In this symposium held at the 8th Congress of the European Academy of Neurology, Vienna, Professor Dawn Buse (Department of Neurology at Albert Einstein College of Medicine, New York, USA), Professor Uwe Reuter (Charité University Hospital, Berlin, Germany), and Professor Simona Sacco (University of L’Aquila, Italy) discuss how the number of days a person experiences migraine a month not only impacts symptom and disability burden on these days, but also ‘interictal burden’ on days when migraine is not experienced. Proper discussion between healthcare professionals and their patients is needed to help assess and treat both migraine symptoms and burdens, with the ‘ask-tell-ask’ method proving useful in this realm. Preventative medication, including the use of calcitonin gene-related peptide monoclonal antibodies, can reduce migraine severity and number of days a migraine is experienced, and also reducing interictal burden.
The large (n=21,143), USA based, OVERCOME study found that for people with migraine, disability, migraine symptom range, and headache severity increased with increasing number of headache days.1,2 Due to such experiences, work productivity can be affected, both through being absent and being present but not able to properly carry out tasks.3-5 Additionally reported are impacts of migraine on participating in family activities6 and the decision to have children.7 There are also economic burdens of migraine with regard to healthcare costs.8
Interictal burden describes how migraine can affect a person beyond symptom days
Even on days when a person is not experiencing a migraine, discussed Professor Buse, they may experience ‘interictal burden.’ This can be assessed using the Migraine Interictal Burden Scale (MIBS-4), which asks how much headaches affect work/school; planning and social/leisure activities; overall life; and feeling helpless.9 In the OVERCOME study, use of this measure revealed that 78% of people reported interictal burden, with 50% reporting it as severe.10 Such interictal burdens can include anxiety and avoiding aspects of daily life that may induce a headache.11
These findings, discussed Professor Buse, show that “migraine-specific quality of life (QoL) is substantially affected.”
Optimizing diagnosis and treatment
One important aspect of migraine and prevention Professor Reuter discussed was that patients may not feel comfortable discussing how their current migraine treatments are working and/or the burden migraine has on them. He encouraged healthcare professionals (HCPs) to build trust and open communication regarding providing a correct diagnosis, QoL, and setting up an effective management plan.
Professor Reuter also discussed the importance of using the correct lexicon to communicate what is known about preventative medication and explain how it can decrease the frequency of headache days and improve QoL.12 In the ‘Ask-Tell-Ask’ strategy, a patient is first asked to explain the issue in their own words, the HCP then tells the patient the relevant facts about their diagnosis and treatment, then, to confirm understanding, asks the patient to recall the information in their own words.9
Patients need proper investigation of symptoms and interictal burden
In the American Migraine Communication study, using this strategy, along with open-ended questioning, led to HCPs having a better understanding of a patients' migraine frequency and interictal burden, more frequent discussions regarding acute and preventative treatment strategies, and, from both the patient and HCP perspective, more satisfaction with the clinical visit.9,13
Calcitonin gene-related peptide monoclonal antibody (CGRP mAb) treatments to address interictal burden
The OVERCOME study revealed that even some people with ≥15 migraines a month had not sought care for such and that 81.6 % of people with 4−7 monthly headache days and 71.1% with ≥15 migraines a month were not taking a preventative medication, despite the majority being eligible for such.1
A variety of studies have investigated use of a CGRP mAb as preventative medication. While, importantly, studies have found direct impacts on levels of severe pain when a migraine was experienced,14 also importantly are findings on overall QoL, including on interictal burden. For instance, in one clinical trial, a CGRP mAb led to significant reductions in Migraine Disability Assessment Questionnaire scores compared to baseline following 4−6 months application15 and in the OVERCOME study, of those taking a CGRP mAb, 79.2% overall and 74.6% with ≥15 migraine days/month had higher Patient Global Impression of Improvement scores compared with baseline.16
Preventative medication can help with both symptoms and interictal burden
A real-world study also found benefits in patient-reported outcomes in those receiving a CGRP mAb,17 with another finding this medication provided an improvement in headache-related impacts on life.14 CGRP mAbs have also been shown to impact work productivity including decreases in missed time from work and impairment while working.18
However, some people are non-responsive to CGRP mAbs, with one study finding approximately 47% of patients with episodic or chronic migraine had a less than 50% responder rate19 and another finding this in approximately 37% of patients.20 Of note though, said Professor Sacco, these studies only measured monthly migraine days and did not assess factors such as residual burden where rates may be different.
Non-response is an issue as the worldwide ‘My Migraine Voice’ survey (n=11,266, migraine ≥4/month) of non-responders to at least one preventative medication found that 80% of respondents had to cancel plans, 52% reported migraine interfered with their cognitive abilities, 50% said they experienced a lack of energy, and 43% said they felt hopeless or helpless.21
For those where people indicated that preventative medication did not help them, it may, Professor Reuter pondered, be due to them not taking their medication for long enough as OVERCOME study results revealed that nearly a third took their preventative treatment for <3 months,22 which, he discussed “is not enough to achieve significant improvement.”
USA: United States of America
OVERCOME: ObserVational survey of the Epidemiology, tReatment and Care of MigrainE
QoL: Quality of Life
HCP: Healthcare professional
CGRP mAb: Calcitonin gene-related peptide monoclonal antibody
BE-NOTPR-0261, approval date 02-2023
