Migraine is one of the most debilitating diseases. It was ranked second regarding years lived with disability and posed a significant economic impact on society. For many patients, acute treatment using simple analgesics or triptans is insu­fficient to control the migraine, and may even worsen it if over-used. Oral preventive treatments aim at reducing monthly migraine days or migraine frequency. However, they were not initially designed for the treatment of migraine, and their use is often limited by an arsenal of side effects or inadequate relief. The adherence to these treatments is also disappointing. The breakthrough came when Prof. Peter Goadsby and other renowned neuroscientists discovered a cause of a migraine attack. They found that calcitonin gene-related peptide (CGRP) could be an important new target for developing new treatments for migraine. Neurologists, headache specialists and patients eagerly awaited the approval of monoclonal antibodies targeting CGRP pathway. They were developed specifically for migraine prevention. In Hong Kong, 4 anti-CGRP antibody therapies have been approved for migraine preventive treatment. They are administered either subcutaneously or intravenously. They revolutionize migraine treatment by providing demonstrated good e­fficacy and low adverse reaction rates. How are the treatment guidelines being revised? Recently, the National Institute for Health and Care Excellence (NICE) also provides some guidance on using these anti-CGRP antibody therapies. What do you need to know about them? How to choose among them? Prof. Peter Goadsby will give you some hints and share with you his clinical experience on this regard.

Antagonism targeting the CGRP pathway would give a hint on treatments countering migraine. Eptinezumab is a humanised monoclonal antibody preventing migraine by selectively and readily binding to both α- and β-CGRP ligands blocking them from binding to CGRP receptors. The e­fficacy of eptinezumab was first established in 2 pivotal studies, PROMISE-1 and PROMISE-2, in episodic and chronic migraine patients, respectively. The migraine preventive effect was observed on the first day after eptinezumab dosing, with more than 50% reduction in patients reported migraine while that in the placebo group was only about the half of the treatment groups. The effi­cacy of eptinezumab in controlling migraine was further demonstrated in the DELIVER study, in which patients failed 2-4 prior preventive treatment. Patients treated with eptinezumab had a greater reduction in the percentage of severe migraine attacks as well as greater reductions in monthly headache days (MHD) and monthly headache episodes compared to placebo. Frequent medication use to treat migraine attacks can lead to increased migraine frequency and is called medication-overuse headache (MOH). In a subgroup analysis of the PROMISE-2 trial, patients with chronic migraine and MOH treated with eptinezumab experienced greater reductions from baseline in MMD than placebo patients over 12 weeks. Moreover, more eptinezumab-treated patients were ≥50% migraine responders or ≥75% responders compared to placebo over 24 weeks. The long-term safety profile of eptinezumab (300mg) was assessed in the PREVAIL trial involving 128 patients with chronic migraine. The results indicated that eptinezumab is safe and well-tolerated. Prof. Diener is going to share with you the data.

In Singapore, migraine ranks 4th among the top 10 most disabling health problems with a lifetime prevalence of 8.2%. Migraine has a negative impact on virtually all aspects of life including work, school, family, social, and finances. However, there is a significant unmet need for preventive migraine therapy. Out of the 40% patients who may be eligible for prevention, only 13% receive prevention. Furthermore, ~80% patients discontinue oral preventative therapy after 1 year of treatment mainly due to lack of e­fficacy and side effects. While there is strong scientific evidence of the e­fficacy of eptinezumab versus placebo in randomized trials, there is limited evidence regarding the effectiveness of eptinezumab (or any anti-CGRP medication) in a “real-world” setting in Asian patients. Dr Jonathan Ong, who is one of the principal investigators, of REAP study in Singapore, will share with you some update of the study.

Prevention of migraine is designed to decrease the number of migraine days per month decrease the severity of each attack, and reduce use of acute headache medications. Primary care providers are positioned to improve care for migraine patients with streamlined approaches to diagnosis and management. This lecture will cover some of the challenges in diagnosing migraine and managing acute and chronic migraine. The speaker will summarise the current understanding of migraine pathophysiology and clinical evidence of new medications and offer practical approaches to diagnosis and contemporary management of migraine in the primary care setting.