Page 137 - The clinical aspects and management of chronic migraine Judith Anne Pijpers

against CGRP or its receptor could be a possibility. As these antibodies are widely studied, the near future will probably show whether migraine chronification and associated mechanisms can be prevented. In addition, the capability of KOR antagonists to reduce central sensitization35 and restore pain inhibitory controIl36 in animals might be promising. The first clinical studies for substance abuse and affective disorders were terminated because of adverse events, but trials at new generation KOR antagonists with potentially less adverse events are ongoing.37,46
Direct intervention on pain facilitation or inhibition pathways in other pain conditions has yielded contradictory results: not all studies show a beneficial effect of similar pharmacological interventions on these pathways. However, in case of a reduction in central sensitization there is a parallel effect on pain intensity, suggesting potential for future treatment.27 Replication of these effects in migraine patients are important, as direct translation might be impaired. For instance amitriptyline, used as a preventative in headache, increased central sensitization.27
Prevention of risk factors for chronic migraine
Awaiting these developments, the best strategy in the prevention of migraine chronification is addressing its risk factors, of which medication overuse is the main factor. Chapter 3, 4, and 5 show the relevance of cessation of overuse and chapter 3 and 5 demonstrate effect of education, support and behavioural intervention by a headache nurse on successful medication withdrawal and a reduced medication intake in the months after withdrawal therapy. In line, prolongation of support by a headache nurse would likely enhance a long- lasting reduction in medication use or even prevent medication overuse. So far, only a small study has been performed with intervention by a headache nurse in a heterogeneous migraine population in a tertiary headache clinic which could not show a reduction of medication intake or a lower percentage of medication overuse.47
This discrepancy might be related to an important question in preventive care: which part of the population should be subjected to the preventive strategy? The population in chapter 5 is a ‘high risk’ migraine population, suffering from chronic migraine and initially medication overuse, with prevalence of other risk factors (cutaneous allodynia 75%, depression 37%, and anxiety 31%). These risk factors are not described in the previous study on a intervention
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Summary and general discussion
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