Review Outlines Pharmacists’ Role in Migraine Management

In a recently published review, researchers highlighted the disease burden of migraine, advances in preventive therapies, key takeaways from the most recent migraine management consensus statement, and advocated for increased pharmacist intervention in migraine medication management.

Although migraine affects more than 10% of the world’s population (roughly 1.04 billion individuals), most patients with migraine are not correctly diagnosed, and do not receive appropriate therapy for acute or preventive treatment of their disease, authors explained.

As some patients are refractory to or unable to tolerate certain traditional oral preventive treatments, underutilization of preventive treatment may occur, in addition to subsequent reliance on acute treatment. Because overuse of acute medications can lead to development of medication overuse headache (MOH) and is associated with increased risk of progression from episodic to chronic migraine, researchers argue “pharmacists should counsel patients receiving over-the-counter or prescription acute migraine medications on when to seek options for preventive treatment to help avoid medication overuse.”

Specifically, pharmacists can educate patients on the benefits of preventive medications, provide realistic expectations of treatment outcomes, and identify migraineurs who may benefit from physician referral for further assessment.

Not only does migraine present a high personal and societal burden, it also has a significant impact on health care systems. According to researchers, there is an emergency room visit for headache or migraine every 10 seconds in the United States, constituting approximately 1.2 million visits annually for acute migraine attacks.

One study found roughly 44% of those with migraine have never received a diagnosis, while those with a diagnosis report extreme difficulty accessing acute and preventive treatment. “More recent data confirm migraine remains underdiagnosed and undertreated,” authors said.

These findings point to greater reliance on over the counter (OTC) medications and prescription analgesics to manage symptoms of migraine. Although some OTC acute medications can be useful for migraine, individuals who use acute medications too frequently are at risk of developing MOH.

MOH occurs in migraineurs who frequently use medications like triptans, ergots, barbiturates, or opiates. High-frequency use of these medications may not only increase frequency and intensity of headaches, but it can also lead to adverse events such as gastrointestinal issues, renal toxicities, and medication dependency and withdrawal.

This risk led the FDA in 2017 to issue a decision requesting new warnings on all OTC migraine headache medications cautioning patients headaches may worsen if these medications were used for 10 or more days a month.

“It is important that pharmacists inform patients of label warnings when recommending acute OTC headache therapies, advise on the importance of seeking medical guidance, and counsel against overuse of prescribed acute medications” in general, and especially when it comes to opioids, researchers wrote.

Among patients who initiate oral preventive therapy, discontinuation rates are high, due mainly to lack of efficacy and adverse events. In addition, “current evidence demonstrates that patients are being treated acutely with non-preferred acute migraine medications (i.e., opioids) and are being undertreated with preventive therapies.”

However, authors noted recent approvals of agents such as erenumab, a calcitonin gene-related peptide (CGRP) inhibitor, have expanded and improved available options for adults with migraine. The treatment blocks the CGRP receptor, which is believed to play a crucial role in migraine.

Monoclonal antibodies against the CGRP ligand, including galcanezumab, fremanezumab, and eptinezumab, were also approved for preventive treatment of migraine. Overall data showed “CGRP-inhibitors, whether they directly interact with the receptor or the ligand, significantly reduced monthly migraine days, significantly increased the proportion of patients achieving a ≥ 50% reduction in monthly migraine days, and significantly reduced monthly acute migraine-specific medication use days compared with placebo in patients with chronic migraine and episodic migraine.”

In 2000, the US Headache Consortium issued the first consensus guidelines for acute treatment and prevention of migraine, many of which remain valid today. In 2018, the American Headache Society built upon this work reflecting the emerging roles of CGRP inhibitors in preventive treatment.

In addition to having the knowledge bae to support migraineurs, pharmacists are extremely accessible health care professionals, authors explained. In particular, “In patients managed on OTC medication alone, the pharmacist has an opportunity to assess treatment outcome and discuss possible use of preventive treatment with those who do not achieve acceptable headache relief.” Pharmacists can also counsel migraineurs to identify and avoid triggers or lifestyle factors that may exacerbate migraine progression.

“By providing an overview of the burden of disease, barriers to care, current evidence-based treatment recommendations, and highlighting the role for the newest preventive therapies in migraine management, pharmacists have the information to make more informed decisions and better advise patients about the treatment of migraine and, in particular, why, how, and when preventive therapy should be initiated,” researchers concluded.

Reference:

Patel N, Barnhart R, Konkol P, Varda J, Nelson R, and Smith T. Treatment of migraine: a review of disease burden and an update on the therapeutic landscape for pharmacists. Drugs Ther Perspect. Published online December 5, 2020. doi: 10.1007/s40267-020-00801-2