Experts discuss: how might we prevent migraine disease progression?

Migraine is a common, chronic neurological disorder resulting from head pain along with sensorial, gastrointestinal, cognitive, and other system involvement, making migraine the second most disabling disease globally.¹

What changes happen in the brain with migraine?

Migraine is a complex disorder of multiple brain regions with wide ranging clinical presentation. Dr Patricia Pozo-Rosich, Vall d’Hebron University Hospital, Barcelona, Spain, explained that between attacks, the migraine brain is characterized by a lack of habituation of evoked responses to repeated stimuli. This abnormal processing of information reaches its peak a few days before an attack and normalizes during the attack at a time when sensitization may manifest.² Frequent attacks lead to dynamic anatomical and biochemical changes in the brain.³

Frequent migraine attacks lead to dynamic anatomical and biochemical changes in the brain

Are the brain changes seen in migraine reversible?

On a positive note, Professor Peter Goadsby, Kings College London, UK highlighted studies which show no effect of migraine status on cognitive decline and no increase in white matter hyperintensity over time.^4-6 In fact, a recent study shows that over 10 years migraine frequency reduced in nearly 50% of patients followed.⁷

Can we predict migraine progression?

Professor Cristina Tassorelli, University of Pavia, Italy, explained that every year around 3% of people with episodic migraine (EM) experience progression to chronic migraine (CM).^8,9 In most patients the process evolves over months or years, and a spontaneous pattern of reversal is also possible.

Every year around 3% of people with episodic migraine experience progression to chronic migraine

Factors responsible for migraine progression include internal (genetics, disease severity, sexual hormones, depression, comorbidities), external (acute medication, low education, alcohol intake, lifestyle, inadequate treatment) and mixed factors (epigenetics, stress/trauma).¹⁰

The evidence for predictors of transformation of EM to CM is high for headache day frequency ≥10 days/month with a 6-fold increase in risk, compared with headache day frequency ≥5 days/month with a 3-fold increase in risk, and there is an 8-fold increased risk of transformation with medication overuse albeit with low level evidence.¹¹

High headache day frequency and medication overuse predict transformation of episodic to chronic migraine

What is the goal of migraine treatment?

A major task for the physician is to reduce the frequency and intensity of attacks and to prevent disease worsening over time. Migraine treatment requires a multi-step approach of corrective steps and pharmacological treatment with acute, preventive, or mixed treatments.¹² A corrective approach involves the identification and removal of triggers and aggravating factors, lifestyle optimization, and correction of postural abnormalities and muscle contractions. For acute treatment the oral triptans, gepants, and ditans are associated with high-level efficacy, while among preventives a high level of evidence for efficacy is afforded by the calcitonin gene-related peptide (CGRP) monoclonal antibodies.¹³

Treat patients appropriately to avoid migraine progression and medication overuse

Dr Pozo-Rosich concluded by showing recent evidence that CGRP inhibitors are effective in both patients with CM and medication overuse, demonstrating clinical improvement with reduction of migraine frequency and improvement in health-related quality of life.¹⁴

Educational financial support for this Satellite symposium was provided by H. Lundbeck A/S.