Background A previous European Headache Federation (EHF) guideline addressed the use of monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway to prevent migraine. Since then, randomized controlled trials (RCTs) and real-world evidence have expanded the evidence and knowledge for those treatments. Therefore, the EHF panel decided to provide an updated guideline on the use of those treatments. Methods The guideline was developed following the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed a systematic review and an analysis of the literature, assessed the quality of the available evidence, and wrote recommendations. Where the GRADE approach was not applicable, expert opinion was provided. Results We found moderate to high quality of evidence to recommend eptinezumab, erenumab, fremanezumab, and galcanezumab in individuals with episodic and chronic migraine. For several important clinical questions, we found not enough evidence to provide evidence-based recommendations and guidance relied on experts’ opinion. Nevertheless, we provided updated suggestions regarding the long-term management of those treatments and their place with respect to the other migraine preventatives. Conclusion Monoclonal antibodies targeting the CGRP pathway are recommended for migraine prevention as they are effective and safe also in the long-term.

BackgroundWhether neck pain (NP) is a prodromal migraine symptom or belongs to the migraine attack feature remains controversial.MethodsIn order to prospectively record neck pain (NP) and non-headache symptoms and to evaluate the percentage of patients having NP as clear premonitory, non-headache symptom of their migraine, a specific self fulfilled questionnaire was designed to record NP and premonitory symptoms in a migraine cohort. All patients who reported NP anytime during the migraine phase were allocated to 3 groups: A = NP starts with the onset of headache; B = NP starts < 2 h before the onset of headache; C = NP starts 2-48 h before the onset of headache.ResultsData were evaluated from 487 migraineurs with episodic migraine (73.1 % females; 77 % had migraine without aura). 338 patients (69.4 %) reported NP anytime during the migraine phase. 184 patients (group A; 54.4 %) noticed NP with the start of the headache phase; 118 patients (group B; 24.2 %) reported NP within 2 h before the headache phase; 36 patients (group C; 7.4 %) experienced NP 2-48 h before the headache phase. In group B we found a high proportion of typical migraine associated symptoms and NP progressed into the headache phase in 82.2 %.ConclusionsThese data indicate that NP is a very common feature of migraine attacks and is more likely to be part of the migraine attack than a prodromal migraine symptom.

BackgroundWe aimed to explore patients’ preferences for headache treatments with a self-administered questionnaire including the Q-No questionnaire for nocebo.MethodsQuestionnaires from 514 outpatients naïve to neurostimulation and monoclonal antibodies were collected.ResultsPatients assessed that the efficacy of a treatment is more important than safety or route of administration. They preferred to use an external neurostimulation device for both acute (67.1%) and preventive treatment (62.8%). Most patients preferred to take a pill (86%) than any other drug given parenterally for symptomatic pharmaceutical treatment. For preventive pharmaceutical treatment, most patients preferred to take a pill once per day (52%) compared to an injection either subcutaneously or intravenously each month (9% and 4%), or three months (15% and 11%). 56.6% of all participants scored more than 15 in Q-No questionnaire indicating potential nocebo behaviors that contributed significantly in their choices.ConclusionThese patient preferences along with efficacy and safety data may help physicians better choose the right treatment for the right person.