By Dr Philip Holland, Reader in Neuroscience and lead for the Headache Group at the Kings College London

If there’s one thing we know for sure about migraine, it’s that no two people experience it in exactly the same way. Some people tend to experience attacks first thing in the morning, others in the middle of the day or evening. For some, certain foods are triggers; for others, it’s sleep changes, hormones or even the weather.

Yet, for decades, migraine care hasn’t really treated people as individuals – most treatments have followed a “one-size-fits-all” approach. That’s finally beginning to change.

What is personalised medicine?

Personalised medicine, or precision medicine as it’s sometimes known, is an emerging approach that takes into account our individual differences to achieve a “tailor-made” treatment strategy. This means it’s based on your specific needs, rather than a standard “one-size-fits-all” approach. Personalised medicine considers your unique genetic make-up, as well as other factors including your lifestyle and environment to try and achieve care that’s tailored to you.

The search for biomarkers

There has been a drive for scientists to identify specific biomarkers that can help to predict who is most likely to respond to a specific migraine drug. Biomarkers are biological “signposts” like molecules, genes or specific characteristics. They might signal a certain condition or show how you would respond to a treatment. A particular area of focus has been on a molecule called calcitonin gene-related peptide (CGRP). It was discovered back in the 1980s that levels of CGRP rise during migraine attacks. This led to the development of today’s CGRP-blocking medicines – a major leap forward for many people with migraine.

However, despite several attempts to explore CGRP as a personalised biomarker, we still can’t predict who will respond to these treatments. What we do know is that a small group of people appear to have a “super-response”. Ongoing research is aiming to determine if there are specific characteristics that predict this super-response rate. More recently, several studies have identified some other potential biomarkers for predicting treatment response. These include genetic factors and changes recorded in brain imaging scans. However, these markers are not readily available in routine clinical practice, leaving the search for widely applicable biomarkers ongoing.

What else might predict treatment response?

Research has also identified other factors that might predict how someone responds to migraine medications.

For example, data from studies has shown:

• lower headache intensity and disability is linked to a better response to NSAID painkillers
• higher BMI (body mass index) and having sensitivity to touch (allodynia) are associated with reduced response to acute medication
• lower migraine attack frequency is linked to a better response to preventive medicines
• longer migraine duration and having symptoms of depression can make attacks harder to treat.

Again, this shows the impact that individual differences can have on treatment response – underlying the importance of a personalised treatment approach.

Practical approaches to personalised treatment

While work in identifying biomarkers continues, there are certain approaches to personalising care that may be more achievable in the short to medium-term. Research is currently looking at the following areas:

• Your chronotype, or natural sleep rhythm (whether you are a “morning-lark” or “night-owl”). This can impact when your attacks are more likely to occur. Your doctor may be able to consider a personalised approach to the timing of when you take your medicine, so it can have the most impact and help minimise the impact potential side effects
• Hormones. We know that migraine is influenced by hormonal changes – such as during menstruation and the menopause. Hormones may also have an impact on how well treatments work. Research is ongoing in this area, but it’s something that your doctor may be able to take into consideration.
• Comorbid disorders. These are conditions that often exist alongside migraine, such as mood disorders and sleep disruption. Taking these into consideration when planning care can make a difference to how well treatment works. For example, effectively managing any sleep disorders can also often lead to a reduction in migraine frequency.
• Migraine comes with enormous variability, and the first challenge is ensuring appropriate diagnosis. This can enable an individualised approach, with more chance of treatment success

What does the future hold?

The challenge to develop a personalised approach to treatment for migraine remains a work in progress. But it’s clear that the field is moving in the right direction, with several targeted therapies already in use and more in the pipeline. The long-term goal is for a “therapeutic toolbox”, where clinicians are able to identify and select the treatment that is likely to work best for an individual patient. Modern tools – such as use of AI to screen large data sets – offer an exciting opportunity to identify potential patterns. With research continuing, we hope that achieving this goal for people with migraine will only be a matter of time.