1) What are the risk factors for migraine becoming chronic?

Key risk factors include reduced quality of life and significant suffering caused by migraine. Poor efficacy of acute medication, overuse of painkillers and triptans, and comorbidities such as depression, anxiety disorders, sleep disorders, and other chronic pain conditions like fibromyalgia and back pain contribute to progression and chronicity. Obesity and high caffeine consumption are additional risk factors.

2) Which prophylaxis is effective in patients with chronic migraine with medication overuse?

Topiramate, onabotulinumtoxin, and monoclonal CGRP antibodies can statistically significantly reduce the number of headache days per month in patients with chronic medication overuse headache (MOH). However, this usually does not result in a medication frequency of fewer than 10 days per month. Therefore, MOH persists. The causal treatment and long-term, sustainably effective therapy is a complete and consistent medication break from acute medication.

3) Which psychiatric comorbidities should be investigated when diagnosing migraine?

The risk of developing a depressive disorder requiring treatment is up to eight times higher in migraine patients. Anxiety disorders occur five times more frequently. Substance abuse and suicidality are also significantly more common than in non-migraine patients. The comorbid occurrence of migraine and depression worsens the treatment outcome of the other condition. 

4) To what extent does constipation as a comorbidity influence treatment decisions and patient education?

Even though only about 3% of patients reported constipation in the registration trials for erenumab and even only about 1% for galcanezumab, this side effect is considered formally common. Therefore, if a persistent tendency towards constipation is already known, this suggests that fremanezumab is a more appropriate choice.

5) Which patient characteristics should be clarified before prescribing CGRP monoclonal antibodies?

It is important to know for whom these antibodies are not suitable, because CGRP may have an important physiological function. This primarily includes patients with coronary artery disease, cerebral ischemia, peripheral arterial disease, inadequately treated hypertension, chronic inflammatory bowel disease, and pregnant women.

6) Which instruments play a major role in the evaluation of disease burden?

Headache frequency and medication use can be effectively monitored digitally with the migraine app (available free in app stores) and on paper with headache diaries. The impact on quality of life and disease-related impairment in work and family life can be assessed using questionnaires such as MIDAS or HIT-6. The migraine app prospectively assesses quality of life digitally using the GdBK score. 

7) How can patient management between neurologists/pain therapists and general practitioners be optimized?

The general practitioner can manage the majority of uncomplicated patients throughout their treatment. If there are uncertainties regarding the diagnosis or if the therapy proves insufficient, a referral to a specialist should be made. Once a treatment plan is established and the patient is progressing well, further treatment can be continued by the general practitioner.

8) Can patients with episodic migraine receive migraine prophylaxis in pain management practice?

Except for CGRP antibodies, which may be used from 4 migraine days/month and onabotulinumtoxin, which is only approved for chronic migraine from 15 headache days per month, all migraine prophylaxis drugs can be started when the patient's suffering requires it, regardless of the frequency of migraines. 

9) What role does medication play in preventing migraine from becoming chronic?

Any effective preventive measure initiated while an episodic migraine is still present can counteract its progression and chronification, as well as the development of medication-overuse headache. This argues in favor of early use of prophylactic medication. Psychological comorbidity and complications of migraine can also be prevented.

10) When should patients be started on migraine prophylaxis in addition to acute treatment?

The main indications for prophylactic medication are significant suffering and impairment of the affected individuals' quality of life, as well as the threat of medication-overuse headache. Significant suffering is particularly evident in cases of frequent, prolonged, and difficult-to-treat attacks, complex auras, and a reduction or loss of work capacity, occupational, and social functioning.

Authors:
Prof. Dr. med. Dipl.-Psych. Hartmut Göbel,
Priv.-Doz. Dr. med. Carl Göbel, MB BChir (Hons) MA (Cantab),
Dr. med. Axel Heinze,
Pain Clinic Kiel,
Migraine and Headache Center,
Heikendorfer Weg 9–27,
24149 Kiel, Germany,
www.schmerzklinik.de