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Evidence of efficacy Medical professional experience Tolerability Patient preference Headache subtype (episodic or chronic) Comorbid and coexistent illnesses Concomitant medications Physiological factors (e.g., heart rate, blood pressure) Pregnancy or the potential for pregnancy among women Ease of use Response to previous treatments Questions Statements Question 1. When should migraine preventive treatments be offered to individuals with migraine? Migraine preventive treatments should be offered to individuals with migraine in the following cases: Four or more migraines per month
Highly disabling migraine attacks (migraine with brainstem aura or hemiplegic migraine)
Two severe or disabling attacks not responding to acute migraine treatment, or acute treatment is contraindicated
Question 2. What are the different preventive treatment classes approved for the preventive treatment of episodic migraine patients and available in Saudi Arabia? Preventive treatments approved for episodic migraine patients in Saudi Arabia include conventional treatment options, which are TCAs, BBs, anti-seizures, and the newer specific class, CGRP mAbs. Question 3. What are the different preventive treatment classes approved for the preventive treatment of chronic migraine patients and available in Saudi Arabia? Preventive treatments approved for chronic migraine patients in Saudi Arabia are TCA, BBs, anti-seizures, and CGRP mAbs, in addition to onabotulinumtoxin A. Question 4. What are the important factors for the optimal drug selection of preventive treatment? Multiple important factors should be considered during the drug selection for optimal preventive treatment, including evidence of efficacy, patient preference, contraindications and allergies, tolerability and adherence, comorbid and coexistent illness, and cost and availability. Question 5. When should the efficacy of migraine preventive treatments be evaluated after initiating treatment? The efficacy of migraine preventive treatments should be evaluated two to three months after treatment initiation. Question 6. What are the parameters for defining successful migraine treatment for migraine patients? Several parameters are used to define migraine treatment success for migraine patients, including the following: 50% reduction with three months in the frequency of days with episodic migraine
30% reduction with three months in the frequency of days with headache or migraine for chronic migraine
Significant decrease in attack duration based on patient’s headache diary
Significant decrease in attack severity based on patient’s headache diary
Reduction in migraine-related disability and improvements in functioning, such as MIDAS
Question 7. Based on the clinical evidence regarding the efficacy and safety of the CGRP mAbs, at what stage can monoclonal antibodies targeting CGRP pathway be offered to individuals with migraine throughout the treatment lines? CGRP monoclonal antibodies targeting the CGRP pathway can be offered to individuals with migraine at any stage of treatment, particularly as a first-line treatment. Question 8. What are the clinical indications to consider for CGRP mAbs at an early stage of migraine treatment, such as first-line treatment? CGRP mAbs can be considered at an early stage of treatment in the following cases: 1) A high chance of developing side effects from oral preventive treatments based on history, comorbidities, or other oral medications
2) A high chance of drug-drug interaction with other oral treatments
3) A high chance of low adherence to oral treatment and/or an inability to take oral preventive treatments due to medical reasons (gastrointestinal reasons), social/religious reasons (fasting, nature of work), or the patient’s preference not to take oral preventive treatments
Question 9. When should stopping treatment with CGRP mAbs be considered in individuals with migraine? CGRP mAbs treatment cessation should be considered in the following cases: The development of life-threatening or severe side effects or complications
The development of intolerable or disabling mild to moderate side effects
After 12 months of treatment with consistent benefits over the last three months of ≥ 75% reduction from baseline before starting CGRP mAbs treatment, as well as improvement in the migraine disability score (such as MIDAS)
Question 10. In individuals with migraine who failed one CGRP mAb, is switching to a different antibody an option? In individuals with migraine who failed one CGRP mAb, switching to a different CGRP mAb—either a CGRP receptor blocker or a CGRP ligand blocker—could be an option. Question 11. Can treatment with CGRP mAbs be combined with other classes of preventive treatments, such as oral preventive treatments or onabotulinumtoxin A? CGRP mAbs can be combined with other classes of preventive treatments, especially the combination of CGRP mAbs and onabotulinumtoxin A. Question 12. In which individuals with migraine is caution suggested when considering treatment with CGRP mAbs? Caution is suggested when considering migraine treatment with CGRP mAbs in pregnant and nursing women, individuals with latex allergy, and individuals with a history of constipation or hypertension (with erenumab). Question 13. Would the availability of a local clinical practice guideline for the diagnosis and treatment of migraine patients, as well as establishing a national registry for migraine, help clinical decision-makers and medical institutions make proper decisions that would improve the clinical care for migraine patients? The availability of a local clinical practice guideline for the diagnosis and treatment of migraine patients and establishing a national registry for migraine could help clinical decision-makers and medical institutions make proper decisions that would improve clinical care for migraine patients.
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