Title : New trends in migraine management: Transcending the traditional divide between acute and preventive treatments
Abstract:
Migraine treatment is categorized into acute and preventive approaches. The primary goal of acute treatment is to alleviate headache and associated symptoms rapidly while minimizing adverse effects, allowing patients to return to normal functioning. Preventive treatment focuses on reducing the frequency, severity, and disability of migraine attacks, as well as enhancing the response to acute treatment. Current guidelines typically address these two approaches separately.However, with the discovery of calcitonin gene-related peptide (CGRP) and its crucial role in migraine pathophysiology, CGRP receptor antagonists have been introduced, including rimegepant, which has been approved for both acute and preventive treatment.
In addition, emerging researches indicate a significant interaction between acute and preventive treatments: First, studies demonstrate that acute treatments such as lasmiditan and rimegepant not only effectively manage symptoms during migraine attacks but also reduce the frequency and disease burden over time. In our clinic, we have observed that patients using rimegepant during an attack experience rapid symptom relief and improved functionality, with subsequent follow-ups revealing a decrease in migraine frequency and degree of disability. Furthermore, findings from the American Migraine Prevalence and Prevention (AMPP) study suggest that more effective acute treatment is associated with a lower likelihood of disease progression, indicating that optimising acute treatment could help to prevent the chronicity of migraine, which is consistent with the aim of preventive treatment. Second, preventive medications can also exert acute effects and influence the efficacy of acute treatment. A randomized controlled trial (RCT) showed that intravenous eptinezumab could provide rapid relief of headache and accompanying symptoms in patients, and subsequent follow-up revealed enhanced effectiveness of acute drugs. These suggest that acute and preventive treatments are not entirely independent; rather, there may be a novel treatment paradigm where acute treatment can offer preventive benefits, meanwhile, preventive treatment also has acute effects and can make acute medication work better. This model transcends traditional divide between acute and preventive treatments and offers a novel perspective for managing migraine.
Currently, indications for preventive treatment initiation are primarily based on headache frequency. However, some patients may meet criteria for prevention yet achieve stable control of migraine with a low-frequency and tolerable state through optimized acute treatment without the need for daily medication, thereby reducing their living and economic burdens. Therefore, clinicians should recognize that acute and preventive treatments are closely linked therapeutic goals aimed at improving migraine management and preventing migraine progression. Personalized treatment plans should be developed to enhance both acute and preventive treatment outcomes and reduce the overall disease burden for patients.
