Primary Care Management of Headache: Part 2

All primary care clinicians should be comfortable with the main categories of oral preventives for migraine. Preventive treatment should be considered for patients with migraine for as few as 2-4 migraine headache days per month if those days are associated with significant severity and interference with the ability to function. When to start a preventive will also depend on the patient’s willingness to take something every day with potential side effects. A collaborative approach with shared decision making is needed.

The 3 categories most commonly used for the prevention of migraine include:

• Antidepressants including tricyclic’s, SSRIs, and SNRIs.
• Antiepileptics including divalproex sodium and topiramate.
• Antihypertensives including beta blockers, ARB’s, and calcium channel blockers.

Primary care clinicians can take into account a patient’s comorbid conditions to help decide which preventive may be ideal to start. Starting low to access tolerability is advisable but should be prescribed with a titration schedule so that efficacy can be obtained. A reasonable goal would be to reduce migraine severity and/or frequency by at least 50% in 2-3 months after starting the preventive.

If a patient has not responded to at least two generic preventives or had tolerability issues, then a primary care clinician may choose to refer to a neurologist or headache specialist for consideration of some of the newer preventives including the CGRP mAB injectables, the oral CGRP receptor antagonist, atogepant, or for onabotulinum toxin A. Most primary care clinicians, however, should feel comfortable prescribing the CGRP mAB injectables including erenumab, fremanezumab, and galcanzumab. They can be used to prevent episodic or chronic migraine in adults. Newer to the marker is an oral CGRP receptor antagonist, atogepant, and is taken daily as a 10 mg, 30 mg, or 60 mg tablet. It has been approved by the US Food and Drug Administration (FDA) for prevention of both episodic migraine and chronic migraine in adults in the US.

Onabotulinum toxin A has been FDA approved for prevention of chronic migraine in the US since 2010. The approved dose is 155 units injected into 31 sites every 12 weeks. This injection procedure is one that can be handled by primary care clinicians who are interested in incorporating this into their practice. Others may prefer to refer out for this procedure.

In summary, the majority of headache patients can be diagnosed and managed in the primary care setting. Keep in mind that most patients presenting with the complaint of headache in the primary care setting will have a primary headache. Rarely will tension or cluster headache present in the primary care setting. Migraine is by far the most common primary headache seen by primary care clinicians.

Worrisome neurological signs or symptoms, failure to respond to migraine specific treatment, new onset headache, strong positional component to the headache, or a pattern of headache escalation warrants referral to a neurologist or headache specialist. If the headache is highly severe and/or associated with head trauma, then immediate evaluation in the emergency department may be indicated.

Recent migraine specific treatments including CGRP targeted acute and preventive options can significantly improve the quality of patients with migraine. Primary care clinicians should become familiar with these new options to better help their patients. Both the patient and the primary care clinician can benefit from incorporating new treatment options into the management of migraine.