Chronic migraine prevention — CGRP monoclonal antibodies vs topiramate vs amitriptyline, which first-line?

3 Answers

### Management of Refractory Chronic Migraine: Preventive Strategies **1. Clinical Context and Indications** Chronic migraine (CM) is defined by the ICHD-3 as ≥15 headache days/month for >3 months, with at least 8 days being migrainous. Preventive therapy is indicated when patients experience significant disability, frequent attacks, or fail acute treatments. In this patient (34F), the diagnosis is clear and she meets criteria for advanced preventive therapy having failed three classes of traditional preventives (Anticonvulsants, Tricyclic Antidepressants, and Beta-blockers). **2. Traditional First-Line Agents vs. CGRP Monoclonal Antibodies** * **Topiramate & Amitriptyline:** Traditionally considered first-line due to cost and long-standing data. However, as seen in this case, side effects (cognitive impairment with topiramate, weight gain/sedation with amitriptyline) often limit adherence. * **CGRP Monoclonal Antibodies (mAbs):** Agents such as Erenumab, Fremanezumab, Galcanezumab, and Eptinezumab have revolutionized CM management. They offer high specificity, favorable side effect profiles (primarily injection site reactions or constipation), and rapid onset of action. **3. Decision Making: Which is "First-Line"?** * While AAN/AHS guidelines traditionally suggested starting with cheaper oral agents, the 2021/2024 AHS Consensus Statements have increasingly supported earlier use of CGRP mAbs, especially in patients who have failed or have contraindications to at least two traditional classes. * For this specific patient, CGRP mAbs are now the appropriate next step. Botox (OnabotulinumtoxinA) is another evidence-based option for CM, but CGRP mAbs are often preferred by patients for ease of administration (monthly/quarterly) and efficacy. **4. Clinical Pearl: Medication Overuse Headache (MOH)** In patients with chronic migraine, always screen for MOH (e.g., triptan use >10 days/month). Interestingly, CGRP mAbs have shown efficacy even in patients with concomitant MOH. **References:** 1. Ailani J, et al. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. *Headache*. 2021. 2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. *Cephalalgia*. 2018. 3. Silberstein SD, et al. Evidence-based guideline update: Adjuvant treatment for episodic migraine prevention in adults. *Neurology*. 2012 (reaffirmed 2021).

### Management of Refractory Chronic Migraine: Preventive Strategies **1. Clinical Context and Indications** Chronic migraine (CM) is defined by the ICHD-3 as ≥15 headache days/month for >3 months, with at least 8 days being migrainous. Preventive therapy is indicated when patients experience significant disability, frequent attacks, or fail acute treatments. In this patient (34F), the diagnosis is clear and she meets criteria for advanced preventive therapy having failed three classes of traditional preventives (Anticonvulsants, Tricyclic Antidepressants, and Beta-blockers). **2. Traditional First-Line Agents vs. CGRP Monoclonal Antibodies** * **Topiramate & Amitriptyline:** Traditionally considered first-line due to cost and long-standing data. However, as seen in this case, side effects (cognitive impairment with topiramate, weight gain/sedation with amitriptyline) often limit adherence. * **CGRP Monoclonal Antibodies (mAbs):** Agents such as Erenumab, Fremanezumab, Galcanezumab, and Eptinezumab have revolutionized CM management. They offer high specificity, favorable side effect profiles (primarily injection site reactions or constipation), and rapid onset of action. **3. Decision Making: Which is "First-Line"?** * While AAN/AHS guidelines traditionally suggested starting with cheaper oral agents, the 2021/2024 AHS Consensus Statements have increasingly supported earlier use of CGRP mAbs, especially in patients who have failed or have contraindications to at least two traditional classes. * For this specific patient, CGRP mAbs are now the appropriate next step. Botox (OnabotulinumtoxinA) is another evidence-based option for CM, but CGRP mAbs are often preferred by patients for ease of administration (monthly/quarterly) and efficacy. **4. Clinical Pearl: Medication Overuse Headache (MOH)** In patients with chronic migraine, always screen for MOH (e.g., triptan use >10 days/month). Interestingly, CGRP mAbs have shown efficacy even in patients with concomitant MOH. **References:** 1. Ailani J, et al. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. *Headache*. 2021. 2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. *Cephalalgia*. 2018. 3. Silberstein SD, et al. Evidence-based guideline update: Adjuvant treatment for episodic migraine prevention in adults. *Neurology*. 2012 (reaffirmed 2021).

### Management of Chronic Migraine: Preventive Strategies **1. Clinical Context and Indications** Chronic migraine (CM) is defined by the ICHD-3 as ≥15 headache days/month for >3 months, with at least 8 days being migrainous. Preventive therapy is indicated when patients experience significant disability, frequent attacks, or fail acute treatments. In this patient (34F), the diagnosis is clear and she meets criteria for advanced preventive therapy having failed three classes of traditional preventives (Anticonvulsants, Tricyclic Antidepressants, and Beta-blockers). **2. Traditional First-Line Agents vs. CGRP Monoclonal Antibodies** * **Topiramate & Amitriptyline:** Traditionally considered first-line due to cost and long-standing data. However, side effects (cognitive impairment with topiramate, weight gain/sedation with amitriptyline) often limit adherence. * **CGRP Monoclonal Antibodies (mAbs):** Agents such as Erenumab, Fremanezumab, Galcanezumab, and Eptinezumab have revolutionized CM management. They offer high specificity, favorable side effect profiles (primarily injection site reactions or constipation), and rapid onset of action. **3. Decision Making: Which is "First-Line"?** * While AAN/AHS guidelines traditionally suggested starting with cheaper oral agents, the 2021/2024 AHS Consensus Statements have increasingly supported earlier use of CGRP mAbs, especially in patients who have failed or have contraindications to at least two traditional classes. * For this specific patient, CGRP mAbs are now the appropriate next step. Botox (OnabotulinumtoxinA) is another evidence-based option for CM, but CGRP mAbs are often preferred by patients for ease of administration (monthly/quarterly) and efficacy. **4. Clinical Pearl: Medication Overuse Headache (MOH)** In patients with chronic migraine, always screen for MOH (e.g., triptan use >10 days/month). Interestingly, CGRP mAbs have shown efficacy even in patients with concomitant MOH. **References:** 1. Ailani J, et al. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. *Headache*. 2021. 2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. *Cephalalgia*. 2018. 3. Silberstein SD, et al. Evidence-based guideline update: Adjuvant treatment for episodic migraine prevention in adults. *Neurology*. 2012 (reaffirmed 2021).