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logoFocus on the person A guide to supporting people with migraine
Treating the individual. Understanding appropriate treatment options and how to provide personalised care

The highly individualised experience of migraine lends itself to shared decision-making around treatment strategies.1,2

The goal: understanding how migraine affects a particular individual, then tailoring treatment to give them the most benefit.1-3

Some patients may prefer nonpharmacological intervention, from lifestyle modification and trigger reduction to neuromodulation and behavioural therapy.4,5

 Acute treatment

Used with the aims of:2,6

  • providing partial or complete pain relief
  • relieving symptoms
  • re-establishing normal functioning as soon as possible
  • preventing recurrence and use of rescue medication

Trial and error may be required to establish the optimum treatment.3

 Preventive treatment

Can be used in addition to acute therapy:3

  • for recurrent migraine (≥4 days per month) causing significant disability2
  • where acute treatment provides inadequate symptom control3 - this may increase risk of developing chronic migraine through reducing the threshold to trigger subsequent attack7 
  • where there is risk of medication overuse headache8*

*Medication overuse headache must be ruled out before preventive treatment is started.8

PUTTING THE PATIENT FIRST: CONSIDERATIONS FOR ACUTE TREATMENTUnmet needs in acute management of migraine

Of 3,930 patients with migraine who were using an oral acute prescription medication in a study in the US, 74.1% reported an inadequate treatment response. Inadequate response included: inadequate 2-hour pain freedom (reported by 48.1% of patients), recurrence within 24 hours of initial pain relief (38.0%), treatment-related nausea (15.2%), delay in taking medication due to concerns about side effects (21.2%), requiring emergency/ urgent care (13.1%).9

Insufficient efficacy can result in

  • patients discontinuing treatment10
  • increased intake of acute medication11
  • risk of ‘chronification’ of disease11
  • trying multiple treatments in order to find an effective one3
Patient-centric treatment
  • Ask open-ended questions to understand migraine-related impairment in your patient and identify your patient's treatment goals. What is most important to them day-to-day and long-term?12-15
  • Understand your patient's most bothersome symptom (MBS). Relief from MBS may be an important indicator of treatment effectiveness2,15
  • Consider treatment in the context of your patient's life. This may include family planning, lifestyle, life events, and current or potential triggers3
Self-medication with OTC treatments
  • In the US, 60% of patients with migraine treat their headache exclusively with over-the-counter (OTC) medication16
  • Self-management with OTC products is sufficient for some people with migraine, but in others it may result in poorly controlled symptoms16
  • With inefficacious treatment comes a risk of migraine developing into chronic migraine.7 Patients who fail to obtain acceptable relief with OTC treatment should consult a clinician16
  • Unmonitored treatment may induce a risk of medication-overuse headache (MOH). Patients should be advised on how frequently they should take their medication17
References: 7. Lipton R B et al. Neurology 2015;84:688-695; 16. Wenzel R G et al. Pharmacotherapy 2003;23:494-505; 17. Tfelt-Hansen P, Steiner T J. CNS Drugs 2007;21:877-883PUTTING THE PATIENT FIRST: CONSIDERATIONS FOR PREVENTIVE TREATMENT

Understanding the effect of migraine on a patient’s quality of life can help to develop an optimum treatment plan for that individual.12

Goals for preventative treatment may include:2

  • reducing frequency, severity and duration of migraine attacks
  • reducing associated disability and improving functions
  • improving responsiveness to acute treatment and/or reducing reliance on poorly tolerated or ineffective acute treatment
  • reducing headache-related distress and psychological symptoms
  • improving quality of life
Monitoring responses to preventative treatment

Trial length

In the absence of unacceptable side effects, an appropriate trial length would be:

  • 8 weeks for oral preventatives, once at a therapeutic/ maintenance dose2,3
  • 3-6 months for injectable preventatives, depending on injection frequency2

Treatment response

Determining efficacy/ tolerability of treatment is a patient-driven decision; outcome metrics may include:2

  • number of migraine headache days
  • severity of pain
  • severity of associated symptoms
  • level of disability and functional impairment over time
Patient acceptance and adherence

In the past, long-term adherence to standard oral preventative medicines has been low, mainly due to suboptimal efficacy and/or tolerability.2,18

Persistence and adherence to injectable preventive therapies appear to be higher.19-21

How can we increase adherence?2

  • Understanding patient preference
  • Identifying effective treatment for that patient
  • Setting realistic expectations
  • Enabling patients to make informed choices about their treatment and management of adverse events

Findings of one retrospective study (2015) into adherence to oral migraine preventative medication:18

8,688 patients with chronic migraine
14 oral migraine medications

Adherence at 6 months: 26%-29%
Adherence at 12 months: 17%-20%

STANDARD TREATMENTS FOR ACUTE
MIGRAINE22-24
  • Paracetamol, NSAIDs
  • 5-HT1B/1D (serotonin) receptor agonists, such as triptans (selective)
  • Anti-emetics such as prochlorperazine
  • Combination medicines (analgesic + anti-emetic)

Note: triptans are contraindicated in patients with cardiovascular disease.2,3

Mechanism of action of different drug classes 

Available over the counter: NSAIDs, sumatriptan, anti-emetics, combination medicines

NICE GUIDELINESNICE guidelines for acute treatment of migraine24image

NICE: National Institute for Health and Care Excellence

Reference: 24. NICE CG150. Accessed September 2022

© NICE 2012 Headaches in over 12s: diagnosis and management. Available from www.nice.org.uk/guidance/cg150. All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/ publication.

STANDARD TREATMENTS FOR PREVENTION OF MIGRAINE2,23
Non-migraine specific or non-specific/ non-targeted treatments include:
  • Antiepileptics (eg topiramate)
  • Beta-blockers (eg propranolol)
  • Tricyclic antidepressants (eg amitriptyline)
  • Botulinum toxin type A (licensed for prevention of chronic migraine)
More recent, migraine-specific, targeted treatments include:
  • Anti-CGRP monoclonal antibodies
 NICE GUIDELINES  NICE guidelines for preventative treatment of migraine24image

NICE: National Institute for Health and Care Excellence

Reference: 24. NICE CG150. Accessed September 2022

© NICE 2012 Headaches in over 12s: diagnosis and management. Available from www.nice.org.uk/guidance/cg150. All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/ publication.

CGRP: calcitonin gene-related peptide; NICE: National Institute for Health and Care Excellence; NSAID: non-steroidal anti-inflammatory drug

ReferenceNHS RightCare. Headache and migraine toolkit optimising a headache and migraine system, December 2019. Available at: england.nhs.uk. Accessed September 2022American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache 2019;59(1):1-18British Association for the Study of Headache. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type headache, cluster headache, medication-overuse headache, September 2010. Available at: bash.org.uk. Accessed September 2022Ashina M, Katsarava Z et al. Migraine: epidemiology and systems of care. Lancet 2021;397(10283):1485-1495Rao P M, Ailani J. Diagnosis and treatment of migraine. J Clin Outcomes Manag 2017;24(11):516-526Lipton R B, Hamelsky S W, Dayno J M. What do patients with migraine want from acute migraine treatment? Headache 2002;42 Suppl 1:3-9Lipton R B, Fanning K M et al. Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine. Neurology 2015;84(7):688-695National Institute for Health and Care Excellence (NICE). Clinical knowledge summary. Scenario: migraine in adults, updated May 2021. Available at: cks.nice.org.uk. Accessed September 2022Lipton R B, Munjal S et al. Unmet acute treatment needs from the 2017 Migraine in America Symptoms and Treatment study. Headache 2019;59(8):1310-1323Wells R E, Markowitz S Y et al. Identifying the factors underlying discontinuation of triptans. Headache 2014;54(2):278-289May A, Schulte L H. Chronic migraine: risk factors, mechanisms and treatment. Nat Rev Neurol 2016;12(8):455-464Buse D C, Rupnow M F, Lipton R B. Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life. Mayo Clin Proc 2009;84(5):422-435American Journal of Managed Care. Acute and preventive therapy for migraine: determining and measuring individualized treatment goals, 20 January 2021. Available at: ajmc.com. Accessed September 2022Antonaci F, Sances G et al. Meeting patient expectations in migraine treatment: what are the key endpoints? J Headache Pain 2008;9(4):207-213Lipton R B, Dodick D W et al. Patient-identified most bothersome symptom in preventive migraine treatment with eptinezumab: a novel patient-centered outcome. Headache 2021;61(5):766-776Wenzel R G, Sarvis C A, Krause M L. Over-the-counter drugs for acute migraine attacks: literature review and recommendations. Pharmacotherapy 2003;23(4):494-505Tfelt-Hansen P, Steiner T J. Over-the-counter triptans for migraine: what are the implications? CNS Drugs 2007;21(11):877-883Hepp Z, Dodick D W et al. Adherence to oral migraine-preventive medications among patients with chronic migraine. Cephalalgia 2015;35(6):478-488Varnado O J, Manjelievskaia J et al. Adherence and persistence to preventive migraine treatments over 12 months follow-up for patients with migraine: calcitonin gene-related peptide monoclonal antibodies versus other preventive treatments. Presented at the International Headache Congress, virtual, 8-12 September 2021; Poster P0218Argyriou A A, Dermitzakis E V et al. Long-term adherence, safety, and efficacy of repeated onabotulinumtoxinA over five years in chronic migraine prophylaxis. Acta Neurol Scand 2022;145(6):676-683Krasenbaum L J, Pedarla V L et al. A real-world study of acute and preventive medication use, adherence, and persistence in patients prescribed fremanezumab in the United States. J Headache Pain 2022;23(1):54The Migraine Trust. Gepants and ditans. Available at: migrainetrust.org. Accessed September 2022Goadsby P J, Holland P R et al. Pathophysiology of migraine: a disorder of sensory processing. Physiol Rev 2017;97(2):553-622National Institute for Health and Care Excellence (NICE). Clinical guideline 150. Headaches in over 12s: diagnosis and management, 19 September 2012 (last updated December 2021). Available at: nice.org.uk. Accessed September 2022
PP-NNT-GBR-1679. April 2024
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