To the Editor:

Family physicians are at the forefront of diagnosing and treating migraine. The article by Moreland, et al., provides a helpful overview of migraine attack prevention but requires important clarifications.¹ The article states that migraine has a prevalence of 1%; however, the estimated prevalence of migraine in adults is in fact 12% to 14% (18% in women and 6% in men), translating to 40 million people in the United States and more than 1 billion globally.^2,3 This places migraine as the largest cause of disability before 50 years of age.³

The authors state that behavior therapies “are not recommended for migraine prophylaxis due to a lack of high-quality supporting evidence.” However, behavior therapies are evidence based, included in the American Headache Society treatment consensus statement, and are recommended globally for migraine prevention.⁴ Additionally, there are six (not three) neuromodulation devices cleared by the US Food and Drug Administration for acute and/or preventive treatment of migraine. Both neuromodulation and behavior therapies can be used alone or in polytherapy, can reduce frequency of attacks and burden, and are valuable when treatment options are limited, such as in children and pregnant women.^4–6

We encourage readers to familiarize themselves with the range of effective pharmacologic and nonpharmacologic preventive therapies recommended in the American Headache Society consensus statements and forthcoming American Academy of Neurology migraine prevention guidelines.^4,7,8

In Reply:

Thank you for your thoughtful letter. We appreciate the correction of the prevalence of migraine in the United States, which is 11% to 14%, whereas the prevalence of chronic migraine is 1%.¹ This highlights the importance of prevention.

Although current clinical practice guidelines conclude there is not enough evidence to recommend behavior therapies, consensus statements and expert opinions often recommend them because they are generally well tolerated, easy to implement, and have growing evidence of benefit. For instance, the 2021 consensus statement published by the American Headache Society encourages clinicians to recommend behavior therapies for select patients. However, it concludes that no evidence has emerged since the last consensus statement that is strong enough to change current migraine prevention guidelines.² The European guidance referenced in this letter is a review article that also encourages clinicians to recommend behavior therapies but is not a formal clinical practice guideline.³ Similar to the use of supplements, we encourage physicians to offer patients resources on behavior therapies while being aware that there are no formal guideline recommendations due to the lack of high-quality evidence. We look forward to possible changes to the American Academy of Neurology guidelines, currently under development.

Of the six neuromodulation devices approved by the US Food and Drug Administration, only five have clearance for prophylactic treatment of migraines (one device is only approved for acute treatment, which was not the focus of the article). Additionally, only two are approved for use in children as young as 12 years, and only one is approved for use in children as young as 8 years.⁴ Neuromodulation devices appear to be a promising treatment option for use in pregnancy; however, the safety evidence is limited for the three devices evaluated in this population.⁵ We encourage physicians to inform their patients of pregnancy registries that are available for some of the devices.