Latest / Medicine Matters: The Springer Medicine Podcast / Episode 28: Optimizing migraine management

Transcript

Episode 28: Optimizing migraine management · Medicine Matters: The Springer Medicine Podcast

• 0:06
  Speaker 0: Welcome to Medicine Matters, the spring and medicine podcast.
• 0:10
  Speaker 0: I'm Dr.
• 0:11
  Speaker 0: Natalie Wood.
• 0:13
  Speaker 0: The recent expansion of treatment options for migraine is undoubtedly excellent news for patients.
• 0:19
  Speaker 0: however it has also made clinical decision-making increasingly complex.
• 0:24
  Speaker 0: To help navigate this evolving landscape the Italian Society For The Study Of Headache And the International headache society published evidence based guidelines on the Pharmacologic Treatment of Migraine in April, twenty-twenty five.
• 0:38
  Speaker 0: Designed to bring greater clarity to care these recommendations provide a standardised framework to support treatment decisions and clinical practice.
• 0:49
  Speaker 0: but how do evidence based recommendations translate into real world care?
• 0:53
  Speaker 0: In the face of time pressures, treatment access challenges We are fortunate to hear from Professor Simona Sacco, a key figure involved in the development of the guidelines.
• 1:10
  Speaker 0: She shares practical insights into applying the recommendations in everyday practice highlighting key considerations around acute and preventive treatment strategies when and how to escalate therapy And the role with specialist referral in optimising outcomes.
• 1:27
  Speaker 0: I invite you stay with us for this insightful conversation on how to translate the advances in treatment into more personalised effective care for people living with migraine.
• 1:38
  Speaker 2: Hello, I'm Lucy Piper Bureau Chief at Medwire News part of Springer Health Plus.
• 1:44
  Speaker 2: i'm joined by Professor Simona Sacco Director of the Clinical Neurology and Stroke Unit At The University Of La Quilla In Italy And Chairperson For The Italian Society for Study of Headache Guidelines Development Group Professor Sacco welcome.
• 1:57
  Speaker 2: it's a pleasure To have you With us today.
• 1:58
  Speaker 2: Before we begin, could you tell our audience a bit about yourself and your work in migraine care?
• 2:04
  Speaker 1: Thank You Lucy.
• 2:06
  Speaker 1: It's a pleasure to be here today.
• 2:09
  Speaker 1: I am neurologist and professor of Neurology at the University of Laquilla In Italy where i also direct new neurology and stroke unit although my clinical spectrum of neurology, headache medicine and migraine have been an important part of my clinical and research activity for many years.
• 2:37
  Speaker 1: I'm also currently past president of the European Stroke Organization and the editor-in chief of Cefalagia and Cefralagia reports The official journals over the International Headache Society.
• 2:53
  Speaker 2: Fantastic!
• 2:54
  Speaker 2: Thank you.
• 2:55
  Speaker 2: I'd like to start by looking at the rationale behind these guidelines and look what gaps in migraine care or areas of uncertainty, these recommendations were designed to address.
• 3:06
  Speaker 1: Yes there were several reasons.
• 3:10
  Speaker 1: first the therapeutic landscape has expanded a lot over recent years.
• 3:19
  Speaker 1: we now have traditional treatments but also new treatment treatments such as G-pants, monoclonal antibodies targeting the CDRP pathway and we have many other options.
• 3:36
  Speaker 1: This is an excellent news for patients but it also makes a clinical decision making more complex.
• 3:46
  Speaker 1: Second, different guidelines have sometimes focused on a different aspect of treatment and recommendations not always been based the same methodology.
• 4:01
  Speaker 1: We wanted to provide comprehensive framework based on systematic assessment over randomized control trials in that grade methodology.
• 4:14
  Speaker 1: And third, evidence alone is not enough.
• 4:17
  Speaker 1: We wanted the guideline to distinguish clearly between what is supported by evidence and what represents expert clinical judgment because clinicians need both when they're making decisions in real life.
• 4:35
  Speaker 1: Lastly, the goal was not to create a rigid algorithm but provide reliable evidence the foundation for individualized treatment.
• 4:48
  Speaker 2: And as you reviewed, did any findings surprise or challenge your current practice?
• 4:56
  Speaker 1: One important lesson was how difficult it is to make direct comparison between treatments.
• 5:04
  Speaker 1: For many drugs, we have very good evidence that they work better than placebo but considerably less evidence directly comparing one effective treatment with another.
• 5:19
  Speaker 1: This means that you should be cautious about creating over rigid hierarchies of treatment.
• 5:28
  Speaker 1: At the same time, newer migra-specific therapies have accumulated a very substantial body of evidence for some of this treatment and strength and consistency is now extremely compelling.
• 5:45
  Speaker 1: so I think One of the challenges to traditional practice is the idea that newer treatments should automatically be reserved for patients who have failed many older treatments.
• 6:01
  Speaker 1: The evidence increasingly supports a more individualized approach where efficacy, tolerability, comorbidity, patient preferences and access all contribute to their decision.
• 6:15
  Speaker 2: Okay, so if I can maybe look more kind of practically and move things into the clinic.
• 6:22
  Speaker 2: If a patient presents with migraine for the first time what treatment pathway do the guidelines recommend?
• 6:28
  Speaker 2: So how should clinicians decide between available acute treatment options?
• 6:34
  Speaker 1: Yeah, this is a great question.
• 6:36
  Speaker 1: The first step to make the correct diagnosis and understand characteristics of individual attacks.
• 6:46
  Speaker 1: Once migraine has been diagnosed acute treatment should be selected with objective restoring patient's ability function as quickly safely possible.
• 7:01
  Speaker 1: The Gaeland does not propose one single drug that should be prescribed to every patient.
• 7:08
  Speaker 1: There are several effective options, including in sales treatments and more recently G-pants.
• 7:17
  Speaker 1: The choice should depend on the severity and speed of attack.
• 7:22
  Speaker 1: associated symptoms such as nausea or vomiting prior to response to treatments, contraindications, comorbidities.
• 7:32
  Speaker 1: And also need for a non-horror route of administration.
• 7:39
  Speaker 1: It's very important take patient preferences into account.
• 7:45
  Speaker 1: I would also emphasize that acute treatment should be taken early in the attack when appropriate rather than waiting until the pain becomes severe.
• 7:58
  Speaker 1: So, the principle is not simply which drug is best but the principle of this particular patient and for these particular attacks.
• 8:13
  Speaker 2: So that makes sense, so involving the patients which is obviously very key as well.
• 8:20
  Speaker 2: Of course you've talked about the kind of factors that might influence treatment selection but treatment initiation is really just a beginning and migraine management often relies on ongoing monitoring an assessment um...so what do you believe effective follow-up looks like?
• 8:36
  Speaker 2: You know for instance how often should clinicians be reviewing patients once they've started treatment?
• 8:42
  Speaker 1: Follow-up should be structured around our cancer, rather simply about the passage of time.
• 8:50
  Speaker 1: I want to know as a clinician how many migraine days that patient is having?
• 8:56
  Speaker 1: How disabling their attacks are or often acute medication being used whether the acute treatment is actually restoring function and whether there are adverse effects.
• 9:11
  Speaker 1: An addict diary can always be extremely useful, especially when a treatment has been initiated or changed.
• 9:23
  Speaker 1: The timing of follow-up should depend on the treatment in clinical situations.
• 9:29
  Speaker 1: We need an early assessment to identify problems with the tolerability or efficacy, and then longer term follow up to determine whether benefit is sustained.
• 9:44
  Speaker 1: And importantly we should not judge a preventive treatment after only few days.
• 9:51
  Speaker 1: preventing therapies generally need an adequate trial at appropriate dose endurations before that we conclude they have failed.
• 10:03
  Speaker 2: And if the treatment is working well then, how should clinicians be defining success and kind of setting expectations with their patients?
• 10:12
  Speaker 2: do you think?
• 10:14
  Speaker 1: For acute treatment, success means that the attack is treated effectively and ideally achieving freedom from pain.
• 10:25
  Speaker 1: And most troublesome associated symptoms with restoration of nobler function without unacceptable adverse effects.
• 10:36
  Speaker 1: For the prevention, reducing migraine days is very important but this not only outcome.
• 10:43
  Speaker 1: We should also consider disability quality of life, acute medication use treatment and the patient's ability to function at work in everyday lives.
• 10:59
  Speaker 1: And those expectations I want say that are very important.
• 11:03
  Speaker 1: we should tell patients meaningful improvement and better control of the disease.
• 11:12
  Speaker 1: A treatment that reduces migraine substantially, improves quality life can be a very successful treatment even if it does not eliminate every
• 11:25
  Speaker 1: attack.".
• 11:27
  Speaker 2: Okay thank you!
• 11:28
  Speaker 2: That's really helpful to know.
• 11:32
  Speaker 2: Obviously, a significant proportion of patients won't achieve adequate relief with initial acute therapies.
• 11:40
  Speaker 2: So I wondered if you could explain a little bit about when clinicians should consider switching treatments maybe combining therapies or even escalating to newer drug options?
• 11:50
  Speaker 1: Yes, this is a very important issue in EDIC care.
• 11:56
  Speaker 1: So in this situation I would first ask why the treatment has failed?
• 12:04
  Speaker 1: The first question was that diagnosis correct – Was the treatment used at right dose and at the right time?
• 12:15
  Speaker 1: Was the duration of treatment adequate?
• 12:18
  Speaker 1: was the root of the administration, that right one.
• 12:23
  Speaker 1: Was there a medication overuse?
• 12:26
  Speaker 1: And it wasn't treatment simply ineffective or not tolerated.
• 12:34
  Speaker 1: if an acute treatment is ineffective, there is no reason to persist indefinitely with an ineffective strategy.
• 12:45
  Speaker 1: We can switch another class or use a different mechanism in some patients.
• 12:53
  Speaker 1: we should also remember that treatment combination can be appropriate For prevention, failure of intolerance or one treatment should not be interpreted as a failure of migraine prevention in general because my migraine is biological heterogeneous and the patient can respond very differently to different mechanisms.
• 13:23
  Speaker 1: And one of the most encouraging aspects in current landscape is that we have multiple therapeutic options, so treatment failure should increasingly be seen as a reason to rethink strategy rather than a reason for giving up.
• 13:44
  Speaker 2: That's really encouraging!
• 13:47
  Speaker 2: I wanted to talk more about prevention.
• 13:52
  Speaker 2: At the end of August, The American Academy of Neurology and the American Headache Society issued practice guidelines that recommended offering patients preventive treatment if they had four or more headaches per month.
• 14:05
  Speaker 2: Do you agree with this threshold?
• 14:07
  Speaker 2: And is preventative therapy being initiated early enough in routine
• 14:12
  Speaker 2: practice?".
• 14:15
  Speaker 1: I agree, with this principle but i would be careful about treating four days as a rigid cut-off.
• 14:25
  Speaker 1: That is important because frequency alone does not capture diseases above them.
• 14:31
  Speaker 1: A patient with four relatively mild attacks may have a very different need from patients with the fourth highly disabling attack.
• 14:44
  Speaker 1: And conversely, someone with fewer headache days might still be an excellent candidate for prevention if their attacks are prolonged, disabling and difficult to treat acutely or associated with substance the personal or occupational consequences.
• 15:05
  Speaker 1: So yes, I believe prevention is still initiated too late in many patients.
• 15:12
  Speaker 1: we often weigh wait for the disease to become frequent or chronic rather than intervening when this is a burden.
• 15:22
  Speaker 1: It's already significant and so, uh... The question is that Is it the burden of migraine sufficient to justify prevention?
• 15:32
  Speaker 1: For these patients other then simply counting headache days?
• 15:39
  Speaker 2: Thanks for that clarity.
• 15:41
  Speaker 2: That's fantastic.
• 15:43
  Speaker 2: What do you think are the biggest barriers perhaps then to preventing earlier intervention?
• 15:49
  Speaker 1: There are barriers at several levels.
• 15:55
  Speaker 1: First of all, it's that nowadays a migrant is still not properly diagnosed and many patients live with migrants but don't know they suffer from this disease.
• 16:10
  Speaker 1: At patient level, migraine is still sometimes normalized.
• 16:15
  Speaker 1: Some patients may think that the current attacks are something they simply have to live with or maybe reluctant to take medication regularly for a condition that's intermittent.
• 16:30
  Speaker 1: and The clinician level, there can be uncertainty about when prevention should begin.
• 16:40
  Speaker 1: There may be concerns about diverse effects limited the consultation time and tendency to continue treating individuals attacks rather addressing underlying disease burdened.
• 16:57
  Speaker 1: And we have also health care system barriers particularly access and reimbursement restrictions.
• 17:06
  Speaker 1: And finally, we should remember that traditional preventive medications often have tolerability and adherence problems.
• 17:17
  Speaker 1: this can discourage both physicians and patients from initiating prevention.
• 17:26
  Speaker 1: So closing the gap requires more than publishing guidelines.
• 17:31
  Speaker 1: We need education, accessible treatment pathways and a healthcare system that allows clinicians to implement evidence-based recommendations.
• 17:45
  Speaker 2: So again in the clinic if you know once preventive treatment is indicated
• 17:50
  Speaker 1: how
• 17:50
  Speaker 2: would clinicians integrate it with sort of ongoing acute treatment?
• 17:56
  Speaker 2: What advice should they give?
• 17:58
  Speaker 2: patients or the clinicians?
• 18:00
  Speaker 2: Yeah,
• 18:02
  Speaker 1: it's very important to know that prevention does not replace acute treatment.
• 18:09
  Speaker 1: Patient starting preventive therapy should still have an effective individualized acute treatment plan because the preventive therapies reduce disease burden but do not necessarily eliminate every attack.
• 18:25
  Speaker 1: I also think that two strategies should be viewed as complementary.
• 18:31
  Speaker 1: An effective preventive treatment may reduce the frequency and severity of attacks, which can sometimes improve responsiveness to acute treatments.
• 18:43
  Speaker 1: At the same time good acute treatments can reduce disability while we wait for a preventative treatment in order The patient should also be given clear instructions about when and how to use their acute medication, including the risk of medication overuse.
• 19:12
  Speaker 1: is very important.
• 19:15
  Speaker 1: In practical terms, every patient receiving preventive treatment should leave the consultation with an acute treatment strategy as
• 19:25
  Speaker 1: well.".
• 19:27
  Speaker 2: So you mentioned that treatments landscapes involve considerably.
• 19:30
  Speaker 2: in recent years and in twenty-twenty four The American Headache Society updated its position statement to indicate that CGRP targeting therapies may be considered a first line option for migraine prevention.
• 19:43
  Speaker 2: yet access remains restricted in many health care systems, including the UK.
• 19:48
  Speaker 0: How
• 19:48
  Speaker 2: important do you think broader access would be for improving patient outcomes and how feasible is this in practice?
• 19:56
  Speaker 1: I want to point out that the European DECA Federation with its guideline, and they had a privilege of leading this guideline was at first.
• 20:09
  Speaker 1: To suggest where the CGRP targeting therapies as our first line options.
• 20:18
  Speaker 1: My opinion is that access is one of most important implementation issues face today.
• 20:28
  Speaker 1: We already recognize the senior p-targeting therapies as first line option for them migrant prevention without requiring patients to fail previous no specific preventive treatment.
• 20:43
  Speaker 1: And this position reflects that substantial evidence accumulated before efficacy, tolerability and safety both from randomized controlled trials under from a very large real-world experience.
• 21:01
  Speaker 1: One important point is that the first line does not mean every patient should receive a CDRP targeting therapy, it means this treatment must be considered among appropriate initial options when clinically suitable.
• 21:20
  Speaker 1: For the health system perspective, however there's a tension between clinical evidence and access policies restriction based primarily on prior treatment failures can delay effective treatments for patients who might benefit earlier.
• 21:42
  Speaker 1: I think that long-term solution is to move from a rigid step care model towards a value-based, individualised approach that considers both the clinical benefits and broader costs of uncontrolled migraine.
• 22:04
  Speaker 2: Even when treatment is available adherence is another significant challenge in managing migraine.
• 22:12
  Speaker 2: Have the newer targeted therapies improved long term treatment adherence or has treatment discontinuation still major unmet need?
• 22:20
  Speaker 1: I think that newer therapies have the potential to improve adherence substantially, particularly because tolerabilities are often better and treatment schedules can be much simpler.
• 22:37
  Speaker 1: For example some preventive treatments are administered monthly or quarterly which is easier for patients taking a tablet every day.
• 22:50
  Speaker 1: Of course, this continuation remains an important unmet need.
• 22:56
  Speaker 1: adherence is not simply a patient behavior.
• 22:59
  Speaker 1: Adherence, it's also treatment that does work sufficiently causes adverse effects and inconvenience difficult to access.
• 23:10
  Speaker 1: this continuation I think can be understandable in several situations.
• 23:18
  Speaker 1: the solution patients to be more, more adherent.
• 23:24
  Speaker 1: We need the two select treatments that a patient can tolerate and sustain explain what they should expect and follow up them closely enough to identify problems early.
• 23:43
  Speaker 1: A treatment that works in a clinical trial, but the patient cannot or do not want to continue is not successful treatment of their
• 23:56
  Speaker 1: life.".
• 23:58
  Speaker 2: So I wanted the primary care and transition to specialists.
• 24:03
  Speaker 2: I mean, most patients with migraine can be successfully managed in primary care but it's also important to recognise their need for specialist insight.
• 24:11
  Speaker 2: so like when do clinicians start thinking about referring their patients?
• 24:16
  Speaker 2: And are there specific warning signs that would prompt specialist assessment?
• 24:21
  Speaker 1: Yes, this is a very important question and thanks for asking.
• 24:26
  Speaker 1: So most patients with straightforward migraine can or should be managed in primary care but of course there are situations where specialist assessment becomes particularly important.
• 24:43
  Speaker 1: I would consider the fact that when diagnosis is uncertain when there are atypical or unusual clinical features, when the treatment is repeatedly unsuccessful.
• 25:02
  Speaker 1: When a patient has significant disability despite treatments and when they have complex comorbidities I think that the fetal is also very important.
• 25:17
  Speaker 1: when there's a diagnosis of chronic migraine, where it is the presence of medication overuse for patients to report prior treatment failure.
• 25:30
  Speaker 1: When they have unusual or persistent neurological symptoms and in all situation where the treatment looks more complex for many different reasons.
• 25:48
  Speaker 1: And of course, any red flag suggesting a secondary headache disorder should prompt appropriate investigation rather than simply escalation.
• 26:00
  Speaker 1: on migrant treatments.
• 26:03
  Speaker 1: I think the key message is that referral should not be seen only as a last resort.
• 26:11
  Speaker 1: Specialist input can sometimes prevent years of ineffective treatment, unnecessary suffering and in some cases prevent investigations.
• 26:24
  Speaker 1: so they are not needed.
• 26:26
  Speaker 2: Thank you, that's really useful.
• 26:29
  Speaker 2: Okay so we've discussed evidence.
• 26:31
  Speaker 2: We have discussed implementation access and patient outcomes.
• 26:34
  Speaker 2: So looking ahead what do you see as the biggest opportunities for further closing the gap between guideline recommendations And real world migraine care?
• 26:45
  Speaker 1: Oh thank You.
• 26:47
  Speaker 1: I See five major Opportunities.
• 26:52
  Speaker 1: First then we need to improve diagnosis.
• 26:56
  Speaker 1: a patient cannot receive the right treatment if migrant is not recognized or is not diagnosed correctly.
• 27:07
  Speaker 1: Second, we need to move from purely stepwise treatment model towards individualized treatment selection.
• 27:20
  Speaker 1: Now, enough therapeutic options to think much more carefully about matching mechanism and treatment characteristics for individual patients.
• 27:33
  Speaker 1: Further we need to intervene earlier particularly with prevention.
• 27:40
  Speaker 1: We should not wait until the patient has developed chronic migraine have a medication overuse or the experience of years of disability.
• 27:55
  Speaker 1: We should offer appropriate treatment as soon as this is needed.
• 28:02
  Speaker 1: Fourth, we need equitable access.
• 28:07
  Speaker 1: The best evidence-based treatment is of no value if a patient cannot obtain it.
• 28:16
  Speaker 1: and finally to make shared decision making part of routine headache care.
• 28:28
  Speaker 1: We should measure not only a day but also disability, quality-of life, acute medication use, tolerability and at the end what matters most for each individual patient?
• 28:43
  Speaker 1: So in my view closing the gap is simply about writing better guidelines.
• 28:49
  Speaker 1: it's the evidence can actually reach a patient.
• 28:57
  Speaker 1: We have to move from an era of limited therapeutic option, to an era or therapeutic choice so that next challenge is make their choice intelligently individually and equitably.
• 29:14
  Speaker 2: That brings us really fascinating conversation and really clinically helpful.
• 29:20
  Speaker 2: So Professor Sako, thank you for sharing your insights and expertise.
• 29:25
  Speaker 2: It's clear that advances in migraine treatment continue to create new opportunities for improving patient care but translating those advances into better outcomes For patients living with migraine requires timely diagnosis individualised treatments selection careful follow-up and equitable access to effective therapies.
• 29:41
  Speaker 2: Thank you for listening to the Springer Medicine podcast.
• 29:44
  Speaker 2: We hope you found this discussion useful in helping navigate the evolving migraine treatment landscape and bringing evidence-based care into everyday clinical practice.
• 29:54
  Speaker 0: This podcast is intended for healthcare professionals, For their ongoing medical education and entertainment.
• 30:00
  Speaker 0: It should not replace professional advice of a doctor or pharmacist And may be used as basis for diagnosis Or any change to prescribed treatment.
• 30:10
  Speaker 0: The views expressed by our moderators and guests are their opinions, do not represent the position of any third parties.