Preventive vs. abortive, hormonal vs. environmental. Migraine headaches and their treatment are complex, but new, more effective medications promise to keep them from happening or stop them once they begin.
Dr. Nicole Gill, a headache specialist with the Hartford HealthCare Headache Center in Cheshire, is an osteopathic physician, which gives her a holistic view of migraine. This helps when treating migraine, which hit more than 37 million Americans each year, mostly women, affecting their ability to work, care for families and even get out of bed.
“Migraines typically affect people when they are in the most productive years of their lives,” Dr. Gill said. “The disabling nature of this disease can affect their education, career and family life. That is why migraine is the second-leading cause of years lived with disability worldwide.”
The medication toolbox expanded with the introduction of triptans, the first-ever class formulated to abort migraine by working on serotonin receptors.
During migraine, Dr. Gill said, the trigeminal nerve is activated, causing pain and sensitivity to the face, head and upper neck. This triggers the release of inflammatory markers such as CGRP (calcitonin gene-related peptide), which bind to receptors on other nerves, blood vessels and inflammatory cells.The CGRP molecule is referred to as a ligand.
“These new medications either bind to the CGRP molecule or block CGRP from binding to its receptor to prevent or abort migraine.” Dr. Gill said.
The preventive medications – large monoclonal antibodies that cannot be absorbed through the gastrointestinal tract so, therefore, are not effective as pills — include:
- Aimovig (erenumab-aooe), a receptor binder given as monthly injections.
- Ajovy (fremanezumab-vfrm), a ligand binder given as a monthly or quarterly injection.
- Emgality (galcanezumab-gnlm), another ligand binder given in monthly injections.
- Vyepti (eptinezumab-jjmr), a ligand binder given as quarterly infusions.
“These medications can be used for patients who have migraine with or without aura,” Dr. Gill noted, adding that the treatments work for people with periodic, or episodic, migraine and chronic ones happening more than 15 times a month. “In studies, after taking them for three months, the monoclonal antibodies decrease the frequency of migraines by about 40 percent. This may increase the longer a person is on the medication.”
Once migraines have begun, patients can take what’s called an abortive medication to stop the migraine’s progression. A new class of these, called gepants, was introduced earlier this year as the tablet Ubrelvy (ubrogepant) or dissolving tablet Nurtec (rimegepant) ODT.
The oral gepants, Dr. Gill said, have similar efficacy as triptans, the standard of care for aborting migraine, but they have fewer side effects. Also, people who don’t respond to triptans may respond to gepants, which target a different part of the migraine pathway.
Dr. Gill said another new class of abortive medications, called ditans, debuted in January. With the brand name Reyvow (lasmiditan), these work on a similar receptor as the triptans, but can be used in patients who cannot take triptans.
Expanding the options for migraine patients is welcome in a field that lags in research, she added.
“Funding for the research of migraine and headache disorders has been lacking despite the high prevalence of migraine,” Dr. Gill said. “CGRP was discovered in 1982 and was shown to be elevated during migraine attacks in the mid 1990s. It took more than 20 years for the first medication to come to market!”
Because migraines are unique experiences based on the patient’s body chemistry, lifestyle and environment, Dr. Gill stressed the importance of working with a headache specialist on a tailored care plan. This can include addressing diet, exercise, caffeine use, sleep and hydration.
“All patients should have at least one acute option to stop the migraine when it comes,” she said. “If migraines are frequent enough, the patient should be started on a preventative medication to decrease the frequency and severity of the migraines.”
For more information on headaches or to meet with a specialist, go to www.hartfordhealthcare.org/headache.
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