A Review published in the Journal of Headache and Pain explores both the biological and clinical rationale for stopping migraine prophylactic therapies.
There remains controversy over whether, in the case of adverse events, we stop a medication completely, or switch to another medication in the same class, i.e. CGRP targeted mAbs. Patients will additionally have differing levels of tolerability, with some people unwilling to remain on a medication with mild side effects, to others tolerating ‘worse’ side effects when weighed up against the severity of their migraines.
For onabotulinumtoxinA, in contrast, stopping rules are longer than those of oral preventive drugs. This is due to its intramuscular administration, which bypasses metabolization via the gastro-intestinal route and avoids interactions with e.g. cytochrome P450 enzymes, in contrast to oral preventives.
For our included studies, the duration is often six months to one year. This highlights the need for longer studies investigating long-term efficacy and long-term discontinuation effects. As gepants and CGRP targeted mAbs become more widely available to EM and CM patients, more robust clinical trials will need to be conducted – not only looking at efficacy, but also discontinuation effects.
]. Ultimately, the identification of objective biomarkers for disease improvement and prognostic features of treatment relapse would bring advantages in determining whether and which migraine patients would benefit from discontinuing migraine prophylaxis.Current guidelines advise clinicians to assess the success of CGRP targeted mAbs after three months and to continue when the treatment is successful.
France Dernières Nouvelles, France Actualités
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