A focused and personalized approach is critical for pharmacists who want to help their patients find and stay on effective migraine treatments, experts said during the educational session High-Stakes Headaches: Update on Headache Pharmacotherapy and Pharmacists' Role in Management, held Sunday at the Midyear Clinical Meeting & Exhibition in Las Vegas, Nevada.
“When you’re seeing the patient for the first time, headache should be the sole purpose for that first visit,” said Olivia Morgan, clinical pharmacist specialist at the Grady Health System Marcus Stroke and Neuroscience Center in Atlanta, Georgia.
Morgan said the initial visit should take 30-40 minutes and have a structured format that includes open-ended questions about the patient’s primary concerns, symptom patterns and triggers, what makes the headaches better or worse, and how headaches interfere with work and life.
The goal, Morgan said, is to elicit “a lot of information” while coming across as a human as well as a clinician.
She said initial migraine treatment and prevention goals should be for the patient to have fewer and less-frequent headaches. But she also encouraged patients and clinicians to aspire to a more ambitious goal.
“We want to achieve migraine freedom, if we can,” Morgan said.
She said both migraine freedom and less aspirational migraine goals require a multifaceted approach that includes medications, lifestyle changes, and frequent check-ins between the patient and clinician to evaluate progress and medication effectiveness and tolerability.
Millad J. Sobhanian, clinical pharmacy specialist in neurology at the University of Maryland Medical System, gave the audience an overview of migraine therapies and preventatives, including newer medications.
“There has been a huge shift, in the last 5-10 years, from non-specific to specific migraine therapies,” Sobhanian said.
Specific migraine medications include various triptans and newer calcitonin gene-related peptide (CGRP) antagonists, such as zavegepant, ubrogepant, and rimegepant. Sobhanian categorized these as abortive medications intended to provide quick relief of acute migraine.
He also discussed newer preventive monoclonal therapies, including the CGRP inhibitors erenumab, fremanezumab, and galcanezumab, which are administered subcutaneously. Sobhanian emphasized that patients should be aware that that these therapies, though effective, won’t bring immediate relief from migraine occurrence.
“It’s going to take at least a month,” he said.
Sobhanian said that preventive therapy is generally recommended for people who have more than four migraine days per month. But he urged clinicians to also consider preventive therapy on the basis of how migraines affect their patients’ ability to function personally, socially, and professionally.
“We do look at compelling indications” for prevention, he said.
The session also covered the role of nonspecific medications, including acetaminophen and ibuprofen, in migraine management, and the importance of starting with an effective dose instead of working up to it.
“Use the optimal dose first,” Morgan said.
