Migraine
Elizabeth Briand
More than 39 million people in the United States experience migraine, according to the American Migraine Foundation. For some, the condition is an infrequent one, but for millions of others, it may be disabling, occurring so frequently and with such ferocity that nearly every aspect of their lives is affected.
On March 11, 2024, representatives of the American Headache Society (AHS) published an update in Headache: The Journal of Head and Face Pain with their official position regarding therapies targeting calcitonin gene-related peptide (CGRP), advocating for their use as a first-line approach to migraine treatment.
“The AHS is here to reduce suffering for anyone with migraine or those with headache disorders,” said Kathleen Digre, MD, a coauthor of the paper and a neuro-ophthalmologist at University of Utah Health. “We decided we needed to say we should be using this treatment. It’s preventative, it works, and there are so few side effects.”
A different approach
“Prior to the development of specific migraine-targeted therapies, all migraine preventive treatments were ‘borrowed’ for migraine management from other indications,” said Nina Riggins, MD, PhD, an AHS member and president of the Brain Performance Center and Research Institute in California. Beta blockers, for example, are used not only for hypertension and elevated heart rate, but also for migraine prevention.
In addition to antihypertensives, other treatments include antiseizure medications, antidepressants, and onabotulinumtoxinA.
CGRP-targeting therapies were developed specifically for the treatment of migraine based on the discovery that CGRP plays a key role in the development and progression of migraine headaches. For individuals coping with migraine, it’s a promising treatment with fewer adverse effects than those currently offered.
The goal now for many headache specialists is to get their patients immediate access to these medications. Currently, in order for insurance to cover the cost of a CGRP-targeting therapy, two other lower-cost treatments must fail for a patient. While many of these treatments do work, they may cause adverse effects such as tingling in the hands and feet, low BP, slower thought processing, and more.
“Imagine you have migraines and we say you have to try two other drugs, each for 8 weeks with side effects,” said Digre. “It’s frustrating for patients and for physicians because there is a preventative available—one shot that could help.”
Pharmacists’ guidance
Digre believes that pharmacists can play a role in advancing this type of care for patients coping with serious migraine conditions. “Pharmacists know their patients well, and if they see that someone is not doing well on their current medication, they could ask if they have tried these therapies,” she said.
Beyond education, pharmacists can also make sure their patients understand how to properly administer CGRP-targeting migraine therapies, which can be taken via monthly injection or in pill form. Other options include a quarterly I.V. treatment.
“This [AHS] position statement is very important as it provides opportunity for patient-centered treatment and is a great tool to use for advocating for CGRP-blocking medications when appropriate,” said Riggins. “It jump-starts an ask for insurance approval of clinicians’ recommendations to start with newer, migraine-specific therapies.”
Digre hopes that increased awareness leads to the removal of the requirement for the prior failure of other classes of migraine prevention treatments. The other medications may be less expensive, she noted, but “if you think of how costly being disabled is—a person [with significant migraine] can’t work, there’s a cost to their spouse, a cost to their family—in the long run, getting people back to work and back to their lives is worth it.”
Ultimately, Riggins said, she would like more physicians, including primary care providers, to know about these therapies and their “potential to change the life of a person living with migraine for the better.” ■