CONSIDERATIONS FOR

MANAGING MIGRAINE

THROUGHOUT THE PATIENT JOURNEY
Roll over to learn more
© 2020 Amgen Inc. All rights reserved.

Use is approved when ALL of the following are met:

  1. Prescribed by a licensed medical provider‡
  2. Patient is at least 18 years of age
  3. Diagnosis of ICHD-3 migraine with or without aura§ (4-7 monthly headache days) and both of the following:
    1. Inability to tolerate (due to side effects) or inadequate response to a 6-week trial of at least 2 of the following:
      1. Topiramate
      2. Divalproex sodium/valproate sodium||
      3. Beta-blocker: metoprolol, propranolol, timolol, atenolol, nadolol
      4. Tricyclic antidepressant: amitriptyline, nortriptyline
      5. Serotonin-norepinephrine reuptake inhibitor: venlafaxine, duloxetine
      6. Other Level A or B treatments (established efficacy or probably effective) according to AAN- AHS guideline
    2. At least moderate disability (MIDAS>11, HIT-6>50)
  4. Diagnosis of ICHD-3 migraine with or without aura§ (8-14 monthly headache days) and inability to tolerate (due to side effects) or inadequate response to a 6-week trial of at least 2 of the following:
    1. Topiramate
    2. Devalproex sodium/valproate sodium||
    3. Beta-blocker: metoprolol, propranolol, timolol, atenolol, nadolol
    4. Tricyclic antidepressant: amitriptyline, nortriptyline
    5. Serotonin-norepinephrine reuptake inhibitor: venlafaxine, duloxetine
    6. Other Level A or B treatments (established efficacy or probably effective) according to AAN-AHS guideline
  5. Diagnosis of ICHD-3 chronic migraine§ and EITHER a or b:
    1. Inability to tolerate (due to side effects) or inadequate response to a 6-week trial of at least 2 of the following:
      1. Topiramate
      2. Divalproex sodium/valproate sodium||
      3. Beta-blocker: metoprolol, propranolol, timolol, atenolol, nadolol
      4. Tricyclic antidepressant: amitriptyline, nortriptyline
      5. Serotonin-norepinephrine reuptake inhibitor: venlafaxine, duloxetine
      6. Other Level A or B treatments (established efficacy or probably effective) according to AAN-AHS guideline
    2. Inability to tolerate or inadequate response to a minimum of 2 quarterly injection (6 months) of onabotulinumtoxinA

AAN-AHS, American Academy of Neurology-American Headache Society; HIT, Headache Impact Test; ICHD, International Classification of Headache Disorders; MHDs, monthly headache days; MIDAS, Migraine Disability Assessment.

‡Doctor of medicine, doctor of osteopathy, advanced practice provider (DDS [Doctor of Dental Surgery] or DMD [Doctor of Medicine in Dentistry or Doctor of Dental Medicine]).

§Patient can only meet criteria for C, D, or E.

||Not for use in women of childbearing potential who lack an appropriate method of birth control.

The Patient Journey
Treatment Information
Migraine: An overview of the patient journey

Consultation

  • Can be conducted by specialists
    and non-specialists1

Diagnosis

  • ~ 44% of patients with migraine
    have not received a diagnosis2
  • Rule out other headache diagnoses3

Referral

  • PCPs may consider referring patients to specialists as needed4

Drug Treatment—Acute and preventive

  • Patients with frequent migraine attacks (≥ 4MHDs) may require both
    preventive and acute medications     as part of their treatment plan5
  • ~ 2 out of 3 patients who qualify for preventive treatment do not receive it6
  • Preventive therapy is effective for some patients. Studies indicate
    that ~45% of patients receiving preventive therapy will experience
    a reduction in the mean monthly frequency of migraine attacks by ≥ 50%

Follow-up

  • ~ 80% of patients discontinue
    preventive treatments commonly
    due to efficacy or safety/
    tolerability concerns7,8
References »
References. 1. Diener HC, Solbach K, Holle D, Gual C. Integrated care for chronic migraine patients: epidemiology, burden, diagnosis and treatment options. Clin Med. 2015;15(4):344-350. 2. Diamond S, Bigal ME, Silberstein S, Loder E, Lipton RB. Patterns of diagnosis and acute and preventive treatment for migraine in the United States: results from the American Migraine Prevalence and Prevention study. Headache. 2007;47(3):355-363. 3. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211. https://doi.org/10.1177/0333102417738202. 4. Starling AJ, Dodick DW. Best practices for patients with chronic migraine: burden, diagnosis, and management in primary care. Mayo Clin Proc. 2015;90(3):408-414. 5. American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache. 2019;59(1):1-18. 6. Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68(5):343-349. 7. Hepp Z, Dodick DW, Varon SF, Chia J, Matthew N, Gillard P, Hansen RN, Devine EB. Persistence and switching patterns of oral migraine prophylactic medications among patients with chronic migraine: A retrospective claims analysis. Cephalalgia. 2017;37(5):470-485. 8. Blumenfeld AM, Bloudek LM, Becker WJ, Buse DC, Varon SF, Maglinte GA, Wilcox TK, Kawata AK, Lipton RB. Patterns of use and reasons for discontinuation of prophylactic medications for episodic migraine and chronic migraine: results from the second international burden of migraine study (IBMS-II). Headache. 2013;53(4):644-655.

Acute and preventive treatment overview and options

ACUTE
PREVENTIVE

Used to abort a migraine attack1,2

Eligible for many patients1

Possibility for overuse1-3

Reduces migraine attack frequency, duration,
and/or severity1

Consider for patients with severe and/or frequent headaches that are not controlled with acute treatment1

Treatment choice factors include drug efficacy/safety, concomitant medications, comorbidities, and patient preference1,4-6

Learn more about MIGRAINE

Acute Treatment Guidance1 » Preventive Treatment Guidance1 » References »

Established efficacy

Triptans

Ergotamine derivatives

NSAIDs: aspirin, diclofenac, ibuprofen, naproxen

Opioids: butorphanol*

Combination medications

Probably effective

Ergotamine and other forms of DHE

NSAIDs: ketoprofen, IV and IM ketorolac, flurbiprofen

IV magnesium

Isometheptene-containing compounds

Combinations: codeine/acetaminophen, tramadol/acetaminophen†

Antiemetics: prochlorperazine, promethazine, droperidol, chlorpromazine, metoclopramide

DHE, dihydroergotamine; IV, intravenous; IM, intramuscular; NSAID, nonsteroidal anti-inflammatory drug.

*Use is not recommended.
†In migraine with aura.

References. 1. American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache. 2019;59(1):1-18. 2. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the American headache society evidence assessment of migraine pharmacotherapies. Headache. 2015;55(1):3-30. 3. Giamberardino MA, Martelletti P. Emerging drugs for migraine treatment. Expert Opin Emerg Drugs. 2015:20(1):137-47. 4. Silberstein SD, Holland S, Freitag F, et al. Evidence based guideline update: Pharmacologic treatment for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78:1337-1345. 5. Reddy DS. The pathophysiological and pharmacological basis of current drug treatment of migraine headache. Expert Rev Clin Pharmacol. 2013:6:271-288. 6. D'Amico D, Tepper SJ. Prophylaxis of migraine: general principles and patient acceptance. Neuropsychiatr Dis Treat. 2008;4:1155-1167.
© 2020 Amgen Inc. All rights reserved. USA-334-83138 11/19