Neil Minkoff, MD: When we talk about patients, it seems as if a lot of patients are transitioning from acute care. They’re getting to the point, whether it’s in one of the primary care settings you described, a headache clinic, or a neurologist, where they’re almost transitioning. They’re going from episodic care to a more wholistic look, both at their symptoms and disability. They’re also bringing in preventive therapies. What is that transition like, and how do patients report that moving toward preventive medicine affects their quality of life, Dr Nahas?

Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: The nature of my practice is that most of my patients have already made that transition. I’m not often having to make it for them. But on the occasion that I do, it comes down to a reality check and discussion of the seriousness of the disease. For many patients, they’ve avoided having to take a daily medicine for this problem for whatever reason. We have to admit that one day, it’s time to do something. How are we going to achieve that? We have lots of options, and that can be somewhat intimidating for a patient.

I always like to give my patients choices and help guide them through the pros and cons of each of the options I’ve given them. I start with what is FDA-approved and evidence-based, and also what’s likely to be a good fit for that individual, based on other medical conditions they may have. I consider other elements of their history and other medications that they’re taking. Our first rule of medicine is to do no harm. In some cases, that will take some options off the table. I find that it takes more time, but patients appreciate being brought into that conversation and being given the tools to make that decision for themselves.

Once in a while, we’ll come across a patient who just wants to be told what to do. That’s a bit disheartening. It makes for a shorter visit, but it’s not so fulfilling. One of the things that I enjoy about practicing in this particular field of medicine is forging these relationships and alliances with patients and fighting together against this thing that is trying to beat them down. It’s fulfilling to team up and form that golden therapeutic alliance that we all talk about and strive for. It’s something that’s not too hard in migraine and headache medicine, if you know how to listen to your patient and discuss options together.

Neil Minkoff, MD: OK. My understanding is that the American Headache Society put forth some guidelines to push forward this idea of moving the patient into preventive therapy. They are trying to delineate the treatment of acute migraine vs prevention. Dr Dodick, is that something you could walk us through, or at least comment on?

David W. Dodick, MD: Sure. We could talk for an hour on the nuances of the guidelines, but essentially, prior to the guidelines, most experts in the field felt that if a patient is having 4 headache days or 4 migraine headache days per month, we ought to be beginning the conversation about prevention. That’s not to say that for patients who are having fewer migraine days, but are missing time and functionally impaired, we couldn’t initiate prevention in them, as well. It’s not to say that just because a patient has 1 per week, they need preventive treatment. If they’re getting an excellent and consistent response to acute medicine, they may not want to be taking a medication every day or every month. But generally, we ought to be having that conversation if they’re having 1 headache day per week.

That is not only because, from a patient-centered standpoint, they may be impaired. It’s also because it seems to be an inflection point. If they’re having 1 day per week, that tends to be a point at which there’s escape velocity. They start to take off, and it increases the risk of progression to a more chronic form of migraine. From both a biological standpoint and a patient-centered standpoint, we ought to be talking to patients about prevention when they’re having headache 1 day per week.

The new guidelines talk about when and how to integrate these newer, preventive monoclonal antibody treatments. Generally speaking, the guidelines say that if you’re having between 4 and 7 headache days per month, you should also have some level of disability. It is at least a moderate level of disability, as measured by MIDAS [Migraine Disability Assessment], HIT-6 [Headache Impact Test-6], or one of these validated instruments. And you should have failed at least 2 older, oral prophylactic medications or preventive medications.

If you’re having between 8 and 14 headache days per month, you don’t need any level of disability. You shouldn’t be having 2 headache days per week or more. All of those patients should be considered for prevention.

In terms of the newer treatments, the requirement is that they should have a contraindication to and/or failed at least 2 oral prophylactic medications.

Patients who have chronic migraine, 15 or more headache days per month, all of those patients should be considered for preventive therapy. But again, as far as the new therapies go, they need to have failed either 2 older, oral preventive medications or onabotulinum toxin A. We tend to divide patients up into those with 4 to 7 headache days per month, 8 to 14 headache days per month, and 15 or more headache days per month.