What´s left and new in the management of migraine?

Abstract

INTRODUCTION Migraine is a neurological disorder that generally manifests in the form of headache. The treatment of migraine is based on changes in lifestyle, symptomatic treatment and preventive therapies. The pharmacotherapeutic approach to migraine is based on widely-used drugs and novel drugs, which include monoclonal antibodies (mAbs), which emerge as an alternative for patients with poor response to standard preventive treatments. PURPOSE The objective of this study is to assess the efficacy and safety of the medications employed for the symptomatic and preventive treatment of migraine. Another objective is to determine its place in therapeutics and identify the best treatment based on the type of migraine and characteristics of the patient. METHODS A A search was performed of clinical practice guidelines, documents from regulatory agencies, systematic reviews and primary studies assessing symptomatic and preventive treatments of migraine. Data related to the use of triptans in Navarra, Spain, was extracted from the prescription database of the Navarre Health Service. Data about patients receiving mAb therapy in our community and their progress was extracted from electronic medical records and the Navarre Health Service pharmacotherapy management system. CONCLUSIONS The symptomatic treatment of choice for mild-moderate migraine includes non-steroidal anti-inflammatory drugs (NSAIDs), whereas triptans are frequently reserved for moderate-severe migraine. Oral drugs are the first-line preventive treatment, with ß-blockers and topiramate as the first choice. Botulinum toxin A is used in patients with chronic migraine who are unresponsive to oral preventive therapies. mAbs emerge as an alternative to prevent chronic or episodic migraine in patients unresponsive to previous treatments. These treatments, however, have a modest efficacy as compared to placebo. In addition, no comparative studies have been published to date about other first-line preventive therapies. The long-term safety and efficacy of mAbs have not yet been established, and their cost is high. MAbs are funded by the public health system only as fourth-line prophylactic therapy for chronic or high-frequency episodic migraine.