Synopsis of AHS criteria for initiation and trial period for acute and preventive therapy

Acute Therapies

AHS guidance for acute therapy1

Acute treatments are taken at the first sign of a migraine attack to reduce pain and attack-related disability.

Use evidence-based treatments, reserving migraine-specific agents for moderate or severe attacks and mild-to-moderate attacks that respond poorly to NSAIDs or caffeinated combinations.
AHS-listed acute therapies
Non-oral formulations should be used in patients with severe nausea or vomiting or who have trouble swallowing orally administered medications.
Use of acute treatments should be limited to an average of 2 headache days per week. Patients who exceed this limit should be offered preventive treatment.

Acute therapy considerations1

Use evidence-based treatments, reserving migraine-specific agents for moderate or severe attacks and mild-to-moderate attacks that respond poorly to NSAIDs or caffeinated combinations.
AHS-listed acute therapies
Non-oral formulations should be used in patients with severe nausea or vomiting or who have trouble swallowing orally administered medications.
Use of acute treatments should be limited to an average of 2 headache days per week. Patients who exceed this limit should be offered preventive treatment.
Oral Preventive Therapies

AHS guidance for preventive therapy1

Preventive treatments should be considered for episodic migraine patients with ≥4 monthly headache days, or when attacks significantly interfere with patients' daily lives despite acute treatment.

Using evidence-based treatments is critical to the success of preventive treatment.
AHS-listed oral preventive therapies
Oral treatments are generally started at a low dose and titrated slowly until the target response develops, the maximum targeted dose is reached, or tolerability issues emerge.
An adequate trial for preventive therapy is at least 8 weeks at a target therapeutic dose; if there is no response after 8 weeks at a target therapeutic dose, switching preventive treatments is recommended.

Oral preventive therapy considerations1

Using evidence-based treatments is critical to the success of preventive treatment.
AHS-listed oral preventive therapies
Oral treatments are generally started at a low dose and titrated slowly until the target response develops, the maximum targeted dose is reached, or tolerability issues emerge.
An adequate trial for preventive therapy is at least 8 weeks at a target therapeutic dose; if there is no response after 8 weeks at a target therapeutic dose, switching preventive treatments is recommended.
After failure on ≥2 oral preventives
Anti-CGRP Therapy

Anti-CGRP therapies are classified by the AHS as emerging preventive options, and they may be appropriate for patients who fail on 2 or more prior preventive therapies.1

For these patients, the AHS indicates initiation of anti-CGRP therapy if they continue to experience either1:

  • 4-7 monthly headache days with moderate disability
  • 8-14 monthly headache days
Anti-CGRPs are dosed monthly or quarterly.
The AHS recommends that the benefits of anti-CGRP mAbs be assessed after 3 months of treatment for those administered monthly and 6 months for those administered quarterly.

Anti-CGRP therapy considerations1

Anti-CGRPs are dosed monthly or quarterly.
The AHS recommends that the benefits of anti-CGRP mAbs be assessed after 3 months of treatment for those administered monthly and 6 months for those administered quarterly.
For full AHS Guidance on the use of acute, preventive, and anti-CGRP therapy, refer to the American Headache Society Position Statement on Integrating New Migraine Treatments Into Clinical Practice.

AHS = American Headache Society; CGRP = calcitonin gene-related peptide; mAbs = monoclonal antibodies; NSAIDs = nonsteroidal anti-inflammatory drugs.

AHS = American Headache Society; CGRP = calcitonin gene-related peptide; mAbs = monoclonal antibodies; NSAIDs = nonsteroidal anti-inflammatory drugs.

AHS criteria for initiation and follow-up for anti-CGRP therapy in adult episodic migraine patients

1

Assess frequency and impact of migraine1

4-7 headache days per month with at least moderate disability (MIDAS >11; HIT-6 >50)

OR

8-14 headache days per month
(no disability requirement)

  • The MIDAS and HIT-6 questionnaires assess impact across these general categories2,3:
  • The MIDAS Questionnaire measures the days missed or impacted by migraine over the past 3 months2,3
  • The HIT-6 survey measures patient limitations and physical changes on a 5-point scale over the past 4 weeks2,3
2

Determine medication history1

Inadequate response or intolerability over a 6-week trial on ≥2 prior oral preventive therapies

  • Topiramate
  • Divalproex sodium/valproate sodium*
  • Beta-blocker (metoprolol, propranolol, timolol, atenolol, nadolol)
  • Tricyclic antidepressant (amitriptyline, nortriptyline)
  • Serotonin-norepinephrine reuptake inhibitor (venlafaxine, duloxetine)
  • Other Level A or B treatments (established efficacy or probably effective) according to AAN-AHS guideline

*Not for use in women of childbearing potential who lack an appropriate method of birth control.

3

If patient meets criteria listed above, consider initiating anti-CGRP therapy1

The patient questionnaire available for download below can help you assess migraine impact and determine whether an anti-CGRP may be an appropriate treatment choice.2

Patient Migraine Impact Questionnaire
4

Assess anti-CGRP effectiveness after 3 months1

According to the AHS Consensus Statement, "It is recommended that the benefits of anti-CGRP mAbs be assessed after 3 months of treatment for those administered monthly."

AAN = American Academy of Neurology; AHS = American Headache Society; CGRP = calcitonin gene-related peptide; HIT-6 = Headache Impact Test; mAbs = monoclonal antibodies; MIDAS = Migraine Disability Assessment.