Diagnosis and management of migraine in ten steps

Anna K Eigenbrodt, Håkan Ashina, Sabrina Khan, Hans-Christoph Diener, Dimos D Mitsikostas, Alexandra J Sinclair, Patricia Pozo-Rosich, Paolo Martelletti, Anne Ducros, Michel Lantéri-Minet, Mark Braschinsky, Margarita Sanchez Del Rio, Oved Daniel, Aynur Özge, Ayten Mammadbayli, Mihails Arons, Kirill Skorobogatykh, Vladimir Romanenko, Gisela M Terwindt, Koen Paemeleire, Simona Sacco, Uwe Reuter, Christian Lampl, Henrik W Schytz, Zaza Katsarava, Timothy J Steiner, Messoud Ashina, Anna K Eigenbrodt, Håkan Ashina, Sabrina Khan, Hans-Christoph Diener, Dimos D Mitsikostas, Alexandra J Sinclair, Patricia Pozo-Rosich, Paolo Martelletti, Anne Ducros, Michel Lantéri-Minet, Mark Braschinsky, Margarita Sanchez Del Rio, Oved Daniel, Aynur Özge, Ayten Mammadbayli, Mihails Arons, Kirill Skorobogatykh, Vladimir Romanenko, Gisela M Terwindt, Koen Paemeleire, Simona Sacco, Uwe Reuter, Christian Lampl, Henrik W Schytz, Zaza Katsarava, Timothy J Steiner, Messoud Ashina

Abstract

Migraine is a disabling primary headache disorder that directly affects more than one billion people worldwide. Despite its widespread prevalence, migraine remains under-diagnosed and under-treated. To support clinical decision-making, we convened a European panel of experts to develop a ten-step approach to the diagnosis and management of migraine. Each step was established by expert consensus and supported by a review of current literature, and the Consensus Statement is endorsed by the European Headache Federation and the European Academy of Neurology. In this Consensus Statement, we introduce typical clinical features, diagnostic criteria and differential diagnoses of migraine. We then emphasize the value of patient centricity and patient education to ensure treatment adherence and satisfaction with care provision. Further, we outline best practices for acute and preventive treatment of migraine in various patient populations, including adults, children and adolescents, pregnant and breastfeeding women, and older people. In addition, we provide recommendations for evaluating treatment response and managing treatment failure. Lastly, we discuss the management of complications and comorbidities as well as the importance of planning long-term follow-up.

Conflict of interest statement

S.K. has been an invited speaker for Novartis. H.-C.D. has received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from Alder, Allergan, Amgen, Electrocore, Ipsen, Lilly, Medtronic, Novartis, Pfizer, Teva and Weber & Weber. Electrocore has provided financial support for his research projects. The German research council (DFG), the German ministry of Education and Research (BMBF) and the European Union support his headache research. He also serves on the editorial boards of Cephalalgia and Lancet Neurology, chairs the clinical guidelines committee of the German Society of Neurology and is a member of the Clinical Trials Committee of the International Headache Society. D.D.M. has received honoraria, research and travel grants from Allergan, Amgen, Biogen, Cefaly, Eli Lilly, Electrocore, Mertz, Novartis, Roche, Sanofi, Specifar and Teva. A.J.S. reports personal fees from Allergan and Novartis, grants from Novartis, and grants and personal fees from Invex Therapeutics. He is a trustee of the board of the International Headache Society and a member of the Council of the European Headache Federation. P.P.-R. has received honoraria as a consultant and speaker for Allergan, Almirall, Biohaven, Chiesi, Eli Lilly, Medlink, Medscape, Neurodiem, Novartis and Teva. Her research group has received research grants from Allergan, AGAUR, la Caixa foundation, EraNET Neuron, FEDER RISC3CAT, Migraine Research Foundation, Instituto Investigación Carlos III, MICINN, Novartis and PERIS, and has received funding for clinical trials from Alder, Amgen, Electrocore, Eli Lilly, Novartis and Teva. She is the founder of www.midolordecabeza.org, a trustee of the board of the International Headache Society and a member of the Council of the European Headache Federation. She is on the editorial board of Revista de Neurologia, an associate editor for Cephalalgia, Frontiers of Neurology and Journal of Headache and Pain. She is also a member of the Clinical Trials Guidelines Committee of the International Headache Society and has edited the Guidelines for the Diagnosis and Treatment of Headache of the Spanish Neurological Society. P.M. has served on advisory boards for Allergan, Lilly, Novartis and Teva. He has received royalties from Springer Nature and travel support from the European Medicines Agency, and serves as Editor-in-Chief for Journal of Headache and Pain. A.D. reports consultant fees from Eli Lilly, Novartis and Teva. She also serves as President of the French Headache Society. M.L.-M. reports personal fees for advisory boards, speaker panels or investigation studies from Allergan, Amgen, Astellas, ATI, BMS, Boehringer, Boston Scientific, CoLucid, Convergence, GlaxoSmithKline, Grunenthal, Lilly, Medtronic, Menarini, MSD, Novartis, Pfizer, ReckittBenckiser, Saint-Jude, Sanofi-Aventis, Teva, UCB and Zambon. M.S.d.R. reports consultant fees as a speaker or participation on advisory boards from Allergan, Eli-Lilly, Novartis and Teva. G.M.T. reports consultant fees from Amgen, Eli Lilly, Novartis and Teva, and has received grant support from the Dutch Brain Foundation, Dutch Heart Foundation, NIH, NOW and ZonMW. K.P. has received honoraria as a speaker and/or consultant, and/or received research support from Allergan, Amgen/Novartis, Autonomic Technologies, Eli-Lilly and Teva. S.S. reports fees as a speaker or consultant for Allergan, Abbott, Eli-Lilly, Novartis and Teva. She is also an associate editor for Stroke and serves as co-editor for Journal of Headache and Pain. U.R. has received consulting fees, speaking or teaching fees and/or research grants from Allergan, Amgen, Autonomic Technologies, CoLucid, ElectroCore and Novartis. H.W.S. has received consultant fees for lectures from Eli-Lilly, Novartis and TEVA. He has received consultant fees for advisory board participation from Balancair and Eli Lilly, and has received funding from Novartis. Z.K. has been a speaker and/or consultant, and/or received research support from Allergan, Amgen/Novartis, Ely-Lilly, Merck and Teva. T.J.S. reports personal fees from Eli Lilly. M.A. has received personal fees from Alder BioPharmaceuticals, Allergan, Amgen, Eli-Lilly, Novartis and Teva. He has been or is currently a principal investigator on clinical trials for Alder, Amgen, ElectroCore, Novartis and Teva. He serves as Associate Editor of Cephalalgia, Headache and Journal of Headache and Pain. He also reports research grants from Lundbeck Foundation, Novo Nordisk Foundation, and Research Foundation of the Capital Region of Denmark. The other authors report no competing interests.

© 2021. The Author(s).

Figures

Fig. 1. Ten-step approach to the diagnosis…
Fig. 1. Ten-step approach to the diagnosis and management of migraine.
CGRP, calcitonin gene-related peptide; MOH, medication overuse headache; NSAID, non-steroidal anti-inflammatory drug. aSodium valproate is absolutely contraindicated in women of childbearing potential. bCGRP monoclonal antibodies target CGRP or its receptor.
Fig. 2. Stepped care across migraine attacks.
Fig. 2. Stepped care across migraine attacks.
Preventive therapy, in addition, may be indicated at any stage. In general, initiation of preventive therapy is indicated in patients who are adversely affected on ≥2 days per month despite acute treatment optimized according to the stepped care approach. NSAID, non-steroidal anti-inflammatory drug.

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