Welcome back . Everyone from the break . We are now going to begin our fifth session , which is titled State of the Art 2023 Patient centered migraine Care Implications for Clinical Practice and presented by Doctor Jessica Alai . Doctor Jessica Alai is the director of the Georgetown Headache Center and Professor of Clinical Neurology at medstar Georgetown University Hospital in Washington DC . She also serves as an advisor to the National Headache Committee . Please welcome Doctor Alai . Hello everyone . Thank you so much for having me join you this afternoon for this session . Uh These are my disclosures , many of which are relevant to our conversation today as they relate to migraine . Next side , please . We're gonna be having a conversation talking about migraine care especially as it pertains to many of the new emerging treatments that have come to market over the last several years . We're gonna talk a little bit about what we have to use currently , what we've been using traditionally in the care of migraine patients . Also talk about some of the emerging treatments and really discuss how we can take clinical evidence in this . Uh look at that and facing patient clinical scenarios and really make decisions and help our patients guided through decisions about what might be the best treatment option for them . In the end , we know that good communication skills and shared decision making is really what should guide patient care . Sometimes this might be limited by insurance or what we have on formulary . But it is always important for patients to know what treatment out options exist out there for them . And I hope at the end of this discussion today , you're gonna have a much better sense of what those options are and how that might be able to fit into a toolkit for a patient who has migraine next slide . So let's start with a case . Here's a patient who's 26 who comes in to see us who's having two days a month of disabling , unilateral head pain with associated nausea , photophobia , dizziness , and poor concentration . She meets what we call standard criteria for migraine without aura . And to make the diagnosis of migraine . Usually what you're looking for are features of head pain which are often one sided though they can be both sided in nature . Usually the head pain is moderate to severe if untreated can last four hours to 72 hours if untreated . And the pain often is throbbing or pounding and gets worse with physical activity . And that's if the patient were even to walk around , they'll notice that the pain tends to worsen . They are also associated symptoms with that head pain that distinguishes the headache from a regular headache and makes it a migraine associated features that are the most common in migraine are nausea and or vomiting or light and sound sensitivity , which are traditionally called photophobia and phonophobia . A person with migraine has to have one grouping of these two , either nausea or vomiting or photo and phonophobia to meet the criteria for diagnosis of migraine without aura , which is the more common type of migraine . So , here's a patient who has migraine without aa coming to your clinical practice telling you that the symptoms are disabling and they're occurring about two days a month . What are we gonna offer her as an option ? Next slide . So here we have a polling question is the first of two in the slide deck and this is just gonna show you how to activate the polling question . You can either go by web or if you're using your cell phone , you can join by text . And this gives you some instructions here . And these are the options . We can either give her Ibuprofen 800 mg or tell her to take Ibuprofen , Sumatriptan 100 mg , Talbot , Acetominophen caffeine combination pill or meclozine 25 mg . I'll give you all a moment to answer . This question . Looks like the responses are settling down a bit . And so here we can see a small portion of people would think about Ibuprofen . Uh Majority of people would choose Sumatriptan , which is a prescription , migraine specific treatment option in the Triptan category . Uh Some patient , some people about a third of you would choose Balbi acetaminophen caffeine , which is a treatment option available for migraine , but is not really a very specific treatment option . And none of you have chosen Meclozine , which is not an option to treat migraine , just throw it in there to make things a little bit confusing . So the answer here would be B Sumatriptan while Ibuprofen is not incorrect . The idea is that this patient likely has already tried something over the counter before she's come in to see you in clinical practice . And most likely she's already tried an NSA a nonsteroidal anti-inflammatory and most often patients have tried acetaminophen over the counter and Ibuprofen over the counter before they come to see you in practice . And a higher dose of Ibuprofen isn't necessarily going to be more effective , especially if someone's having disabling attacks , you want to try to get her a more migraine specific treatment option . And the trick hands being around for decades now being all generic are generally the most affordable treatment options , especially for an individual who's healthy and doesn't have any comorbid issues that are contraindicated for use in a patient with migraine and generally are the first line things we're going to for a person who comes in with disabling migraine attacks . So this is an example of something called acute treatment for all people with migraine . Every patient should have an acute treatment in their toolbox to use when they're having a migraine attack . Unfortunately , we see that less than one in five people with migraine have a migraine specific option to use to treat their migraine attack . We can see here by some of these statistics that less than 40% of people have ever tried a trip and that less than 15% are currently using a Triptan at a given time and many people who try Triptan don't end up refilling it . And this is for various reasons including side effects and feeling incomplete efficacy . Many people who end up on treatment for migraine aren't really satisfied with the treatment options . They have , they feel it doesn't work fast enough . They feel like there's not enough efficacy . Maybe they have partial response but it's not complete . Maybe it takes care of the headache but not the associated symptoms . Maybe they feel like they can't use it as often as they need or they're concerned about medication , overuse headache . And then our patients that have more frequent migraine , this tends to be a concern and we're gonna talk about all these items . So don't worry that I'm rattling off a whole bunch of symptoms all at once . When we survey people with migraine who have a migraine and have treatment options available to them . We see that most all people who have migraine still have at least one unmet acute treatment need next slide . So this continues to be a problem because when we look at people with migraine , if everybody needs something to treat their attack , and we ask patients and we ask providers , well , what are the goals that are needed to be met to make sure that they have good treatment for those attacks ? We can start to understand why maybe there's still some unmet needs on the table . Well , patients and us both want these attacks to be treated very quickly . Whereas a health care provider might think 1 to 2 hours is pretty good . Most patients can understandably want treatment to start to work in as soon as 15 minutes . That can be problematic if they're going to take a pill , which is usually the most preferable way to take an option for migraine . That's gonna take a little longer to work . Nobody wants the patient to have to use multiple medications to get rid of their migraine attack . They , they want it to be one and done and that's what we want for them as well . Patients and providers want the person to go back to full functioning after treating the attack , get back to work , get back to picking up your kids , get back to normal life . That's really the goal of acute treatment . We also don't want our patients to have to call us to find out what to do next because their treatment didn't work and we don't want them going to the emergency room . We want them to be self sufficient , able to take the treatment and not have to rely on anybody , especially since this disease tends to take so much away from them and takes away so much of their independence . So being able to be self reliant is very important . Now , we want all of this and our patients want all of this in a very cost effective manner with minimal side effects . Now you can see why there tends to be continued unmet needs in the field . Next slide . So let's talk about what the options are . And you can see here , we have grown quite tremendously as a field and that we have a number of established effective options available to our patients with migraine established efficacy would be what we consider level a evidence for acute treatment and migraine and probably effective are what we consider level B evidence . You can see there's a lot of treatment options out there for patients with migraine and none of these include opioid treatments , which is really important to us is is the field has for a very long time moved into more specific treatment options for migraine focusing on the path of physiology . This talk is really gonna focus in on this orange box of established efficacy and we'll talk a little bit about probably effective uh ergotamine . So the orange stuff . So you uh the the green um box , just the ergotamine category . So we're gonna talk about Triptans . We're gonna talk about G pans . We're gonna talk about LAS and we'll talk about um , one of the newer uh NSA that have come out in the past year . Next slide . So let's start by talking about Triptans . I mentioned these are one of our oldest drugs that have been out there . They are several of them , as you can see from the list here and they are generic . They're also available as oral nasal and injectable options , which are really great for our patients who have a lot of nausea or who potentially have vomiting at the onset of their migraine . If you're going to swallow a pill and then throw up , it can be very problematic because that pill is not going to do its job . So having non oral options for our patients with migraine is extremely important . Triptans work as an agonist of five HT one B one D receptor . These are serotonin receptors when they were first created , it was thought that they were effective because they caused vasoconstriction . And at that time period in migraine , the thought was vasodilation was a cause of migraine and vasoconstriction would heal migraine . Around that time . Some scientists were starting to also realize that by using a triptan , you were also modulating a protein called calcitonin gene related peptide CGRP . And that when you blocked five or stopped this five HT one B activity from happening when you were um activating the receptor and changing the receptor activity . And changing um this serotonin levels , you were also reducing CGRP effect in the trigeminal system . And by doing that , was it possible that's actually how the chip TI was working ? And if so , could we reduce some of the downstream side effects that chip ti was having ? So that was the start back in the early nineties of a theory that it might not just be vasodilation that's causing a migraine , but there might be something else going on and we could maybe make a better treatment option that doesn't cause vasoconstriction , which is the problem with the Triptans while they are effective for up to 65% of people with migraine , they're not 100% effective . They come with some negative side effects for some patients where they can feel some chest pressure , some shortness of breath pain in the jaw , tingling in the body . And sometimes patients can have a , a lot of fatigue with this medication which will delay their use in and when they're having a migraine and then it's not as effective . The other trouble with strip tans is that more often you use them , they can cause medication , overuse headache , which again , we'll discuss a little bit later in this talk . Again , an important thing to know about the Triptans is there's several of them , they're generic . They're great options as a first line generic treatment for patients with migraine who do not have uncontrolled hypertension , who do not have vascular issues and someone who's never tried a prescription medicine before , they are some that work quickly and then get out of your system quickly . That's the majority of them . And then there's some that work fast , but stay in your system longer . That's near Tripp Tan and frovatriptan . And they should be the preferred for someone who has very long onset attacks like menstrual migraine or just longer duration attacks . Next slide . Now , I mentioned what if we could design a drug that's a little bit more specific than a trip . And that would be a Ditan . Right now , there's only one available titan on the market and that's called Lami . It's a five ht one F agonist , the beauty of a five ht one F receptor . It is not located on blood vessels . So here we have a scenario where we modulate the serotonin system block CGRP activation but do not cause vasoconstriction , making a drug that's safer without the chest pain or chest tightness or shortness of breath side effects safe to use in somebody who has cardiovascular contraindications , but still effective for migraine . So , when Lamina Da was created and studies were done , we saw similar efficacy rates to Triptan without the cardiovascular complications . So this was pretty amazing . The trouble with the die tan is that it is both centrally and peripherally acting . So it does come with some central side effects like fatigue sedation and dizziness , which can be a limiting factor for the treatment studies show that only a single tablet is needed to treat a migraine attack and it is available in three doses . Though the higher two doses of 102 100 mg seem to be more effective . They can cause more sedating side effects . So it's just a limiting factor of the treatment . There are some important precautions to know about les Medan . You cannot drive for eight hours after use and the patient needs to be advised about this . It is a controlled substance because it's centrally acting and new FDA requirements require that centrally acting agents at this time require a special study done to look at um their likability compared to uh other controlled substances like alprazolam . Uh And because it works on the serotonin system , there's a small chance of serotonin syndrome just with Lesin alone . They don't need to be on another uh serotonin drug for this to occur . The chance is very small because it's a five ht one agonist and it's an agonist medication . It still can potentially cause medication , overuse headache . So the limit is no more than eight days of treatment per month . Next slide , what if we were able to get even more specific and just block the activation of CGRP ? Could we actually move away from the idea of medication overuse headache ? Which again seems to be a limiting problem also by blocking CGRP . What if we stay more peripheral in the nervous system ? Could we still treat migraine without getting those central nervous system side effects that can sometimes be problematic for patients . So here they've created a drug in a category called G pants . These are medications that block the CGRP receptor , they're antagonists . So they're not agonists and they don't cause medication , overuse headache , they're blocking the activity of CGRP by blocking its ability to bind to the receptor . Currently , there are three CGRP receptor antagonists that are available for acute use in migraine . Two of them are tablets and we'll talk about them here . One of them is a nasal spray . We'll talk about later . Ebro and rant were the first two G pans approved for acute treatment and migraine uro Japan has two doses available . Rant has a single dose available . The main difference between the two is the half-life ripen is a single dose in a day , has a longer half . Life is an oral dissolvable tablet . Bro has a shorter half life comes in multiple doses and it is uh a tablet . So the patient has to swallow it . How do you choose between a longer duration , a shorter duration ? A tablet , an ODT formulation . Well , if a patient has a lot of nausea doesn't want to swallow . A pill has migraine that starts in the middle of the night and drinking some water might be hard . An ODT formulation might be better , longer lasting migraine , menstrual migraine , they have uh attacks that tend to last a day a day and a half a longer half life is gonna be a better option for them . They have short attacks , they wanna rescue . They want to take a second dose of the same medicine if they had to , having an option of a second dose is usually something a patient might like in those scenarios . So ebro pan might be a better option for them . These are medications that process through the liver . The sip three a four system . So there could be drug drug interactions because your bro pan has multiple doses . If a patient is on a medication that might have a drug drug interaction , you can actually adjust the dosing with your bro . You don't have that option with the , this is where having multiple options is really nice because you can help the patient choose the right one based on other medications they have and the type of migraine profile they do have . You can see here , the side effects are generally well tolerated . There is a mild uh ability for the patient to have some nausea on these treatments usually less than 4% . U bro had some soul at doses of 100 mg at around 3% dry mouth came up at 100 mg of uro at about 2% . So again , there was no driving warnings , no central system nervous system side effects that were significant and no serotonin syndrome that came up . So that was nice with these treatment options . Next slide . So what if we have a patient , um , who's tried a trip tan ? It kind of works . They've tried a G pan , it doesn't really work . The Triptan kind of works but makes them tired . So they delay treatment . How do you treat that ? Sit ? What do we do for that patient ? What Toolkit do we develop in that scenario ? We might add an N A so the patient can start treatment early and if the treatment doesn't work , they can rescue with their trick tan , which they'll take later in the day . And if they're tired in the evening , usually patients like to get better rest with their migraine . If the migraine gets better and then they get a good night's rest , it doesn't come back the next day . This might be a scenario where we will pull out an option like some of the new nsaids that have come out for migraine cello coi oral solution is an example of that . It's a Cello Cox is a well known NSA , a cox two inhibitor in the field of pain and has actually been only studied as an oral solution for a migraine . And this is a liquid solution comes in a tiny bottle . The patient can take it to go . This is a pooled efficacy data from two randomized control studies for acute treatment of migraine in adults . They treated a number of attacks and you can see here their pain freedom rates for silico were somewhere in the 30 to 40% range . Pain freedom rates for the G pants are usually around 21% . And pain freedom rates for Trip Tans are usually in the 30 40% range . So their pain freedom rates here were pretty comparable to Trip Tan . Uh their one hour pain freedom rate was also statistically significant . So here we're seeing maybe we're getting closer to that desire for patients to have faster onset efficacy . Main treatment , side effects are dysgeusia and nausea and clinical practice . Main complaint is the taste of the medication easily solved by having some water after use . So we'll often use this medication if a patient wants a faster on of efficacy . If they've tried a G pan and Triptan and they weren't effective or if they need an additional help , they want something that's faster than their GP or , or with less side effects than their trip tan , they might use this first and tend to use those less often next slide . So how do we decide when we're gonna use a traditional Trip tan compared to some of these newer medications that might be a little bit more costly . Well , we have some consensus from the American Headache Society that gives us some suggestions . When do we go to newer trip tans ? And the general guide is try , uh , try a generic treatment , first , try a Triptan at least twice , two different types . And if the patients intolerant to them has side effects or they're not effective or for any reason if there's medical contra indications , you know , then move on to a newer therapy and you need to document this and document it clearly or send a letter of medical contra indication . Like my patient has had a stroke , it's not safe for them to use a trip tan . Uh A gant is a much safer option or a die tan is a safer option for them . And that's why I'm recommending we go straight to that treatment option . Next slide , I'll often get asked at conferences and a very good question . So there are all these new treatment options . Are they better than our traditional option ? Well , the answer is when we look at pain freedom and pain relief . If the patients actually feeling better on a trip tan versus our newer treatment options like Las rip or uro pan , the answer is actually no , the Triptans have better pain freedom and pain relief data . Uh when we do any kind of meta analysis , but when it comes to side effects , Ebro pan or Midan perform much better than Lami or the Triptans and Las Mitan performed the worst in meta analysis compared to the trip tans and the G pans . So why is this important to understand if you give a patient a treatment and they tend to be worried about side effects or they tend to have a lot of side effects and they use a treatment and they have a very bad side effect . If you recall the very first slide where I said most patients don't end up refilling their tripped hands , they won't refill and they might not come back to see you again or talk about this problem in the future . And that's a really big issue . If many of our patients with migraine are significantly disabled from the disease and think there might not be other options out there . That doesn't mean I automatically go to expensive treatments . It means I tell my patient , I'm starting with this because this is a trip tan because it does work better for many patients . If you do experience side effects , we do have many other options . So it's important you tell me this when we come back the next visit and then we talk about how they're doing in a follow up . But that open dialogue and communication , it's important . They know there are other options out there . So they do come back and they're not left disabled and it just ends right there . Next slide . So just two points I want to make about some real world evidence we have about the g pants and just to summarize real world studies have a lot of limitations , but they do teach us a little bit about what actually happens when patients like the treatment they're taking . And the limit is if a person likes a treatment and does a study , you're only gonna learn that they like the treatment that they're taking . But what I like about some of this is what does happen when they like the treatment . This study here tells us what happens when a patient's on ebro pan and they like ebro pan . Well , they're really satisfied , they feel very normal and they stop taking opioids and balbi , which we know leads to brain changes that can actually worsen pain and can worsen migraine . To me , this is extremely important because we spend a lot of our time trying to wean patients off butalbital and opioids and overuse of triptans . And if all we have to do is find a better acute option and stop lecturing them about all of these other things . That's pretty amazing . Next slide , we also have a lot of long term data , long term safety data from open label studies from these treatments . And this is one looking at remi over 52 weeks , showing us that in some of these studies , this is a study where patients could take up to 15 days a month of remi for acute treatment of migraine . And they looked at their patients in the study and they found if patients had at least six days of migraine per month and used acute treatment up to 10 , 12 days a month , they actually had a reduction in the number of migraine days a month . They had over time , all you had to do is give the patient remeant and say use it all you need to and do nothing else . And their migraine improved . This to me is also exciting because it makes my job so much easier . I just give a patient an acute treatment that actually works for them and let them be without again giving them lectures about things . They need to do better to be a better patient . It just needs to be treating the disease in a way that works without the treatment we're giving them causing them more problems . So when the treatment works , it can be really effective in not only treating the acute attack but treating the disease process over time . Next slide . So I mentioned before that having non oral options is extremely important because just like this case here , we have patients that take tablets because it's easy for us to write them and it's easy for them to take them , but then they can have trouble . So here's Niel , she's 44 . She's chronic migraine . She's on two preventive treatments for migraine and we get a little bit better control of her disease , but she still needs to take an acute treatment when she has attacks . So she gets a nausea and every once in a while she vomits with her attacks and she takes an oral Rhiza Triptan a trip , which is usually very effective for her except for the times that she vomits . And she says , Doctor Alani , sometimes I take the viso trippin and I throw it up and I can see the pill in the toilet . But do you think it still worked ? Because I , I don't , I don't know , I don't know what I'm supposed to do when I , when that happens . Like , do I take another one right away if I'm still feeling nauseous , is it still gonna come back up ? I mean , that's a really good question . And often when things like that happen , I feel really pretty dumb because I haven't figured out that my patient is nauseous and is vomiting and I should have given them a non oral option . Next slide . So we are lucky that there has been development of non oral treatments for migraine . But this list is much shorter than many of our other lists . It's always important for us to ask proactively about if the patient has vomiting with their attacks , how often they have vomiting and the fact that there might be non oral options , we need to add into their regimen , but they might not be using it for every attack . A patient might not want to always use an injection , but they're gonna have to know if they're using an injection for some attacks . How , um , are they going to use a noninjectable for other attacks ? And I'll give you an example from my clinic today . I have a patient who some of her attacks build very gradually and the others are very sudden wake her up at night and she starts vomiting . So for her , we use Sumatriptan . She has a tablet form for those that build gradually and she has an injectable form for those that are sudden and onset and she knows how she can mix and match them if one starts gradually and then suddenly turns into an attack where she's throwing up . What the time difference is between the two , how she can layer the two together and what's safe to use . And that's the kind of important information they need to know if . However , I had her on um an oral trip tan and her rescue was and then said , you know , again , it would be safe to combine them , but she just needs to understand how to do that and it all should be written up for them . Next slide , I did mention that there are other um non oral medications we're gonna talk about one of them being an Ergo me . So DH E is kind of , I think of it as the oldest forms of migraine treatments that we have . It was actually uh looked at for a migraine in the 19 thirties originally was um found to be effective , but it's , it's not the easiest thing to take because as a tablet it doesn't work so well and it has to either be injected or used as a nasal formulation . It is what we call a dirtier compound than even a trip tan . It's even broader acting than a trip tan . But this I think is what makes it so special and so effective . When you have a patient that uh the more specific you get those options are working . Sometimes you need to take that step back and be broader in your action . And that's where DH E can come in your patient , where the Triptan is not effective , the GP is partially effective , then you want to step back and be broader in your action . And this is where DH E can be effective . It is important to realize though it's vasoconstrictive , it's a veno um constrictor . So you want to be careful in patients who have hypertension or uncontrolled hypertension or other cardiovascular disease . Um But another positive about DH E is it can work day two of an attack , it can work day three of an attack . It can be very long in its onset . So someone can take a dose and feel better , not only that day , but the next day too . So it has some benefits that the other treatments don't . Next slide , there has been um a new device within DH E that's come out . It's a pod that you put on top of a nasal spray . And they've studied how this device makes DH E nasal spray more effective than the traditional um Migra uh which is available as the nasal spray itself . And they compared this to usual standard of care that patients that have migraine use . And they found that people who took this pod device with DH G nasal spray found it to be very effective though many patients did have side effects , most often they feel congestion in the nasal cavity probably because of the venoconstriction that happens in that region from exposure to DH E . Next slide . Uh There is that one G pan that is uh now FDA approved for use as a nasal spray called zap pan . It will be available sometime in July . It's a single dose that can be used as needed when you're having a migraine attack . And their two hour pain freedom rates were similar to other G pans in that 24% range . Uh important to realize that , you know , it can be a little bit faster onset than an oral Gantt where some patients are starting to feel better in that 15 to 30 minute range . But really important to have a non oral treatment option for patients who G pants are very effective . Main side effect really is that um dys and nasal discomfort again , any time you're putting something in the nasal cavity , these are not uncommon side effects and important to consider in someone who has nausea and vomiting with their um treatment or who not with their treatment or nausea , vomiting with their migraine , someone who wants a slightly faster onset , someone who prefers a GPA but wants a non oral route . And this is the a next generation G pan . It's a third generation G pan . So someone who maybe thinks you go Japan or Rean is only partially effective . This might work differently what , what we don't know yet , but that remains to be seen next slide . So we have so much acute stuff to talk about , but probably what I think excites many of us is the idea of neuromodulation . It sits in this bridge between acute and preventive treatment and we have many devices that change brain activity by using them as needed for migraine but sometimes also frequently . And I'll show you a slide later for prevention of migraine . These are either tens unit devices like the super orbital transcranial stimulator which sits right in between the nerves up top . There's also the non-invasive combined occipital trigeminal nerve stimulator that stimulates both the occipital and the super orbital nerves . That's also a tens unit device . Then we have a single Transcranial magnetic stimulator . You put at the back of the head and it does pulses . That way we have a non-invasive vagal nerve stimulator sits on the neck and the remote electrical neuromodulation which sits on the arm and shuts off , turns on the brain shut off pain valve as I like to call it , it's a little bit more complex than that but has a very different mechanism of action . We think about neuromodulation devices and any person who wants a nonmedication option has tried medications and they're not effective or they cause side effects , needs more options in their treatment plan . And in a headache center , I would say about half of our patients are on some sort of neuromodulation device have been discussed . Some neuromodulation devices tried at least one or two of them . Um and either is using one for prevention or one for acute treatment . Next slide , there was actually a publication just came out a few days ago for the a remote electrical neuromodulation device and safety in pregnancy . So some of these were actually using for patients during pregnancy as a treatment option as well . So I've been mentioning a lot about medication , overuse headache . And it's this idea that when you overuse certain treatment options for acute treatment and migraine that they can actually make the migraine worse . And we think this is true based on epidemiology data that we have . And we think it's particularly true for Triptans when they're used more than 10 days a month . Uh combination analgesics used more than 8 to 10 days a month , opioids , more than eight days a month . Um when you use balbi combination or Balbo alone more than five days a month . And then , um there's some controversy about DH G . The suggestion is more than 10 days a month , but it's not really clear . And then nsaids can be protective if used up to nine days a month and then could potentially cause medication overuse headache if you use more than 15 days a month . So there's some confusion about that . We think that a medication overuse headache is probably under reported , but a lot more complicated to make the diagnosis . It's hard to really say somebody's having headache related to acute treatment until you stop the acute treatment and the headache gets better . It's difficult to say this because many times a person's headache was just getting worse and they're just using the treatment as a way to try to gain some control back of the headache . But you really can't figure out if that's the problem until you stop the treatment , which is not easy to do if somebody is suffering every day . This is very different than the idea of medication overuse . If somebody's over using medication , there's significant other problems going on . This might be due to anxiety . This can cause significant other side effects like G I bleed renal problems , liver problems . And we see this very frequently in headache clinic . I cannot tell you how many of my third year old patients have already had a peptic ulcer because over the counter treatments are not considered treatment . So they tend to under report their use of nsaids and tend to overuse them for so many issues and end up with problems . There was a publication not too long ago , taking a look at rates of G I bleeds in people with migraine finding exactly that , that rates of peptic ulcer disease of 30 year old women with migraine were much higher than the average population . And that's probably related to their use of over the counter treatments for migraine next slide . So I've been mentioning this uh tool kit to build for your patients with migraine . You don't necessarily give them all of these things on the slide . But the idea is to slowly over time , build a kit that they can use to treat their attacks and the kits can have things like medication , it can have deep breathing exercises , some behavioral techniques . Um But they should have a good idea of what to use during which kind of attack . And they can be able to pull that out when they're a little bit unsure what to do . And that the idea here is we have so many treatment options again , not including opioids , not including vital that we can really use to help our patients when they're struggling with different attacks . Next slide . So we're gonna move on to talk about prevention . Now , what's the idea of prevention ? Here is a patient 42 . She has migraine attacks about 5 to 7 days a month and she's coming in for management . She tells you , you know , I'm , I'm missing work a few days a month . I'm missing social events two days a month . But really what brought me in today is that just recently I came late to my sister's baby shower because I had an attack that just wouldn't stop . And now my sister and I aren't talking and I , I had enough . I really really need some help . And this is the types of scenarios we hear all the time when a person has finally hit their limit and someone in the family or loved one has pushed them to come in for help . It's amazing how much we as humans put up with before we hit that like point that we won't take it anymore . I saw someone the other day has had uh disabling migraines since 10 years old . She's 38 and she finally came in for her very first visit with anybody to discuss her attacks . Uh It's , it's always an interesting point . What pivots them to have this happen . It's usually a critical moment in their life or a loved one telling them this is not normal , but there's probably something you can do about this next slide . So prevention is the idea of using some sort of treatment to really improve the quality of life of the person living with migraine . We want to increase their functionality . We want to reduce the frequency of migraine . And our hope is that we're modifying the disease . It is not a cure . And I think this is the hardest thing for us to have to tell the patient that at this moment , we don't really have a cure for migraine . And people are usually coming to see us because they want an answer . Like there's some single thing that's causing migraine and that there's a cure and then , then we're gonna move on with their life after . Uh , and it's very hard to kind of overcome that idea that , you know , actually this is lifelong . It's a neurological disease . It's a genetic basis and we're going to do things to modify the disease course to help you live a better quality of life , but that there's not a cure at this time . Next slide , just like we have um options for acute treatment , we have many options for prevention . The question really is , when do we pull those options out ? The suggestion is any time the patient feels their attacks are starting to interfere with their life , interfere with their daily routine . Despite taking acute treatment , it's time to talk prevention . We have many suggestions . There's guidelines behind numbers of days . The general consensus is if a person's at six migraine headache days per month and they have no disability , it's time to have a conversation about prevention or they have three migraine headache days a month and severe disability . It's time to have a conversation about prevention , but it really comes down to the patient feeling that regardless of the number of days they're impacted by their disease , it's time to have a conversation about prevention . In the end , the patient has to make the choice that they're ready for prevention or they're not going to take it . So don't just prescribe the treatment , have that conversation about , are they ready ? And how do you come to a middle ground ? About what might be the right thing to do next slide . So every patient , we discuss lifestyle modifications just as a routine base of things they might do to help them live a little bit of a more stable life with migraine . These are regular moderate cardiovascular exercise , good , healthy living , regular sleep wake times , regular eating times . I just heard a talk the other day at our annual scientific meeting for headache and the talk was everybody needs to eat . It's not about a specific diet for migraine , but regular eating times are important as well as drinking water . Trying to manage your stress to some degree . Everybody has stress in their life . Stress isn't necessarily the cause of migraine but managing your stress a little bit better can definitely help modify the disease . Next slide . All right , we're gonna ask a polling question just to remind you how to pull up your pole . So I kind of hinted at this . But what diet recommendations should you make for patients with migraine ? No caffeine or alcohol ? No MS G or Tyramine containing foods , regular eating times or A and B ? OK . So for the sake of time , I'm gonna move us from here . But the correct answer is c regular eating times . And just because I'm sure some of you are gonna be shocked by this caffeine or alcohol , MS G tyramine . So MS G and Tyramine has actually not been well studied in migraine . I was very shocked by this when I was a fellow . Um and after fellowship and went digging around , there are very few studies that actually show good correlation between MS G and tyramine consumption and migraine . In this past year , we've had four studies showing that there is no direct correlation with alcohol consumption and migraine . I am still not so sure about this . My theory is that regular consumption of alcohol might not trigger migraine . But if you're not a regular consumer of alcohol , you're more likely to have migraine . And people tend to do protective factors where they might not drink alcohol because they think it's a trigger . And then when they do drink alcohol , it triggers migraine . Now , that theory of mine is not proven . These articles are written by very well known authors um using some pretty good um A I technology and calendars and a lot of data . Um So it is going to be intriguing as we learn more about this . But we're really moving away from the idea of triggers is what I'm trying to say . And the idea that many times migraine has already started before uh a patient notes a trigger and the trigger might just be their sense that they are having . Um they're starting to have a migraine attack . So there's many ways to prevent migraine after lifestyle changes . If a patient is on a low frequency of migraine , you can start with nutraceuticals , which are vitamin supplements for migraine prevention . Out of all the different nutraceuticals out there , probably best evidence lies with riboflavin and magnesium . And you can see some of the data on the slide here . Um riboflavin , we usually recommend 400 mg a day and magnesium up to 500 mg a day . Sometimes we use higher doses . Uh these are generally safe and well tolerated and can show reduction in migraine frequency over a three month time period . Next slide , there's always behavioral techniques that have good , strong evidence in migraine prevention , especially when added on to medication , cognitive behavioral therapy , biofeedback , easiest is relaxation therapy . You can teach your patients how to do this during a clinic . And then there are newer techniques like mindful based stress reduction and act therapy that's actually being investigated at this time and acupuncture , which has some evidence as well . Next slide , the suggestion is always to um consider using behavioral techniques on its own but trying to integrate it really well into a treatment plan , especially in patients who um are having more frequent migraine or not having adequate response to their current treatment plan using medications frequently for acute treatment or not tolerating acute treatment . Well , these are the times you want to try to pull in behavioral techniques , but really thinking about layering it in in addition to lifestyle changes and perhaps a medication that seems to be when your outcomes are best . Next slide , as I mentioned before , we have a number of different preventive treatment options available for migraine . Uh We're really gonna focus on some of the newer treatment options in the next few minutes . Next slide , we know that there have been many options available to patients over the last several years . But unfortunately , uh uptake of preventive treatment options still seems to be very low . About 40% of people who have migraine qualify for preventive treatment based on disability , but very few actually end up on prevention . And this tends a lot to be due to barriers of , of having that conversation about disability being prescribed or offered prevention and then feeling comfortable with the idea of having um preventive care . So there tends to be a lot of issues for patients really getting through all those barriers and then getting started on treatment and then having the treatment consistently approved by insurance . So once they get started , they can feel better and then that treatment might be stopped by insurance for some reason or there might be cessation of insurance because the patient loses their job . Next life . Here's a slide that just talks about our traditional oral therapeutics , like toy or amma or propranolol . And there's been many studies that show that when these types of treatments are started that over the course of the year , only 20% of patients remain on these treatments . And the reason tends to be because patients have side effects , they don't feel like they're really very effective . More commonly amari gabapentin . And valproate compared to toy . Uh and sometimes they can be costly for patients and these are older studies . So cost might have been when they , some of these were branded drugs . So this can be very problematic if you start a treatment and adherence starts to fall and then they don't come in for follow up next slide . Just like we've had newer treatment options that have been CGRP dedicated and approved um for oral treatment . We also have CGRP dedicated treatments for migraine prevention . Here , you can see that these treatment options that I'm showing you are injectable options . They're monoclonal antibodies , they're very directly targeting CGRP anima targets the CGRP receptor , the other three Galka feminism and EPB target the CGRP ligand . Overall , they're well tolerated and can be very effective . They're dosed either monthly or Galz and Epza can be dosed quarterly . And so that's a much easier option for patients to tolerate . Next slide . There are two oral G pans that are available for patients um to use . We'll actually talk about that . Sorry , in two slides . Uh Just like we have criteria for when to use new treatment options . Uh for acute treatment , we have the same criteria for when to use new treatment options for prevention . The suggestion is patients try two oral uh traditional treatment options first and if they're ineffective or not well tolerated , uh you move on to the newer treatment options , whether these are monoclonal antibodies or they're the G pans for prevention . You can again always write a medical attestation saying there's another reason you think they should move on to newer treatments because of side effects or contraindications or some medical reason that you think the newer treatment option is indicated . Next slide . As I was saying , there's uh two oral G pants that have been approved for prevention and migraine remi pan , which is the same acute tablet . It can be used every other day for prevention of episodic migraine . A study showed about four days , less of migraine attacks compared to three days , less with placebo side effects for every other day use was very similar to using it just once as needed for an attack . So this is um really well tolerated by patients in clinical practice . A Toja pan is another G pan that's been approved for prevention of migraine . Uh at this point , it was actually just recently also approved for chronic migraine . So it covers the span of both episodic and chronic . Uh It comes in three dose options , 10 , 30 or 60 mg once a day , all of which showed a reduction of up to four days a month . Uh In migraine frequency for episodic compared to 2.5 days a month in um placebo and for chronic migraine , it was about four days less per month compared to about two days less per month for placebo . Toja pan does carry uh rates of constipation and nausea and in clinical practice , constipation is frequently seen at rates probably higher than 7% . So that can be sometimes limiting though uh most patients don't tend to stop the treatment . You just have to be proactive about talking to them about fiber supplementation . Next slide . So we also use neuromodulation uh as we do for acute treatment for prevention as well . Also just recently updated it because our field does move quickly . The ren device for the arm that can be used acutely has also just been cleared for preventive treatment as well . And that's every other day . Uh So you can see here , we have options for patients that maybe don't want to take medication can be on neuromodulation . We have several patients who we lay our treatment on , who are having near daily headache with frequent episodes of severe headache , but they might end up on perhaps a traditional treatment , a nerve modulation and maybe one of the newer treatment options just to really get them as low as possible when it comes to frequency of migraine attacks . Next slide , there are several procedures that are done in clinical practice . Uh peripheral nerve blocks , trigger point injections , pheno patine gangle blocks and an abo toxin . A next slide . But out of all of these procedures only on a boon and toxin A has level a evidence for prevention of chronic migraine , uh occipital nerve blocks which are done frequently have weak evidence for chronic migraine prevention . Though we are using it sometimes for acute treatment in clinical practice , trigger point injections for migraine prevention really doesn't have good evidence at all . Next slide . So just some key takeaways to end before we get to some questions , unmet treatment needs really create a big burden for our patients with migraine and addressing acute treatment needs is really the most important . First step for all people who have migraine for those with a great degree of disability thinking and discussing prevention is just as important as having an acute treatment option . And now that we have many newer disease state specific treatment options , building that toolbox for your patient has become much easier . Uh and really allows us that flexibility to work with the patient and really get to know their different types of attacks to help them guide them in the right direction for the treatment options that work for them and hopefully really help reduce burden of disease , reduce risk of medication over these headache um and move them in a direction of greater flexibility . Thank you for your attention . Uh Thanks Doctor Alai for that really comprehensive and valuable presentation . We're so grateful to have you here with us today . Um So now uh for our audience , we have a few minutes left to do some questions and answers . And so if you haven't already done , so please put any questions that you might have for Doctor Alai in the chat . We do have one question . So far that just says does neuro magnetic option impact patients with heart pacemaker or other artificial heart medical devices ? Yeah , it's a good question . So our neuromodulation devices , they usually recommend if a patient has a history of epilepsy or has um like a pacemaker or other implant that's in the heart . They recommend that they don't use those devices . Each of these companies has really great assistance like phone assistance program because sometimes I'll have people with like a hip implant ask me that . And I'm like , I'm pretty sure the hip implant is ok , but it's very easy to call them to make sure that it's not gonna be a problem and they , they're very good about answering . But yes , you avoid them in heart um implants or a pacemaker and epilepsy is the other one . Got you . Thank you so much for that . Um While folks are still thinking of additional questions , uh I know that we had several presentations today talking about the importance of sleep and nutrition . I know you touched on this as well with regards to prevention and I was just curious if you had thoughts on um how receptive patients are to these things as far as augmenting their treatment and and also how receptive clinicians are to help share with patients these potential options to help augment treatment . Yes . So um patients are , they range in their desire to do nonmedication options . I think those that have more frequent attacks are very , very open and willing to discuss all anything that makes me better . We'll hear that , uh , sleep becomes a big part of our conversation . Um , sending patients for evaluation for sleep apnea , working about , uh , cognitive behavioral therapies for sleep issues , you really started to move away from medication to address sleep issues and moving more into the domain for therapies . I feel like since I was a resident , we were always trained to have that conversation about no phones in the bedroom , the TV shouldn't be in the bedroom , the light should be dim , dark in shades . And so that's kind of become a very routine part of the conversation . Uh And you get a very quick sense right away how willing the patient is to go into the depths of trying to fix that problem . Uh And along with sleep is stress management because that is , I think a big part of the everyday in , in America . I , I , I'm sure it's a big part of many other places but any other place in the world , I've been to give these types of talks . People tell us that they're like you Americans are definitely something for a little bit heavy on the stressor side . We don't take any breaks . So talking through ways , they can take a few moments in their day and work in some meditation or stretches . But the importance of that is the follow up if we don't ask about it at the follow up visit , they're not gonna do it . So we have to be accountable for that too . We have to ask them and we have to be accountable ourselves that we're asking them . So is no , look , what did I talk about ? Did I follow up on that ? Otherwise they're not , they're not seeing that we care enough to follow up on it and once they realize we will , then they will do it . That's a great point . Yeah , I love that . Thanks for sharing that . Um One person asked back to the neuromodulation devices . Will those transfer into a deployment environment ? Yeah , they're very small . They're really easy to travel with many of them come with carrying cases . Um I I didn't mention earlier but migraine is more common in women , common in men , 8% in men , 16% in women , 8% is still a very high number . I think it's just 16% is so high . So because of that marketing is so important , how they make the device , how portable it is . Does it fit in a purse ? That's the first thing . Any time a device is made is the first concern . So these devices are very portable , very small , they fit into these tiny little cases . The um just to give you an example , the ren device is this tiny and folds on itself . The um Phalle device , the super orbital uh device , it's a triangle that's here and the carrying case is about this big . So they're very , very small and portable and they go through TS A all the time . It's really not hard to deploy with them . Great . Thank you . All right . And I think we have time for one more question . Um , one person asked as far as getting meds covered . If on State Medicare plans , do you know if any of these newer treatments are getting covered and would sending to neurology help ? Yes . So most of the time we fought really hard to make sure that primary care can write them just as easily as a neurologist . So that I think it's important to realize in the beginning , they were making it difficult that only a neurologist can write them . But at this point , anyone can . And that's because we advocated , first of all , you should know , 65% of people with migraine only will ever see their primary care . So it was very important for the field that we made sure to advocate that primary care could write just the same for these treatments . Medicare does cover but not well , meaning if it , they only have a Medicare plan , it's that 80% coverage and depending on the state , um The CGRP monoclonal antibodies , for example , they might cover . One depends which state they're in or which plan they have which one will get covered . But if they only have Medicare , 80% of $800 still leaves $200 on the table . So what we might sometimes do some of these companies , even if the patients on Medicare will offer like an assistance program . If they are under a certain income level , you have to check though with the company , if they'll qualify , some companies will do it even if they're a Medicare patient . Uh an example is a , that makes Ebro and uh a to pan offers an assistance for Medicare patients . Um Other companies won't . Uh So it's , it's always an individual . I ask if they have a secondary , I do the investigation , I have them call because they won't tell me the provider , they'll tell the patient . Um , and we do try to set them up with some help because the treatments , I mean , they're very safe for that population and they can be very helpful . Perfect . All right . Well , thank you so much , Doctor Alani . We certainly appreciate this wonderful presentation . Uh , just as a quick recap . You know , we were talking about both acute and acute treatment and preventive strategies for helping folks with migraines . And , uh , with that , we will go ahead and take our 10 minute break . So , um , this is gonna be our last presentation coming up starting at 15 , 10 Eastern time titled Promising Practices For the Treatment of post traumatic stress disorder in veterans and service members . So , we'll see you shortly . Thanks , Doctor Alani . Thank you . Bye .