Headache and migraine in focus

The Irish Neurological Association 2026 Annual Meeting featured a session titled ‘Update on Headache’.

The session, which was chaired by Dr Martin Ruttledge, included a talk on migraine care using CGRP-targeted therapies, the demand for specialist care, a review of two clinics, and a patient-reported outcomes study on eptinezumab and its impact on migraine-related disability and quality-of-life.

Dr Ruttledge discussed updates in chronic, unremitting, persistent headache. “We all know that new daily persistent headache is the primary headache disorder,” he said, stressing the importance of ascertaining whether the patient’s headache has a CGRP biology. “That’s what everybody is thinking about now… there are no known treatments for the constant, unremitting headaches that are daily and persistent; there are only really treatments for the migrainous part of these disorders. The first thing we have to ask ourselves is, does the CGRP pathway become involved in this headache disorder?” he continued. “Do they have chronic, daily, unremitting headache with exacerbations for 10 days per month that look like migraine?”

Dr Ruttledge discussed pharmacological treatment options and provided an overview of his own clinical practice in Ireland. “We mainly see chronic migraine and migraine, which makes up about 70 per cent [of patients],” he told the conference. “About 20 per cent of these will be new daily persistent headache, or persistent post-traumatic headache, and then you have a small proportion of patients who have other conditions, such as TACs [trigeminal autonomic cephalalgias].

“If there is a clear migraine biology, we would generally use GEPANTs, CGRP monoclonal antibodies, or Botox, either together in combination, or individually,” he continued. “You will find that with most of these patients, you will need to layer treatment. We do a lot of layering in our clinic.”

Dr Ruttledge explained: “These patients are extremely refractory. There is a lot of biology to support the CGRP component, especially with exacerbations, and that’s really where the disability comes from… if a patient says they have an 8/10 headache for 10 days per month, they are in bed, they can’t lift their head, they are nauseated – if you can treat those 10 days per month, you are doing the patient a huge service, and you will improve their quality-of-life.”

“There are several lines of evidence from human and animal studies to show that CGRP plays a role in persistent post-traumatic headache and new daily, persistent headache,” he continued. “When you see these patients, take them at face value and start layering the treatment. If basic things do not work, you will usually end up with multiple modalities.” He added that in elderly patients, monoclonal antibodies (mAbs) can be useful, as they do not interact with other medications that the elderly patient may be taking.

He also touched on evidence to show that GLP-1 medications not only have an effect on weight, but also provide some benefit for migraine sufferers. “We now think that it also has an independent role, probably in neuro-inflammation, and this is something you will be hearing a lot about over the next couple of years.”