More than one billion people worldwide live with migraines, and, for many, managing them remains a challenge. That’s because no two cases are exactly the same, nor do they always respond to the same treatments.
Meet the Experts: Adil F. Niaz, D.O., a neurologist and migraine specialist at the Hackensack Meridian Neuroscience Institute at Jersey Shore University Medical Center; and Patricia Scripko, M.D., neurologist at the University of Maryland Medical Center.
Migraine care can be quite complex, which makes it all the more important for clinicians—and patients—to be aware of the research-backed options out there for managing them. And now, they have updated recommendations to guide them: Recently, the American Academy of Neurology refreshed its migraine treatment guidelines—a report that hadn’t been revised since 2012, according to Adil F. Niaz, D.O., a neurologist and migraine specialist at the Hackensack Meridian Neuroscience Institute at Jersey Shore University Medical Center.
And the update was much-needed: “The landscape of migraine preventive treatment has changed drastically since then,” he adds. Below, Dr. Niaz and another neurologist weigh in on the new parameters and explain how they can make a difference in patients’ lives.
What the new guidelines say
The guidelines are lengthy, but there are a few main takeaways, according to both Dr. Niaz and Patricia Scripko, M.D., neurologist at the University of Maryland Medical Center.
One of the most important ones reduces the minimum number of monthly migraines that triggers preventive care. The new guidelines now recommend that providers offer preventive treatment to patients who experience four or more migraines per month—a frequency level that was previously generally considered low by practitioners, notes Dr. Niaz. “Many physicians are trained to not offer prevention for ‘low frequency’ episodic migraine, and to wait until patients have eight or more migraine days a month,” he adds. These updates stress the need not to withhold prevention—especially if patients aren’t responding to other more acute or standard headache therapies and continue to experience debilitating attacks.
Relatedly, the new guidelines also support the use of calcitonin gene-related peptide (CGRP) inhibitor medications to prevent migraines. These drugs, which work by dulling pain signals sent by the brain, are now recommended as a first line of prevention “alongside traditional preventive options like topiramate or valproate,” notes Dr. Niaz. Examples of CGRP inhibitors include prescription drugs like Aimovig or Nurtec ODT, among others.
The report also recommends that physicians not withhold CGRP inhibitors from patients who also use other prescription treatments. This addresses previous concerns about overmedication—more specifically, that it could cause another type of headache called a “medication overuse headache.” But according to the new guidelines, that condition needs further investigation, and it shouldn’t keep people from receiving the treatment and relief that they need. If providers do recommend weaning off other meds, the guidelines advise prescribing other tapering care, if needed, Dr. Niaz explains.
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It also hits on Botox, a common preventive treatment for migraine, which blocks nerve signals to reduce perceptions of pain. The new guidelines recommend waiting to assess the procedure’s efficacy until after 24 weeks—which could also be considered two rounds of treatment, notes Dr. Niaz—before deciding if it is or isn’t a good fit for a patient.
Finally, a very simple but important feature of the guidelines highlights the need for shared decision-making between physician and patient—a relationship that Dr. Niaz says is “so crucial.”
“I really appreciate this tone throughout the guidelines, as it reflects my clinical practice,” he adds. “Patients experiencing migraine must be offered a choice to individualize their care.”
Why the new guidelines are important
These guidelines spotlight the growing advances not just in migraine treatment, but in understanding of what a migraine actually is—a neurological and nervous system-related disease.
“We have come to better understand migraine as more than ‘just a headache,’” explains Dr. Scripko. And there is still more work to be done. “We still have data gaps for certain subpopulations, such as those who are pregnant, but this is a great step forward,” she adds.
In other words, guidelines like these are helping work toward not only greater prevention of migraines, but also more awareness of the importance of developing custom treatment plans for all who need them—ideally without extreme disruption to their lives.
The bottom line
What works well for one person’s migraine may not work to treat another’s, which is why it’s important that nuanced guidelines like these exist. “If you are having frequent headaches, you do not have to just live with them,” says Dr. Niaz. “We have many more effective treatment options than we did in the past.”
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