Monteith, Teshamae S

We here present evidence-based guidelines for the pharmacological treatment of migraine. These guidelines, created by the Italian Society for the Study of Headache and the International Headache Society, aim to offer clear, actionable recommendations to healthcare professionals. They incorporate evidence-based recommendations from randomized controlled trials and expert-based opinions. The guidelines follow the GRADE approach for assessing the quality of evidence. The guideline development involved a systematic review of literature across multiple databases, adherence to Cochrane review methods, and a structured framework for data extraction and interpretation. Although the guidelines provide a robust foundation for migraine treatment, they also highlight gaps in current research, such as the paucity of head-to-head drug comparisons and the need for long-term outcome studies. These guidelines serve as a resource to standardize migraine treatment and promote high-quality care across different healthcare settings.

We here present evidence-based guidelines for the pharmacological treatment of migraine. These guidelines, created by the Italian Society for the Study of Headache and the International Headache Society, aim to offer clear, actionable recommendations to healthcare professionals. They incorporate evidence-based recommendations from randomized controlled trials and expert-based opinions. The guidelines follow the Grading of Recommendations, Assessment, Development and Evaluation approach for assessing the quality of evidence. The guideline development involved a systematic review of literature across multiple databases, adherence to Cochrane review methods, and a structured framework for data extraction and interpretation. Although the guidelines provide a robust foundation for migraine treatment, they also highlight gaps in current research, such as the paucity of head-to-head drug comparisons and the need for long-term outcome studies. These guidelines serve as a resource to standardize migraine treatment and promote high-quality care across different healthcare settings.

Migraine is one of the most prevalent and disabling neurological diseases, significantly affecting quality of life and productivity, as well as contributing to substantial societal costs. Recent innovations, including calcitonin gene-related peptide (CGRP) pathway inhibitors and onabotulinumtoxinA, have transformed migraine prevention by offering high efficacy and excellent tolerability, thus improving adherence. Clinical trials and real-world studies show that significant reductions in migraine frequency and, in some cases, complete migraine freedom is achievable. In this Position Statement, we advocate for raising the standards of migraine prevention by setting ambitious treatment goals aimed at optimal outcomes, such as migraine freedom or very low number of days with migraine or moderate/severe headache. We emphasize the importance of addressing residual migraine burden, highlighting that achieving a ≥50% reduction in monthly migraine days, although often considered a successful response, may not fully restore quality of life. Relying solely on percentage-based improvements can obscure the persisting impact of residual burden. This Position Statement does not want to change the standards for clinical trials but aims primarily at real-world clinical practice and proposes a shift from percentage-based measures of success to absolute goals while on treatment. We outline a framework that categorizes outcomes into four tiers: migraine freedom (no days with migraine or moderate-to-severe headache), optimal control (less than four days with migraine or moderate-to-severe headache), modest control (four to six days with migraine or moderate-to-severe headache) and insufficient control (more than days with migraine or moderate-to-severe headache). Focusing on residual burden while on treatment aims to further improve patient quality of life and drive innovation in preventive therapies and non-pharmacological approaches. By advocating for higher standards, this Position Statement, is not aimed primarily to drive reimbursement policies for migraine preventive treatments, but seeks to inspire clinicians, researchers and policymakers to prioritize ambitious goals in migraine prevention, ultimately enhancing patient outcomes and reducing the broader societal and economic impact of this debilitating condition.

Background In an effort to improve migraine management around the world, the International Headache Society (IHS) has here developed a list of practical recommendations for the acute pharmacological treatment of migraine. The recommendations are categorized into optimal and essential, in order to provide treatment options for all possible settings, including those with limited access to migraine medications. Methods An IHS steering committee developed a list of clinical questions based on practical issues in the management of migraine. A selected group of international senior and junior headache experts developed the recommendations, following expert consensus and the review of available national and international headache guidelines and guidance documents. Following the initial search, a bibliography of twenty-one national and international guidelines was created and reviewed by the working group. Results A total of seventeen questions addressing different aspects of acute migraine treatment have been outlined. For each of them we provide an optimal recommendation, to be used whenever possible, and an essential recommendation to be used when the optimal level cannot be attained. Conclusion Adoption of these international recommendations will improve the quality of acute migraine treatment around the world, even where pharmacological options remain limited.

Objectives We sought to survey the N ew I nvestigators and T rainees S ection ( NITS ) members of the A merican H eadache S ociety ( AHS ) to better understand their exposure to headache medicine during training and to determine their perceptions and attitudes about the field and the future of headache medicine. Background Despite the high prevalence of headache disorders in the general population, only about 2% of neurology residents pursue headache medicine fellowships. Furthermore, there is a paucity of U nited C ouncil of N eurologic S ubspecialties headache specialists in the country to meet the population demands. Thus, there needs to be a focus on how to recruit and retain more headache specialists. Methods A survey was distributed via S urvey M onkey to the NITS listserv. It remained online for 60 days, during which reminder emails were sent to members of the listserv. In addition, the survey was available on laptops at NITS ‐related events at an annual AHS meeting. Descriptive analyses were then conducted using S urvey M onkey and E xcel. Results Of the 93 members of NITS , 64 of the 96 (68.8%) clicked to initiate the survey and 52.7% successfully completed it. Attendings made up the majority of respondents (62.5%), followed by fellows (10.9%), and residents (7.8%). Key highlights of the survey included the following: just under 10% reported no exposure to a headache center during any time in their training (medical school, residency, or fellowship); less than 2% had exposure to a headache center during medical school; less than half of participants reported exposure to a headache center in residency (45.3%) and during fellowship (43.4%). Having a mentor in the field, liking the patient population, and working in a headache center, 64.7%, 52.9%, and 41.2%, respectively, were the top ways in which participants became interested in headache. The journal H eadache (56.9%), attendings (56.3%), and the AHS / A merican A cademy of N eurology guidelines for migraine management (52.0%) are the resources cited as being used all/most of the time. About 82.4% strongly agree that there needs to be improved headache education for physicians of all specialties (primary care, emergency department, psychiatry); 84.4% feel that they are appreciated by their patients; 68.6% feel that there is strong support in their departments for headache; 56.9% believe that their work schedule leaves enough time for personal and family life; and 60.8% agreed that their professional life will improve in years to come. Participants agreed/strongly agreed that they like to treat the following diseases/symptoms: migraine headache (98.0%), cluster headache (92%), chronic daily headache (84%), and post‐concussive syndrome (71.4%). Participants disagreed/strongly disagreed that they like to treat the following comorbid conditions/symptoms: low back pain (66.6%), dizziness (42.9%), sleep apnea (36.7%), depression (32.0%), and anxiety (32.0%). Conclusions In this detailed survey on the recruitment and retention of headache specialists, the following themes emerged: mentorship and exposure to a headache center are key foundations in the young investigator/trainee experience. Young headache specialists appear positive about their field of medicine. These specialists like to treat various headache types but not necessarily some of the related comorbidities (sleep disorders, depression, anxiety, back pain, and dizziness). Finally, there was strong agreement that there needs to be improved headache education for physicians of other medical specialties.