Migraine: Modern Medical Understanding and Therapeutic Approaches

Introduction

This article is based on the consensus statement by the American Headache Society, published in 2021 in the reputable journal Headache: "The American Headache Society Consensus Statement: Update on Integrating New Migraine Treatments into Clinical Practice." The primary authors of this work—Dr. Jessica Ailani (MedStar Georgetown University Hospital, Washington, DC), Dr. Rebecca Burch (Brigham and Women’s Hospital, Harvard Medical School, Boston), and Dr. Matthew Robbins (Weill Cornell Medicine, New York)—are leading American neurologists and researchers in the field of migraine and serve on the board of directors of the American Headache Society. Their goal is to provide the most recent, evidence-based, and expert-consensus information on the diagnosis and modern treatment options for migraine, integrating the perspectives of physicians, scientists, and patients.

Experts Speak

1. What are the goals of acute migraine treatment?

“The goals of acute treatment in patients with migraine include: rapid and sustained relief from pain and accompanying symptoms without recurrence, restored functionality, minimal need for repeat doses or additional medications, optimal self-management, reduced use of emergency care and other healthcare resources, minimal or no adverse events, and consideration of cost.”

The primary goal of acute treatment is for the patient to regain their activity as quickly as possible and to avoid chronification or worsening of the condition. It is important for the approach to be individualized based on each patient’s needs, and not solely based on standard protocols.

2. When should preventive treatment be considered for migraine?

“Preventive treatment in patients with migraine should be considered in the following cases: if the attacks significantly interfere with daily life despite acute treatment; in frequent attacks; in case of contraindications or ineffectiveness of acute therapies; in case of adverse effects from acute medications; based on the patient’s preference.”

Preventive therapy is not only for patients with frequent attacks, but for anyone whose migraine results in significantly reduced quality of life, inability to work or study, or for whom standard medications are not sufficiently effective or tolerable.

3. What are the new medications and approaches for migraine approved in recent years?

“New acute therapies include two small-molecule CGRP receptor antagonists (ubrogepant, rimegepant), a serotonin 5-HT1F receptor agonist (lasmiditan), a nonsteroidal anti-inflammatory (celecoxib – oral solution), and a neuromodulation device (remote electrical neuromodulation). New preventive options include the intravenous anti-CGRP monoclonal antibody (eptinezumab).”

In recent years, there has been significant progress with the introduction of medications targeting new biochemical pathways (the CGRP pathway), as well as neuromodulation devices that offer an alternative for patients who do not wish to use or cannot tolerate drug-based treatment.

4. How is the success of a treatment evaluated, and when should the approach be changed?

“Patient-oriented, validated outcome measures for acute treatment success can help determine whether the patient has achieved a meaningful response and can identify the need for therapy adjustments. Failure of first-line treatment with a triptan, or the emergence of intolerance or contraindications, means it may be appropriate to switch to another pharmacologic or non-pharmacologic strategy.”

Modern migraine treatment focuses not only on the number of attacks but also on the patient's quality of life and functionality. If a particular medication does not yield the expected result after a sufficiently long trial period, it is recommended to change the strategy rather than persist with an ineffective treatment.

5. What are the prospects and recommendations for integrating new therapies?

“The integration of new therapies should be informed by their potential benefits compared to established methods, as well as the characteristics and preferences of the individual patient… Personalized therapeutic plans are more likely to provide appropriate treatment during the initial consultation and spare the patient a series of unsuccessful attempts, leading to better outcomes and lower healthcare costs.”

Despite the wide range of medications available, there is no universally “best” treatment for everyone. Decisions should be based on the experience of the treating physician, the individual characteristics of the patient, the available evidence, and—more importantly—shared decision-making between doctor and patient.

Questions and Answers

1. How do I choose the most appropriate treatment for my migraine—medications or non-drug methods?

Answer: The choice of treatment depends on your individual needs, the severity and frequency of attacks, and the presence of other medical conditions. If you have mild to moderate attacks, you may start with common pain relievers (such as nonsteroidal anti-inflammatory drugs or combination products). For more severe attacks, or when these medications are ineffective, specific drugs like triptans, the newer “gepants” or “ditans” are recommended. If you prefer to avoid medications or cannot tolerate them, there are now medical devices for electrical stimulation and proven behavioral therapies (such as cognitive behavioral therapy, biofeedback, and relaxation techniques).

2. What should I do if I frequently vomit or experience severe nausea during attacks?

Answer: If you suffer from severe nausea or vomiting, the most suitable medications are those not taken orally—for example, in the form of injections, nasal sprays, or specialized electrostimulation devices. This is important because the drug is absorbed faster and its effect is not lost due to gastrointestinal symptoms. In some cases, antiemetic agents (suppositories or injections) are also used.

3. Can I take acute treatment medications frequently, or are there risks?

Answer: It is important not to use acute medications (to stop an attack) more than twice a week on average. Frequent use increases the risk of "medication-overuse headache," which can lead to chronic migraines and make them harder to treat. If you find yourself needing medication often, discuss preventive treatment with your doctor.

4. How long should I try a new treatment before deciding whether it is effective?

Answer: It is generally recommended to try acute medications in at least three separate attacks to assess their effectiveness. For preventive medications, the trial period is longer—at least 8 weeks at the maximum or usual dose. For injectable medications (such as monoclonal antibodies), the first evaluation of effectiveness is done after about 3 months, and sometimes after 6 months.

5. Can migraine be related to other medical conditions, and should I tell my doctor about them?

Answer: Yes, migraine often occurs alongside other medical conditions—anxiety, depression, asthma, epilepsy, stroke, and cardiovascular problems. It is essential to inform your doctor about all existing conditions and medications you are taking, as some treatments may be inappropriate for certain conditions (for example, triptans are not recommended for people with cardiovascular disease).

Conclusion

Modern migraine management requires more than a one-size-fits-all solution—it calls for a personalized approach based on the most current scientific data and strong communication between patient and physician. The 2021 consensus statement from the American Headache Society highlights the wide range of therapeutic options—from traditional medications to the latest biological therapies, non-drug approaches, and neuromodulation devices. Treatment choices should always reflect the personal characteristics, needs, and preferences of the patient, as well as the presence of other coexisting conditions. Only in this way can the path to better quality of life and effective migraine control become a reality for those affected by this often underestimated but significant medical condition.

Source Used: Headache. 2021;61:1021–1039. The American Headache Society Consensus Statement: Update on Integrating New Migraine Treatments into Clinical Practice. Jessica Ailani, Rebecca C. Burch, Matthew S. Robbins, et al. DOI: 10.1111/head.14153