Best Next Drug Migraine Algorithm

Mayo Clinic neurologist creates smart tool to support personalized migraine treatment programs

Algorithm seeks to cut wait times and enable more effective management

Migraines affect about 12% of people in the United States, amounting to around 40 million people.1 They are commonly characterized as intense headaches that are often accompanied by nausea, vomiting and intense sensitivity to light and sound. Migraines can be debilitating for hours or days for those who experience them.

There are only around 500 board-certified headache specialized neurologists in the United States.2 The wait times to see a headache neurologist are often extensive, with some institutions averaging a year and a half, or longer.3

There is a need for this specialized expertise, and the Next Best Drug algorithm was designed to support primary care providers and neurologists without specialized training to help migraine patients find relief.

In the current state, finding an effective treatment program is usually an iterative process. The neurologist assesses the patient’s health and other conditions, relevant influential factors, and prescribes a drug to try to mitigate symptoms. Much like anti-depressant medication, migraine medication may take weeks or months before it starts working. At the end of the trial period, if the medication is not effective or has intolerable side effects, the process starts over with a new drug. This cycle is repeated until the drug, or combination of drugs, that works for that patient is found.

Complicating the process further, most drugs used to treat migraines were originally developed for other diseases, and side effects are common. Migraines are also diverse and have a variety of characteristics; an experienced headache neurologist can recognize these features and use them to adjust a patient’s care plan.

Making uncommon expertise accessible to all

Fred (Michael) M. Cutrer, M.D.

Fred (Michael) Cutrer, M.D., a headache neurologist at Mayo Clinic, saw an opportunity to improve the current system and began development of the Next Best Drug algorithm.

Trained using anonymized data from thousands of patients who went through the long process of finding effective treatment for their chronic migraines, and incorporating Dr. Cutrer’s extensive expertise in headache neurology, the algorithm is a clinical decision support tool currently designed as a resource for non-specialist medical practitioners choosing which medication to try next for their own patients going through the process of finding migraine relief.

To use this tool, the patient must first complete a headache profile that includes headache symptoms, details of previous medications tried and why they failed. Because migraine medications may take months to have an effect, the algorithm also evaluates whether medications that failed to be effective were used long enough and at an appropriate dose for treating headaches before dismissing those drugs as options.

The Next Best Drug algorithm then takes the patient’s headache profile and medical record and creates a personalized, prioritized list of recommendations for the next best drug for that patient to try. While this tool could be helpful for experienced headache neurologists, Dr. Cutrer sees particular promise as a tool for neurologists and primary care providers without specialized expertise. If a primary care provider is able to find a medication that effectively manages a patient’s symptoms in fewer drug trials and without the need to refer to a specialist, it would mean fewer appointments, fewer months trialing medication, fewer days in pain, and more availability for new patients.

Always seeking to improve

“I want to take the current process and make it far more precise, giving patients effective, tolerable treatment from the very first drug they receive,” said Dr. Cutrer, “If we can pinpoint exactly what’s effective for different patient profiles, and why, we can minimize side effects and transform these treatments to be very effective for each individual.”

The Next Best Drug is patented and currently in use by Mayo Clinic Neurology. Dr. Cutrer’s current research is focused on understanding the role of genetics in migraine treatment response, and his team are developing treatment response prediction algorithms with a version that can include pharmacogenomics. Prospective validation in progress (2024).

      1. Burch RC, Buse DC, Lipton RB. Migraine: Epidemiology, Burden, and Comorbidity. Neurol Clin. 2019 Nov;37(4):631-649. doi: 10.1016/j.ncl.2019.06.001. Epub 2019 Aug 27. PMID: 31563224.
      2. McAllister, Peter, MD, Headache Horizons, June 2018
      3. Headache Education Active‐Waiting Directive: A Program to Enhance Well‐Being During Long Referral Wait Times – Lagman‐Bartolome – 2018 – Headache: The Journal of Head and Face Pain – Wiley Online Library

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