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Along with the development of novel migraine therapies as the monoclonal antibodies against calcitonin gene-related peptide (CGRP) and its receptor, the question arises if the treatment of chronic migraine (CM) and medication overuse headache (MOH) must be reconsidered. Have previous therapeutic approaches, including glucocorticoids, lost their role in the management of this debilitating disorder? In this narrative review, we present an overview of the available treatment options in CM and MOH in light of CGRP antibodies as well as an evaluation of the role of glucocorticoids in withdrawal therapy.Chronic migraine and medication overuse continues to be a difficult to treat condition. To date, potent treatment options are scarce and algorithms for advising patients with MOH are often still based on expert consensus rather than evidence-based medicine. For years and probably due to lack of effective alternatives, glucocorticoids have been used in MOH, especially to alleviate withdrawal symptoms caused by detoxification. Small case series report positive effects of steroids in this respective patient group; however, randomized controlled trials did not show a consistent benefit, although this may be due to methodological limitations. Because of these discrepancies, their role in MOH has been under debate ever since.We searched the electronic database PubMed for articles up to June 1, 2022 on the use of glucocorticoids in CM and MOH.Despite popular use in clinical practice, there is currently still no scientific evidence for the efficacy of glucocorticoids in patients with CM and MOH. Treatment with monoclonal antibodies achieved high transition rates from medication overuse to non-overuse. However, further research is needed to evaluate the additional benefit of these new agents.

Die Migrane ist eine haufig unterdiagnostizierte Erkrankung, die mit einer hohen Belastung der Betroffenen einhergeht. Es steht eine Vielzahl an prophylaktischen Behandlungsoptionen zur Verfugung, die mit der Einfuhrung der CGRP-(Rezeptor‑)Antikorper erweitert wurden. Stellenwert der medikamentosen und nichtmedikamentosen Masnahmen in der Behandlung der Migrane. Analyse und Auswertung von international veroffentlichten Artikeln bezuglich der prophylaktischen Therapie der episodischen und chronischen Migrane. Es existiert eine Vielzahl an zugelassenen Medikamenten fur die Migraneprophylaxe mit unterschiedlicher Evidenz. Mit den CGRP-Antikorpern wurden die Moglichkeiten nochmals erweitert. Vergleichsstudien der neuen Antikorper mit bisherigen Prophylaktika wurden bislang noch nicht publiziert, sodass unklar ist, ob die Antikorper therapeutisch uberlegen sind. Herauszustellen sind aber ihr schneller Wirkeintritt und ihre gute Vertraglichkeit. Grundsatzlich gilt, dass eine individuelle Auswahl der Prophylaxe, die sich an Betroffenheit, Komorbiditaten und Komedikation orientiert, sinnvoll ist. Zudem sollte immer eine Kombination mit nichtmedikamentosen Masnahmen angestrebt werden. Fur die Behandlung der Migrane steht eine Vielzahl an medikamentosen und nichtmedikamentosen Masnahmen zur Verfugung, die multimodal angewandt werden sollten.

ZUSAMMENFASSUNGMonoclonal antibodies against the calcitonin gene-related peptide (CGRP) receptor (erenumab) or against CGRP (eptinezumab, fremanezumab, galcanezumab) are new substances for the preventive treatment of migraine. They represent an extension of the therapeutic options which already exist in migraine prevention. In registration studies, the efficacy and good tolerability of these specific substances have been demonstrated in patients with episodic and chronic migraine. The following treatment recommendation presents a summary of the pivotal studies. Recommendations are given for the targeted selection of patients as well as for the evaluation of therapeutic success and the duration of treatment. Finally, possible restrictions in the use of this new substance group are discussed.

Migraine is associated with a high individual level of suffering. Therefore, an effective preventive treatment is highly important. The spectrum of classical prophylactic drugs has now been expanded to include monoclonal antibodies against calcitonin gene-related peptide (CGRP) and its receptor. These antibodies have shown reliable efficacy compared to placebo and a rapid onset of action with a low rate of side effects and negligible interactions in pivotal studies. Recently, the efficacy of the antibody was shown in many studies even on drug-refractory migraine and migraine associated with medication overuse. Comprehensive head to head comparisons with previously established drugs and among the antibodies are not yet available; however, initial studies suggest better tolerability and efficacy compared to conventional drugs and other antibodies. The role of antibodies in established treatment cascades still needs to be clarified.Die Migräne geht mit einem starken individuellen Leidensdruck einher, weshalb einer effektiven prophylaktischen Behandlung hohe Bedeutung zukommt. Das Spektrum klassischer Prophylaktika wird nun durch monoklonale Antikörper gegen das „calcitonin gene-related peptide“ (CGRP) und dessen Rezeptor erweitert. Die Antikörper wiesen in den Zulassungsstudien eine zuverlässige Wirksamkeit gegenüber Placebo und einen raschen Wirkeintritt bei niedriger Nebenwirkungsrate und vernachlässigbaren Interaktionen auf. Zudem wurde in zahlreichen Studien unter anderem eine Wirkung der Antikörper auch bei therapierefraktärer Migräne nachgewiesen. Umfassende direkte Vergleiche der Antikörper untereinander und mit den bisher etablierten Medikamenten gibt es noch nicht. Erste Studien legen aber eine bessere Verträglichkeit und Wirksamkeit gegenüber etablierten Medikamenten oder anderen Antikörpern nahe. Die Rolle der Antikörper in den etablierten Therapiekaskaden bleibt zu klären.

Background The use of new concepts in patient care, such as video-consultations, reminder systems, and online evaluation portals, is becoming increasingly important in the physician–patient relationship and outpatient care. This study examines the acceptance of these approaches in a neurological setting and determines the patients’ preferences. Methods We analyzed 16 guideline-based qualitative interviews with neurological patients using qualitative content analysis (inductive category formation). Results The patients commented on the benefits and challenges of integrating new concepts of medical care. They identified advantages of telemedical care, including time savings (7 of 16; 43,8%) for both the patient and the physician, the prospect of more intensive (4 of 16; 25%) care, and the possibility for a quick response in case of urgent needs (3 of 16; 18.8%). Several challenges were reported, such as the limitations for patients with psychiatric (2 of 16; 12.5%) or complex diseases (4 of 16; 25%) and limited options for diagnostic procedures (such as physical examination (4 of 16; 25%)). For individual neurological patients' needs, telemedical and telecommunication structures could be discussed, which support the patients' specific requirements, such as answering questions while having a recall (2 of 16; 12.5%) and avoiding the journey (8 of 16; 50%). Also, patients are rejecting evaluation portals and are skeptical of telecare in the treatment of neurological diseases. Discussion The perception of telemedical care and the successful integration of new medical care concepts depend on fulfilling the individual patient’s needs. Regardless of the preferred nature of physician–patient interactions, there are specific instruments that can intensify the relationship. These individual needs of the patients must be inquired about and accommodated for. Conclusions For the first time, we could characterize the properties of optimal telemedical care for neurological patients. Interviews like the ones we conducted should be repeated during and after the pandemic, referring to our results and compare.

BackgroundThe use of new concepts in patient care, such as video-consultation, reminder systems and online-evaluation portals is becoming increasingly important in the physician-patient relation and in the care of outpatients. This study examines the acceptance of these approaches in a neurological setting and characterizes the patients’ preferences.MethodsWe analyzed 16 guideline-based qualitative interviews with neurological patients using qualitative content analysis (inductive category formation). ResultsThe patients commented on benefits and challenges of integrating new concepts of medical care. They identified advantages of telemedical care, including time savings for both the patient and the physician, the prospect of more intensive care and the possibility of quick response in case of urgent needs. Several challenges were reported, such as the limitations for patients with chronic or complex diseases and limited options for diagnostic procedures (such as physical examination)For individual neurological patient’s needs, telemedical and telecommunication structures could be discussed which support the respective requirements of the patients such as answering questions while having a recall, avoiding of the journey and time-savings. Also, they are rejecting evaluation portals and are skeptical about telecare in the treatment of neurological diseases.Discussion/ConclusionsThe neurological patients can be characterized as individuals with different ideas of an optimal physician-patient relationship. A successful integration of new concepts in medical care depends on fulfilling the individual patient’s needs. Regardless of the preferred form of the physician-patient relationship, there are specific instruments that can intensify the relationship. These individual needs of the patients must be inquired about and implemented.

Migraine is a frequently underdiagnosed disease that is associated with a high burden on affected patients. There are a variety of prophylactic treatment options available, that have been expanded with the introduction of the CGRP-(receptor-)antibodies.Status of pharmacologic and nonpharmacologic preventive treatment in migraine therapy.Analysis and evaluation of internationally published articles concerning preventive treatment of episodic and chronic migraine.There are many approved medications for migraine prophylaxis with different evidence. The possibilities were further expanded with CGRP antibodies. Comparative studies of the new antibodies with previous prophylactic drugs have not yet been published, so it's unclear whether the antibodies are therapeutically superior. What should be emphasized is their rapid onset of action and their good tolerance. Basically, an individual choice of prophylaxis, which is based on affectedness, comorbidities and comedication, makes sense. In addition, a combination with nondrug measures is always mandatory.A variety of medicinal and non-medicinal measures are available for the treatment of migraine, which should be used multimodally.

Monoclonal antibodies against the calcitonin gene-related peptide (CGRP) receptor (Erenumab) or against CGRP (Eptinezumab, Fremanezumab, Galcanezumab) are new substances for the preventive treatment of migraine. They represent an extension of the therapeutic options, which already exist in migraine prevention. In randomized, placebo-controlled studies, the efficacy and good tolerability of these specific substances have been demonstrated in patients with episodic and chronic migraine. The following treatment recommendation presents a summary of the pivotal studies. Recommendations are provided for the targeted selection of patients as well as for the evaluation of therapeutic success and the duration of treatment. Finally, possible restrictions on the use of this new substance group are discussed.This guideline is an abridged and translated version of the guideline published by Diener H-C, May A et al., Prevention of migraine with monoclonal antibodies against CGRP or the CGRP receptor, Supplement to S1 Guideline Therapy of Migraine Attack and Prevention of Migraine, 2019, Deutsche Gesellschaft für Neurologie (eds.), Guidelines for Diagnostics and Therapy in Neurology. A complete version of this guideline can be found on the website of the Deutsche Gesellschaft für Neurologie (www.dgn.org/leitlinien) and the AWMF (Arbeitsgemeinschaft wissenschaftlicher Medizinischer Gesellschaften).This guideline has been approved by the German Neurological Society (DGN) and the German Migraine and Headache Society (GMHS) and was reviewed by the two societies.