OSA screening before CGRP mAbs in chronic migraine

Chronic migraine is a disabling disorder of a neurological nature. In the present biologic therapy, especially calcitonin gene-related peptide (CGRP)-monoclonal antibodies, the most frequent approach is to reduce the frequency and disability of the headache, not taking into account comorbid conditions which significantly contribute to patient burden.

Obstructive sleep apnea (OSA) is a very widespread and underdiagnosed disease in people with chronic migraine. OSA symptoms include mandatory symptoms- such as sleep fragmentation, daytime fatigue, and impaired functioning as core- which are intersecting and aggravating to migraine-related disability. Established OSA therapies such as continuous positive airway pressure (CPAP) enhance the quality of sleep, mood, and alertness and anecdotal evidence suggests that there may be a decrease in the frequency and severity of headaches.

Our proposal is to recommend routine OSA screening in patients with chronic migraine before starting the use of CGRP monoclonal antibodies. Diagnosis and management of OSA are extremely cheap, ubiquitous, and present a non-pharmacologic intervention with potential to decrease the level of symptom effects but increase functioning overall relative to those who initiate more costly biologic treatments.

The inclusion of sleep health in chronic migraine management is patient-centered, addresses reversible comorbidities, and has the potential to improve cost-effectiveness and equity as well as health-related quality of life. This suggested care pathway must be tested in randomized trials that can measure the outcomes of headaches and patient-reported sleep quality, fatigue, and functional ability.