EAN 2026 | Guidance for switching preventive migraine treatment: why and when?
Piero Barbanti, MD, PhD, IRCCS San Raffaele Pisana, Rome, Italy, discusses when clinicians should consider switching preventive migraine therapies in patients with a suboptimal response. He highlights the importance of timely treatment evaluation, recognizing late responders, and using differences in drug targets and pharmacokinetics to optimize long-term migraine management. This interview took place at the 12th Congress of the European Academy of Neurology (EAN) in Geneva, Switzerland.
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Transcript
With my patients, sometimes I say, well, I would like to act as to provide a sort of restoration of fine art, because after all, every brain is a fine art, is a masterpiece. And we have to make all we can to improve the quality of life of the patient. And so the message is never give up. And sometimes we have to do something more with our treatment, sometimes even switching. But the question is when to switch...
With my patients, sometimes I say, well, I would like to act as to provide a sort of restoration of fine art, because after all, every brain is a fine art, is a masterpiece. And we have to make all we can to improve the quality of life of the patient. And so the message is never give up. And sometimes we have to do something more with our treatment, sometimes even switching. But the question is when to switch. We have learned from real-world studies that actually a proportion of patients, which is up to 30%, does respond after three months and some of them after six months, what we call late response and ultra-late response. Obviously, we cannot ask a patient to wait one year to switch. It’s probably unethical. But I think that after 12 weeks, that is after three months, we should start thinking about potential switching. And to me, if you want to know my personal view, I will switch at week six. Why, when, and what? Switching is not like a game, it’s not like a lottery. We have to think about it. Are we using a monoclonal antibody targeting the receptor? Well, it’s reasonable to move to a monoclonal antibody targeting the ligand. Are we using a monoclonal antibody targeting the ligand which is delivered subcutaneously? So I would change the route of administration using the intravenous one. So using all the alternatives of pharmacokinetics that we have. However, there is one question left. If the patient improves after switch, has it been the new drug to provide a good result or something else. We do not know. Obviously, the new drug is very relevant, matters a lot, but we have also to consider that migraine may have a spontaneous fluctuation and that sometimes we can have a delayed effect on the prior treatment. Nevertheless, the take-home message is don’t give up. Switch and switch using reasoning very well, trying to change the kinetic parameters or the dynamic parameters of the drug. I would say usually at week three or to me better six.
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