Acute and Preventive Therapy for Migraine - Episode 12
Key opinion leaders discuss the process of selecting the right therapy for patients with migraine, with special consideration of the importance of patient preference, and how long to stick with a therapy.
Neil Minkoff, MD: Once we’re getting a patient on one of these drugs, we’ve talked a bit about how you choose them for a patient, and I’d like to ask Dr Dodick if he could speak to that, as well. Can you speak to the route of administration and picking the right medication for the right patient?
David W. Dodick, MD: Yes. It comes down to patient preference. Many of these antibodies look very similar from an efficacy standpoint in clinical trials. Because of our inability to predict which treatment is best for a particular patient, it comes down to patient preference.
There are some patients who would prefer to stay home and inject themselves monthly. While to Dr Nahas’ point, there are some patients who would rather come in quarterly and get an IV [intravenous] catheter put in and get the infusion. They only have to have 4 treatments a year, and it prevents them from having to inject themselves once a month.
That’s a big part of where patient preference comes in. Some patients could still treat themselves at home with fremanezumab, for example. They still don’t have to come in for an IV, but they can treat themselves at home by injecting a larger dose every 3 months.
There are variations in the way patients can inject and whether patients want to inject or get the medication infused. Also, to Dr Nahas’ point, sometimes we choose based on [adverse] effect profiles. But to date, by and large, these monoclonal antibodies are very well-tolerated.
We talked about constipation, but constipation also occurs with the other antibodies, although perhaps not as often as with erenumab. Like Dr Nahas, I haven’t had a patient who has had difficulty with hypertension or who has had serious constipation that’s landed them in the hospital. Many times, it’s surprising that when you ask a patient, they come back to your office and you say, “You’re responding terrifically. Have you had any [adverse] effects?” Oftentimes, they’ll say no. But then when you list the potential [adverse] effects and you bring up constipation, they say, “I have some constipation, but I just modify my diet or I take a laxative.” They don’t even mention it.
That was part of the disconnect for why sometimes adverse events are seen less commonly in clinical trials than they are in clinical practice. We ascertain adverse events in a different way. But just because there is an adverse event, that doesn’t mean it’s serious or treatment-limiting. It comes down to patient preference and, to some extent, patient profile. If a patient has had a small bowel obstruction resulting in surgery, then probably we’re going to avoid the antibody that’s most often associated with constipation, even though it may cause no constipation whatsoever.
Neil Minkoff, MD: Could I ask both of the folks in the room who are seeing these patients regularly a question? Once you’ve made a decision, what’s considered an appropriate length of therapy to see how the patient is doing? We’ve talked about goal-orientated therapy and trying to set goals with your patients. How long do you give one of these therapies, in terms of checking with the patient and seeing how they’re doing? What’s an adequate therapeutic trial?
Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: I like to check in with my patients frequently, and we’re hoping for the fastest response possible.
Neil Minkoff, MD: Sure.
Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: But it can take as long as it takes. With a drug or a treatment that’s as benign relatively, compared with the oral agents, we can give it a really long time. During that time, we can do other things, but my philosophy is, let’s get this started. You might feel better within a week. There are some data to suggest that some patients even feel better the next day, particularly for the IV eptinezumab.
But generally, it’s going to take a bit longer. I like to give it at least 3 months, as long as it’s not causing a problem. By and large, these treatments don’t usually cause a problem. The biggest problem is an injection site reaction that includes pain, redness, or swelling from putting the needle in. That’s just something we’re going to have to accept. It’s the nature of the treatment. But I’ve encouraged patients, even those who haven’t responded after 3 months, to just let it keep going if there’s not a compelling reason to switch course, or to switch to a different product entirely. I’ve seen patients take 6 months, 9 months, or even close to a year on stable therapy before we actually start to see that we’re making some inroads.
Granted, that might be because of a number of the other things that we’re doing in managing their problem over these repeated visits during that period. But again, if it’s low impact and low risk with the potential for high reward, let’s just keep going with it. Some patients are impatient, and if 2 months go by and they don’t see anything, they want to switch. “OK, we’ll switch you to another,” but I try to encourage them to stay in this pathway. These drugs work similarly and perform similarly, at least in clinical trials. We get the sense that they perform similarly in populations.
If I had someone on drug A for 3 months and then switched them to drug B, and they got better in month 4, am I really sure it was drug B that did the trick? Or was it that they were on therapy for 4 months? Any of these could’ve worked. We just had to stick with it long enough. I don’t know and I don’t care, as long as they get better.
Neil Minkoff, MD: Yes, and I want to come right back to that. But I want to see if Dr Dodick is also in agreement about 3-or-more-months therapeutic trials across these agents.
David W. Dodick, MD: The American Headache Society has taken a position on this, that a 3-month trial is usually adequate for these treatments. But it’s nuanced. What do we mean by respond, right?
Neil Minkoff, MD: That was my next question, in fact.
David W. Dodick, MD: Yes. If a patient has noticed zero effect, and not even a partial effect, even on pain intensity, after 3 months, I’ll generally switch that patient. To Dr Nahas’ point, they may start to notice an effect within the first day or within the first week, but I wouldn’t consider them a responder yet. But if they’re starting to notice a response on either pain intensity or the number of days of migraine, in other words, they get a partial response. If the patient comes back and says to me, “I think something’s happening here. I think this may be working,” even though they haven’t had a “50%” reduction in the number of days, I’m going to stick with it. To Dr. Nahas’ point, as in every other prophylactic medication we use, there’s a cumulative response over time. As we turn things down in the brain, they tend to do better over time. But if a patient has had zero response after 3 months, I’m impatient and generally, the patient is impatient. I’m going to switch that patient.