Migraine care tailored to you: A debate on precision medicine

Precision medicine is an approach for disease treatment that takes into account individual differences in each person’s genetics, environment and lifestyle.¹ This type of medicine became a topic of discussion in 2015, when Barack Obama announced the Precision Medicine Initiative, a program to implement precision medicine in the United States.¹ One might wonder: how does this form of medicine impact the field of migraine care? At the International Headache Congress (IHC) 2021—being held as a joint congress of the International Headache Society (IHS) and the European Headache Federation (EHF)—Prof. Cristina Tassorelli (University of Pavia, Italy) and Prof. Hans Cristoph Diener (University of Duisburg-Essen, Germany) engaged in a debate to answer the question: is precision medicine possible in migraine? Prof. Tassorelli provided the “pro” argument in favour of precision medicine, opposed by Prof. Diener’s “con” argument.

The case for precision medicine

Prof. Tassorelli initiated the debate, noting that precision medicine is not a new concept; ABO blood types were discovered in 1901, which led to improved and individualized methods of blood transfusion. She then quoted President Obama, who once opined that doctors have always recognized that every patient is unique, and have always tried to tailor their treatments to suit each individual.

To further her argument, Prof. Tassorelli remarked that precision medicine would be extremely helpful for migraine, a disease with high variability. The diagnostic criteria for migraine, she noted, are polythetic by necessity, accounting for many different kinds of migraine. She then asked her audience to consider how current migraine treatments perform against efficacy benchmarks. For example, between 31% and 57% of patients see a 50% reduction of migraine days with preventive treatments.² “Is this enough, or can we do more?” Prof. Tassorelli said. “I think we can do more.”

Next, Prof. Tassorelli presented data from several studies that she believes demonstrate the possibilities of precision medicine in migraine. For instance, a 2019 report on results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study showed that dividing migraine patients into subgroups based on comorbidities helps predict progression of the disease.³ Additionally, she discussed an ongoing study in her own laboratory, which aims to identify a panel of biomarkers that could predict a patient’s response to new treatments. She concluded her argument by summarizing the potential benefits of precision medicine, noting that the implementation of precision medicine will not be easy, but that “the process has already started,” and precision medicine is “already on its way.”

The case against precision medicine

Prof. Diener then tackled what he described as “the difficult task” of providing the position against precision medicine in migraine. He argued that, instead of personalized treatment, all we need to properly treat migraine are clinical criteria: to take a proper prior history, do a careful neurological examination and, most importantly, consider comorbidities as part of the diagnosis. He also noted that, on average, a general practitioner in Europe can only devote approximately six to eight minutes to a particular patient with migraine. “How much precision medicine,” he asked, “can you achieve in six minutes?”

Biomarkers are an important part of precision medicine in the context of migraine and, as Prof. Diener remarked, reliable and robust neuroimaging biomarkers are still lacking for migraine. He believes that even if we could predict treatment response for acute and preventive treatment, health technology assessment bodies and payers would immediately stop reimbursement for patients who could be predicted as non-responders. Prof. Diener concluded his argument by stating that, currently, the treatment of migraine based on biomarkers is a hypothetical construct. He opined that the only exception where precision medicine could work in migraine is in patients with migraine and comorbidities, as preventive therapy could be selected based on the comorbidity.