1) What are the risk factors for chronic migraines?

The central risk factors are reduced quality of life and high levels of suffering caused by migraines. Poor effect of acute medication, overuse of painkillers and triptans as well as comorbidities such as depression, anxiety disorders, sleep disorders and other chronic pain disorders such as fibromyalgia and back pain lead to progression and chronification. Obesity and high caffeine consumption are additional risk factors.

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

Topiramate, onabotulinum toxin and the CGRP monoclonal antibodies can statistically significantly reduce headache days per month in chronic migraine with medication overuse (MOH). However, the frequency of taking acute medications on fewer than 10 days per month is usually not achieved. The MÜK therefore remains in place. The causal treatment and long-term, sustainably effective therapy is a consistent medication break for acute medication.

3) Which psychiatric comorbidities need to be clarified when making a migraine diagnosis?

The risk of also developing a depressive disorder that requires treatment is up to eight-fold increased in migraine patients. Anxiety disorders are five times more common. Substance overuse and suicidality are also significantly more common than in people who are not affected. The comorbid occurrence of migraine and depression worsens the treatment outcome of the other disease.  

4) To what extent does constipation as a comorbidity influence the treatment decision and patient information?

Even though only around 3% of patients in the approval studies with erenumab and only around 1% with galcanezumab reported constipation, this side effect is considered to be formally common. If a persistent tendency to constipation is known, this suggests the use of fremanezumab.

5) What patient characteristics should be assessed before prescribing CGRP monoclonal antibodies?

What is important is who the antibodies are not suitable for because CGRP may have an important physiological function. These are primarily patients with CHD, cerebral ischemia, PAD, inadequately treated high blood pressure, chronic inflammatory bowel disease and pregnant women.

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

Headache frequency and medication use can be easily monitored digitally with the migraine app (free in the app stores) and on paper with headache calendars. The influence on quality of life and the illness-related impairment in work and family can be recorded with questionnaires such as MIDAS or HIT-6. The migraine app digitally records quality of life using the GdBK score.  

7) How can patient management between neurologist/pain therapist and family doctor be optimized?

The family doctor can care for the majority of uncomplicated patients over time. If there is any uncertainty about the diagnosis or if the therapy proves to be inadequate, you should be referred to a specialist. If a therapy concept has been established and the course is going well, further treatment can be carried out again by the family doctor.

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

With the exception of the CGRP antibodies, which can be used from 4 migraine days per month and onabotulinumtoxin, which is only approved for chronic migraines from 15 headache days per month, all migraine prophylactics can be started if the patient's level of suffering requires it, regardless of the frequency of migraines. 

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

Any effective preventative measure initiated while episodic migraine is still present can counteract the progression and chronicity and development of medication overuse headache. This speaks for the early use of drug prophylaxis. Psychological comorbidities and complications of migraines can also be prevented.

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

The main indications for drug prophylaxis are significant suffering and a reduction in the quality of life of those affected, as well as an impending headache if medication is overused. Significant suffering occurs particularly in the case of frequent, long and difficult-to-treat attacks, complex auras, reduction or loss of ability to work, professional and social functions.

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