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Expert Interview Headache Preventative Therapies for Migraine An expert interview with Uwe Reuter Charité Universitätsmedizin Berlin, Berlin, Germany Uwe Reuter Uwe Reuter is a neurologist and partner in the headache programme at Charité Universitätsmedizin Berlin. After finishing his residency training in Berlin he went to Harvard Medical School for a postdoctoral fellowship as a scholar for three years. During his time in Boston he focused on basic research in primary headaches and migraine aura and published several peer-reviewed publications in high-impact journals. Ever since, Dr Reuter has had a strong interest in basic and clinical headache research. He is a member of several national and international headache organisations and currently serves as board member of the European Headache Federation (EHF). Keywords Chronic migraine, episodic migraine, preventative therapy, discontinuation Disclosure: Uwe Reuter serves as a consultant and on speakers bureau for Amgen, Allergan, Co-Lucid, Eli Lilly, Novartis and TEVA, he is also on advisory boards for Amgen, Allergan, Eli Lilly, Novartis and TEVA. This is an expert interview and as such has not undergone the journal’s standard peer review process. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: 9 November 2017 Published Online: 4 December 2017 S hortly after the 18th Congress of the International Headache Society in Vancouver, Canada, in September 2017, Uwe Reuter participated in an expert interview. Here, he shares his insights and perspective on preventative therapies for migraine, discontinuation rates on current therapies, the need for new therapies with alternate targets and most promising potential therapies currently in development. Q: At present, what are the most effective preventative therapies for migraine? To answer this question, we first need to differentiate between episodic migraine and chronic migraine. Chronic migraine is defined as more than or equal to 15 headache days per month for at least 3 months, of which eight days or more meet the criteria for migraine with or without aura, or which responds to migraine-specific treatment. Episodic migraine is generally defined as 14 or fewer migraine days per month. 1 Preventative medications for migraine aim to decrease the overall clinical characteristics of migraine including the frequency of attacks and their severity, while also being aware of their response to acute medications. Citation: European Neurological Review, 2017;12(2):64–5 Corresponding Author: Uwe Reuter, Charité Universitätsmedizin Berlin, Department of Neurology, Charitéplatz 1, 10117 Berlin, Germany. E: Support: No funding was received in the publication of this article. In Europe, although options differ by country, the four frontline therapies that are used in preventing episodic migraine are: anti-epileptics, beta-blockers, amitriptyline and valproic acid which is used to treat bipolar disorder and epilepsy. For chronic migraine, topiramate, an anti- epileptic, may also be used. Botulinum toxin was approved for the prevention of chronic migraine in 2010 and is the second main preventative option used in patients with chronic migraine. Physicians formulate a treatment strategy on a case-by-case basis while keeping in mind the patient’s history. As such, the treatment prescribed is dependent on patient and physician preference, but will also take into account the frequency and severity of migraine and the patient’s comorbidities. For example, certain anti-epileptics (e.g. topiramate) which may be prescribed for both chronic and episodic migraine, should be used with caution in patients with depression as they can further induce depression. Other comorbidities which may need consideration include vascular disease or cardiac conditions. In all cases, pharmacologic treatment should be supported by non-medical treatment, such as exercise or relaxation training. Q: Why are new preventative therapies needed? There are several reasons why new preventative therapies are needed. Firstly, there are no specific anti-migraine preventatives available – they have all been re-purposed from other disease areas. This is critical for the patient who would prefer to receive a therapy designed for their specific condition. Another important reason is that the preventative treatments currently available take a number 64 TOU C H ME D ICA L ME D IA