Migraine
Clarissa Chan, PharmD
In June, the American Headache Society (AHS) released an updated consensus statement to help guide health care providers in the treatment of migraine. The consensus statement includes an updated review of data regarding the efficacy, safety, and clinical use of migraine treatments and most notably presents new FDA-approved treatments.
“Migraine, a genetic neurologic disease, is the most prevalent headache disorder that we see in the neurology clinic,” said Amaal J. Starling, MD, FAHS, FAAN, from the department of neurology at the Mayo Clinic in Scottsdale, AZ. Over 100 different genetic mutations can make patients vulnerable to migraine disease.
“Everyone has a different collection of genetic mutations that make them vulnerable to migraine disease, which is why it’s important to have a variety of [medications] available for acute and preventive therapy,” said Starling, who was not associated with the writing of the AHS statement.
Acute vs. preventive therapies
Since oral migraine medications work in only 50% of patients, figuring out the right therapies and doses for patients is determined by trial and error with information from evidence-based clinical trials guiding providers’ recommendations, noted Starling.
Treatment is partially determined based on diagnosis, which can either be episodic, where the patient experiences fewer than 14 attacks or “headache days” per month, or chronic, where they have 15 or more headache days per month.
It is also influenced by severity, frequency, and duration of attacks and patient preference, said Teshamae Monteith, MD, FAHS, FAAN, an associate professor of clinical neurology at the University of Miami Miller of Medicine in Miami, who was not associated with the writing of the statement.
Treatments fall into 2 categories—acute and preventive therapies. “When someone has a migraine attack, they need a rescue, or acute, therapy to treat that attack. Whereas for migraine prevention, the goal is to reduce the severity, duration, and frequency of attacks,” said Starling.
Whether a patient needs preventive therapy depends on the frequency of their migraine attacks and their response and tolerability to acute treatment options.
“Currently, the recommendations for initiating a preventive migraine therapy is based on a patient experiencing four or more headache days per month with some degree of disability,” added Starling.
“A good response is considered a 50% reduction in migraine days; however, some patients may achieve a 75% or even a 100% response with a combination of effective preventive treatments, both non-pharmacological and pharmacological,” said Monteith.
Novel treatments fill a need
Triptans have been the established first-line therapy option for acute treatment of migraine attacks for some time and work well for many patients, but there are still many patients who either don’t respond to triptan medications or have contraindications or poor tolerability to them, noted Starling.
“The data show that up to about 30% of patients who are given triptans don’t have an adequate response, don’t tolerate, or have contraindications to therapy; so other options are needed,” she continued.
The newly FDA-approved acute migraine treatments include celecoxib, lasmiditan, rimegepant, ubrogepant, and remote electrical neuromodulation (REN) devices.
Ubrogepant and rimegepant are gepants, non-vasoconstrictive calcitonin gene-related peptide (CGRP) small receptor antagonists. The only available ditan (5-HT1F agonist) is lasmiditan.
“Both classes are indicated when patients have not adequately responded to standard treatments, have intolerances, or have contraindications to migraine-specific treatments like triptans, dihydroergotamine, or ergotamine due to vasoconstrictive properties,” said Monteith. “Gepants and lasmiditan may be well-tolerated and safer to use in patients with multiple cardiovascular risk factors, although patients may experience sedation with lasmitidan. Due to cost, gepants and lasmiditan are considered second-line, but may be appropriate first-line treatments in some patients.”
Triptans vs. gepants and lasmiditan
There are currently no head-to-head studies to inform the efficacy of standard treatments like triptans versus gepants or lasmiditan, said Monteith.
Acute treatment with medications like triptans have the risk of inducing medication-overuse headache, also known as ‘rebound headaches,’ if used on a regular basis or more than 2 headache days weekly.
“The consensus statement discusses that gepants do not have the risk of medication overuse, which is a huge advantage because they don’t increase risk of medication-overuse headache like other acute treatments,” said Starling. Recent clinical trials led to FDA approval of rimegepant for every other day use for migraine prevention.