Stephanie J. Nahas, MD, MSEd, on What’s New in Headache Medicine

Headaches are very common among the general population in the United States. As one of the most common presenting symptoms, it is important for neurologists to stay up to date with practical and evidence-based clinical information.

To answer our questions about headache and advancements in management, Neurology Consultant caught up with Stephanie J. Nahas, MD, MSEd, who is the director of the Headache Medicine Fellowship Program, the assistant director of the Neurology Residency Program, and associate professor in the Department of Neurology at Thomas Jefferson University and Jefferson Headache Center in Philadelphia, Pennsylvania.

She recently spoke about headache and neuro-ophthalmology at the American Association of Neurology 2019 Fall Meeting.

NEURO CON: What is new in the area of headache medicine?

Stephanie Nahas: There is renewed interest in combination preventive therapy. This is something we have done in practice for decades without much scientific basis. Years ago, a large-scale National Institutes of Health–funded controlled trial, which assessed combination preventive therapy, was terminated early due to futility. However, more recent clinical trials of new and emerging preventive therapies (e.g., monoclonal antibodies designed to prevent the binding of calcitonin gene-related peptide [CGRP] to its receptor) have clearly demonstrated that adding on these new therapies to existing ones results in a similar degree of improvement compared with treatment-naïve individuals. Furthermore, as our understanding of migraine pathophysiologic mechanisms improves, we can envision combining preventive therapies with specific and potentially complementary, or even synergistic, mechanisms of action.

Additional reports of long-term safety and post-hoc analyses for the monoclonal antibodies continue to mount. We are learning that these treatments can be well-tolerated and effective for years. Patients who have experienced multiple treatment failures may improve with these new therapies, and in some ways, they may do even better than treatment-naïve individuals. They have also been shown to reduce disability by utilizing a variety of validated measures for it.

Other updates to be aware of include:

• One of the monoclonal antibodies has been approved for the treatment of episodic cluster headache.
• A first-in-class new acute treatment was approved by the US Food and Drug Administration (FDA) in July and is anticipated to come to market in early 2020.
• A new remote electrical stimulation device is available for the acute treatment of migraine attacks.
• Several additional acute and preventive medications and devices are currently being investigated and are anticipated to become available in 2020 as well.

NEURO CON: Can you give us a specific example of a challenging case? How did you manage that patient?

SN: A typical challenging case in our practice is someone in middle age who has had migraine for decades along with several other comorbidities (both medical and psychiatric) and presents with daily or even continuous migraine symptoms, for which dozens of past treatments have been inadequate or not tolerated. These individuals tend to be taking a lot of medication—not just for headache—and often cannot function normally.

They are disabled and unable to work, they can no longer enjoy activities that used to give them great pleasure, and their relationships have suffered. In many cases, they rely too heavily on medication, potentially to the point of requiring detoxification. Typically, inadequately managed mood and anxiety disorders can complicate the situation. They may even come to us stating we are their “last hope.” In such cases, careful attention to all the details is necessary to craft a tailored and efficient treatment plan in collaboration with our medical and psychiatry/psychology colleagues.

In the most extreme cases, inpatient treatment is required. In the hospital, we prescribe an aggressive regimen of intravenous medication to be given for several days until the pain cycle breaks. In addition, we re-examine their overall treatment plan, have them try devices, provide classes for headache education, and offer consultations for collaboration with psychology, psychiatry, nutrition, spiritual services, and physical therapy. In most cases, patients leave the hospital headache free or close to it and with renewed hope for a brighter future with their new headache plan.

NEURO CON: What are the key take-home messages from your session for neurologists?

SF:

• We are learning more about headache pathophysiology continually, with significant treatment implications.
• Antagonizing CGRP is now the most targeted approach to migraine and cluster headache therapy.
• Devices are gaining popularity.
• New treatments are here and are on the way, so get to know them!
• There remains much to be discovered—get in the game!