New ACP guideline on migraine prevention advises starting with monotherapy
ACP's recommendations to prevent migraines in nonpregnant adults favor metoprolol or propranolol, valproate, venlafaxine, or amitriptyline as initial therapy and reported that all treatments provide similar net clinical benefit.
To prevent episodic migraines, a new ACP guideline suggests clinicians start with monotherapy using a beta-adrenergic blocker, either metoprolol or propranolol; the antiseizure medication valproate; the serotonin and norepinephrine reuptake inhibitor venlafaxine; or the tricyclic antidepressant amitriptyline.
The guideline, which was published Feb. 4 in Annals of Internal Medicine, also suggests that patients who do not tolerate these drugs or have an inadequate response should next try monotherapy with a calcitonin gene-related peptide (CGRP) antagonist, atogepant or rimegepant, or a CGRP monoclonal antibody such as eptinezumab, erenumab, fremanezumab, or galcanezumab. Patients who still do not tolerate therapy or have inadequate response should use monotherapy with the antiseizure medication topiramate, the guideline suggested.
The guideline used economic evidence and evidence on patients' values and preferences as primary decision factors in creating the recommendations.
Costs differed substantially between drug classes with median annual costs for the first-line options ranging from $67 to $393. Median annual costs for injectable CGRP monoclonal antibodies and oral CGRP antagonists, for which there are no generics, range from $7,071 to $22,790, and there are further associated costs that the guideline did not assess, such as those associated with outpatient IV infusions.
An evidence review of patients' values and preferences showed that they may prioritize the effect of migraine prevention treatments over the possibility of adverse events. Duration of migraine headache and its effect on daily activities may be more important than migraine recurrence. Migraine severity may be more important than migraine frequency, and both were more important than adverse events. Route of administration of pharmacologic treatments was probably as important as their effect on migraine frequency, with patients preferring oral treatments over injectables.
The guideline emphasizes that a patient's adherence to pharmacologic treatment is crucial because improvement may occur gradually after long-term treatment for preventing episodic migraine.
The guideline also mentioned discussing lifestyle interventions, such as advising the patient to stay hydrated, maintain regular and adequate sleep and physical activity, and keep a migraine diary. Clinicians should also evaluate whether the patient is using appropriate and adequate-strength medications to treat an acute migraine headache and can recommend cognitive behavioral therapy, relaxation training, or mindfulness-based treatment, the guideline said.