Which acute migraine treatment? For which patient? For which attack?

The migraine treatment toolbox is expanding, and acute treatment options can now be matched to different types of attacks. How do clinicians help patients choose the right treatment for their different migraine attacks? asked Professor Jessica Ailani, Medstar Georgetown University Hospital, Washington D.C. at the Virtual Scottsdale Headache Symposium 2020.

Acute treatment for migraine toolbox

An effect on headache pain alone is not sufficient to grant a claim for the acute treatment of migraine1

The migraine toolbox contains not only the traditional specific and nonspecific therapies but also many new pharmacologic therapies and neuromodulation devices with many different mechanisms of action, said Professor Ailani.

But which treatment is best for which patient and for which attack?

Professor Ailani said that the decision should be based upon:

  • the evidence base
  • an individual patient’s migraine characteristics including variety of attacks
  • potential barriers to prescribing


The evidence base—clinical trial endpoints and patient-reported outcomes

Moderate-to-severe pain must go to NO PAIN in 2 hours

Clinical trial endpoints to demonstrate efficacy have changed and this needs to be borne in mind when comparing current evidence with older evidence, said Professor Ailani.

In 2018, the US Food and Drug Administration (FDA) published new guidance for co-primary endpoints stating that an effect on headache pain alone is not sufficient to grant a claim for the acute treatment of migraine.1

The guidance aims to align study outcomes with the symptom(s) of most importance to patients by demonstrating an effect on both pain and the patient’s most bothersome symptom connected with the migraine attack—ie, nausea, photophobia or phonophobia.

Epidemiology studies have shown that photophobia is the most bothersome symptom for ∼50% of people with migraine,2 said Professor Ailani.

The most bothersome symptom is chosen from nausea, photophobia, or phonophobia

The two co-primary endpoints cited by the FDA for acute migraine therapeutic trials are:

  • No headache pain 2 hours after dosing
  • A demonstrated effect on the most bothersome migraine-associated symptom 2 hours after dosing1

Regardless of which is the most bothersome migraine-associated symptom, nausea, photophobia, and phonophobia, should all be assessed separately as secondary endpoints.1

Professor Ailani commented that the evidence base also needs to provide information on patient-reported outcomes such as return to normal function, satisfaction with treatment, and reduction in disability.3


Migraine and patient characteristics and barriers

New mechanisms of action may benefit patients experiencing issues with traditional therapies

Novel treatments have new mechanisms of action that target specific issues and concerns for patients, said Professor Ailani. For example, new treatments may be indicated for:

  • patients experiencing adverse events or lack of efficacy with traditional therapies
  • patients with cardiovascular disease or other comorbidities that might preclude use of traditional therapies

A potential barrier, however, can be cost for patients without insurance.

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

  1. U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research (CDER). Migraine: Developing Drugs for Acute Treatment Guidance for Industry. 2018. See https://www.fda.gov/media/89829/download Accessed 12 Dec 2020.
  2. Munjal S, et al. Headache 2020;60:416–29.
  3. Mannix S, et al. Health Qual Life Outcomes 2016;14:143.
You are leaving Progress in Mind
Please confirm your email
We have just sent you an email, with a confirmation link.
Before you can gain full access - you need to confirm your email.
The information on this site is exclusively intented for health care professionals.
All the information included in the Website is related to products of the local market and, therefore, directed to health professionals legally authorized to prescribe or dispense medications with professional practice. The technical information of the drugs is provided merely informative, being the responsibility of the professionals authorized to prescribe drugs and decide, in each concrete case, the most appropriate treatment to the needs of the patient.
Register for access to Progress in Mind in your country