Current and Emerging Migraine Treatments

By Guadalupe Chavez, PharmD Candidate 2021
University of Iowa College of Pharmacy

March 02, 2021

Migraine Pain

Migraines are a serious public health concern in the United States, especially in women. In 2016, migraines accounted for 4 million emergency department (ED) visits. Headaches were the third most common reason for ED visits in females aged 15 to 64, preceded by abdominal pain and chest pain. However, in males of the same age, they were the fifth most common reason for ED visits.  

Migraines are recurrent, one-sided, and throbbing headaches of moderate-to-severe pain intensity. Attacks are often debilitating and can last 4 to 72 hours. Before or during an episode, some people experience reversible facial or visual disturbances that include auras, nausea, vomiting, or light and noise sensitivity.

These symptoms can affect people's quality of life through loss of workdays and ability to participate in family and social events. Because there is no cure, the goal for treatment is to reduce how often they happen, how long they happen for, and how severe the migraines are. Currently available medicines for migraines are FDA approved for either the prevention or relief of migraines, but not both.

How do I prevent my migraines?

Keeping a headache calendar where you document daily activities may help you identify triggers and avoid them (i.e., stress, lack of or too much sleep, particular foods, not eating, alcohol, and hormonal changes). Aerobic exercise, relaxation training, cognitive-behavioral therapies, acupuncture, and transcutaneous electrical nerve stimulation (TENS) may also prevent episodic migraines. However, if your migraines are frequent and severe you may require additional treatment.

Medications to prevent migraines include beta-blockers, anti-depressants, anti-seizure, and anti-histamines. Because they were originally designed for other conditions, their effectiveness varies person to person, often have intolerable side effects, or are not recommended in certain individuals.

 In the last three years, the FDA has approved a group of injectable medications called calcitonin gene-related peptide (CGRP) antagonists (Emgality and Vyepti, are two examples). Although they are not more effective than previous therapies, they do have an advantage of requiring less frequent dosing, less side effects, less restrictions, and less interactions with other drugs. Your trusted healthcare provider can help you find the best prevention strategy for you. 

For those diagnosed with chronic migraines, botulinum toxin type A injections (BTX-A), also known as Botox, is another option. After an extensive work-up, low doses of BTX-A are injected into trigger points. They provide relief to the nerves associated with the migraines and are best suited for those unresponsive to other medications.

How can I treat my migraines? 

For mild migraines, doctors may recommend over-the-counter pain medicine such as Tylenol, Advil, or Excedrin. It is important that you do not try to treat migraines on your own with these medications more than once or twice per week. Taking too much or too often can cause more headaches!

For more severe migraines, there are prescription medications (commonly known as triptans, ergots, ditans, etc.,) that disrupt how migraines develop rather than just targeting the pain. In the last two years, two oral calcitonin gene-related peptide (CGRP) antagonists have been FDA approved for the acute treatment of migraine with or without aura.

Ubrelvy and Nurtec ODT (oral disintegrating tablet) also known as “gepants” work by blocking the transmission of pain for those that fail, cannot tolerate side effects, or cannot take other therapies. Their comparative efficacy with current therapies and long-term safety is not yet known. However, Nurtec ODT has promising success as an oral disintegrating tablet and once daily dosing, compared to Ubrelvy which requires multiple doses per day. A single dose of Nurtec ODT provides pain relief and allows patients to return to normal function in less than 2 hours with minimal side effects (nausea 2%).

What do future therapies look like?

Nurtec ODT is not currently indicated for the prevention of migraines but the manufacturer is seeking approval. In clinical trials, when taken every other day, it decreased patient’s average migraine days by 4.3 days per month. It also reduced the number of moderate-to-severe migraines per month by more than 50%. If approved for prevention, Nurtec ODT would be the first dual therapy for both the preventative and acute treatment of migraines.

References:

Ashina M. Migraine. N Engl J Med. 2020 Nov 5;383(19):1866-1876. doi: 10.1056/NEJMra1915327. PMID: 33211930.

Burch R, Rizzoli P, Loder E. The prevalence and impact of migraine and severe headache in the United States: Updated age, sex, and socioeconomic-specific estimates from government health surveys. Headache. 2020 Dec 21. doi: 10.1111/head.14024. Epub ahead of print. PMID: 33349955.

Croop R, Goadsby PJ, Stock DA, et al. Efficacy, safety, and tolerability of rimegepant orally disintegrating tablet for the acute treatment of migraine: a randomised, phase 3, double-blind, placebo-controlled trial. Lancet. 2019;394(10200):737-745. doi: 10.1016/S0140-6736(19)31606-X.Olla D, Sawyer J,

Sommer N, Moore JB 4th. Migraine Treatment. Clin Plast Surg. 2020 Apr;47(2):295-303. doi: 10.1016/j.cps.2020.01.003. Epub 2020 Feb 6. PMID: 32115055.

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