Literature Review

Pandemic necessitates new strategies to treat migraine



Patients with migraine who are unable to continue preventive procedures such as onabotulinumtoxinA injections during the COVID-19 pandemic may be at risk of worsening migraine, according to an article published March 30 in Headache. To address this scenario, clinicians may need to prescribe additional acute or preventive medications. Insurance providers should adjust their policies to facilitate transitions to other preventive therapies, including monoclonal antibodies against calcitonin gene-related peptide (CGRP) or the CGRP receptor, the authors said.

“This is a particularly vulnerable time for individuals with migraine and other disabling headache disorders, with many physical and mental stressors, increased anxiety, and changes in daily routine which may serve as triggering factors for worsening headache,” said lead author Christina L. Szperka, MD, director of the pediatric headache program at Children’s Hospital of Philadelphia, and colleagues.

Acute treatment

The authors described potential treatment regimens based on their experience as headache specialists and the experiences of their colleagues. For acute therapy options, NSAIDs, triptans, and neuroleptics may be used in combination when needed. Medications within the same drug category should not be combined, however, and triptans, dihydroergotamine, and lasmiditan should not be coadministered within 24 hours. Since the 2015 American Headache Society guideline for the acute treatment of migraine, the Food and Drug Administration has approved additional acute migraine medications, including ubrogepant, rimegepant, and lasmiditan, the authors said. The agency also cleared several neuromodulation devices for the acute treatment of migraine.

Although few drugs have been studied as treatments for unusually prolonged severe headaches, headache doctors often recommend NSAIDs before patients seek care at an emergency department or infusion center, the authors said. NSAID options include indomethacin, ketorolac, naproxen, nabumetone, diclofenac, and mefenamic acid. Neuroleptics also may be used. “Long-acting triptan medications can be used as bridge therapies, as is often done in the treatment of menstrually related migraine or in the treatment of medication overuse headache,” they said. “We propose a similar strategy can be trialed as a therapeutic option for refractory or persistent migraine.”

The authors also described the use of antiepileptics and corticosteroids, as well as drugs that may treat specific symptoms, such as difficulty sleeping (hydroxyzine or amitriptyline), neck or muscle pain (tizanidine), and aura with migraine (magnesium). Clinicians should avoid the use of opioids and butalbital, they said.

Preventive treatment

“While the injection of onabotulinumtoxinA is an effective treatment for chronic migraine, the procedure can put the patient and the provider at higher risk of COVID-19 given the close contact encounter,” wrote Dr. Szperka and colleagues. “We believe that other migraine preventive treatments should be utilized first when possible.” Since the publication of a guideline on preventive migraine therapies in 2012, the FDA has approved additional preventive therapies, including the anti-CGRP monoclonal antibodies erenumab‐aooe, galcanezumab‐gnlm, fremanezumab‐vfrm, and eptinezumab‐jjmr. “The first three are intended for self‐injection at home, with detailed instructions available for each product on its website,” they said.

Among angiotensin‐converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), candesartan has evidence of efficacy and tolerability in migraine prevention. Lisinopril has been considered possibly effective. “There has been recent concern in the media about the possibility of these medications interfering with the body’s response to COVID‐19,” the authors said, although this theoretical concern was not based on experimental or clinical data. “For patients in need of a new preventive therapy, the potential for benefit with an ACE/ARB must be weighed against the theoretical increased risk of infection.”

In addition, studies indicate that melatonin may prevent migraine with few side effects and that zonisamide may be effective in patients who have an inadequate response to or experience side effects with topiramate.

Policy changes and telehealth options

Effectively treating patients with migraine during the pandemic requires policy changes, according to the authors. “Migraine preventive prior authorization restrictions need to be lifted for evidence‐based, FDA‐approved therapies; patients need to be able to access these medications quickly and easily. Patients should not be required to fail older medications,” they said. “Similarly, in order to permit the transition of patients from onabotulinumtoxinA to anti‐CGRP [monoclonal antibodies], insurers should remove the prohibition against simultaneous coverage of these drug classes.” Insurers also should loosen restrictions on the off-label use of acute and preventive medication for adolescents, Dr. Szperka and coauthors suggest.

“In the era of COVID‐19, telehealth has become an essential modality for most headache specialists, given the need for providers to take significant precautions for both their patients and themselves, limiting touch or close contact,” they said. Patients with headache may warrant additional screening for COVID-19 as well. “As headache has been reported as an early symptom of COVID‐19, patients with worsening or new onset severe headache should be reviewed for exposure risk and any other symptoms which may be consistent with COVID‐19 infection,” the authors said.

There was no direct funding for the report. Dr. Szperka and a coauthor receive salary support from the National Institutes of Health. Dr. Szperka also has received grant support from Pfizer, and her institution has received compensation for her consulting work for Allergan. Several coauthors disclosed consulting and serving on speakers’ bureaus for and receiving research support from various pharmaceutical companies.

SOURCE: Szperka CL et al. Headache. 2020 Mar 30. doi: 10.1111/head.13810.

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