthcare professional every six weeks or two months or three months, seeing how the current regimen is working, tweaking it, and improving it to find something that really works well for each individual. Ultimately, we want the individual with migraine to be an equal team member with the healthcare professional. We want to see joint decisions that both the healthcare professional recommends and the person with migraine feels comfortable with. And then we keep following up, see how it's working, tweak and reassess, and make it better and better until we find that
optimized treatment regimen.

Key Questions
What are the first steps a provider might take to help someone with migraine?
How does migraine disease change during perimenopause?
What treatment strategies are available for managing migraine during perimenopause?
Do women delay pregnancy or choose not to have children because of migraine?
What are some safe migraine treatment options for someone trying to conceive?
Why is it important for a doctor to know if you have migraine with aura?
What nondrug treatment options can help manage migraine?

Treatments Mentioned
Beta-blockers
Biofeedback
Cognitive behavioral therapy (CBT)
CGRP monoclonal antibodies (mAbs)
CGRP small-molecule receptor antagonists (gepants)
Ditans (selective 5HT1F receptor agonists)
Exercise
Hormone therapy
Lifestyle changes
Mindfulness
Nerve blocks
Neuromodulation devices
Nutraceuticals
OnabotulinumtoxinA (Botox)
Physical therapy/Physiotherapy
Sleep management
Stress management
Topiramate (Topamax)
Trigger point injections
Triptans