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AHS GUIDANCE FOR TREATMENT COURSE
AHS GUIDANCE FOR ANTI-CGRPs

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.

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.

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.

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.

Oral preventive therapy considerations¹

Using evidence-based treatments is critical to the success of preventive treatment.

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.

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-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.

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 Guidance for anti-CGRPs

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)

MIDAS and HIT-6 questionnaires evaluate migraine burden

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

2

Determine medication history¹

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

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."

AHS Guidance for treatment course

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.

Established efficacy*

Triptans
NSAIDs
- Aspirin
- Diclofenac
- Ibuprofen
- Naproxen

Ergotamine derivatives
Opiods
- Butorphanol^†
Combination medications

Emerging agents

Gepants^‡
- Ubrogepant
- Rimegepant

Lasmiditan

*Consider single-pulse transcranial magnetic stimulation, noninvasive vagus nerve stimulation, or electrical trigeminal nerve stimulation in patients who prefer nondrug treatments or in whom drug treatment is ineffective, intolerable, or contraindicated.
^†Use is not recommended.
^‡Patients who have contraindications to the use of triptans or who have failed to respond to or tolerate at least 2 oral triptans, as determined by either a validated acute treatment patient-reported outcome questionnaire or healthcare provider attestation are eligible for ubrogepant, rimegepant, or a neuromodulation device.

Established efficacy^†

Antiepileptic drugs^‡
- Divalproex sodium^‡
- Valproate sodium^‡
- Topiramate^‡
Triptans
- Frovatriptan^§

Beta-blockers
- Metoprolol
- Propranolol
- Timolol

Probably effective**

Antidepressants
- Amitriptyline
- Venlafaxine

Beta-blockers
- Atenolol
- Nadolol

Possibly effective^††

ACE inhibitors
- Lisinopril
Antiepileptic drugs
- Carbamazepine
Antihistamines
- Cyproheptadine

Alpha-agonists
- Clondine
- Guanfacine
Beta-blockers
- Nebivolol
- Pindolol
Angiotensin receptor blockers
- Candesartan

*Medications may not be FDA approved for the preventive treatment of migraine.
^†More than 2 Class I trials based on AAN Scheme for Classification of Evidence.
^‡Not for use in women of childbearing potential who are not using an appropriate method of birth control.
^§Short-term prevention of menstrual migraine.
**One Class I or 2 Class II studies based on AAN Scheme for Classification of Evidence.
^††One Class II study based on AAN Scheme for Classification of Evidence.

Indication