Know Your Options: Innovations in Migraine Treatment

We have done some research to better understand the innovations in migraine treatment. If you wish to add resources to this content please reach out to our editor Jim Sliney Jr at jsliney@patientsrising.org with subject line “Migraine Innovations”

Medicines

Migraine innovation has resulted in new classes of drugs for prevention and treatment. Some of these agents target calcitonin gene-related peptide (CGRP), a protein known to be released around the brain during a migraine attack, causing inflammation and pain.

Anti-CGRP and Anti-CGRP Receptor Monoclonal Antibodies

These are large biological molecules that need to be injected (not oral) and have minimal side effects. This class of drugs are specifically designed to prevent migraine attacks. Patients in whom these drugs work can expect to see a difference in their migraine headaches within a month. The following anti-CGRP antibodies have been FDA approved:

• Aimovig (erenumab)
  1. Binds the CGRP receptor
  2. Self-administered as a monthly subcutaneous injection
• Ajovy (fremanezumab)
  1. Binds the CGRP ligand and prevents its interaction with the CGRP receptor
  2. Self-administered as a subcutaneous injection once per month or every three months
• Emgality (galcanezumab)
  1. Binds the CGRP ligand and prevents its interaction with the CGRP receptor
  2. Self-administered as a monthly subcutaneous injection
• Vyepti (eptinezumab)
  1. Binds the CGRP ligand and prevents its interaction with the CGRP receptor
  2. 30-minute infusion administered every 3 months

Side effects: While clinical trial data reported minimal side effects of these monoclonal antibodies, the FDA Adverse Event Reporting System includes reports of gastrointestinal disorders including constipation, which may be aggravated by other drugs that the person may be taking.

Gepants and Ditans class drugs

Ditans (next generation of triptans) and gepants (CGRP antagonist) represent self-administerable migraine innovations. Taken as a pill or a dissolvable tablet, at the onset of an attack these treat symptoms like moderate to severe pain, light and sound sensitivity (aura), nausea, and vomiting.

Gepants

are small-molecule inhibitors of the CGRP receptor that do not cause vasoconstriction—a side effect of triptans. So, patients who cannot take triptans can consider gepants as an alternative treatment for migraine. Dr. Jesica Ailani of the Medstar Georgetown Headache Center believes that these rapid-acting agents are more specific than drugs used for acute migraine treatment. Approved gepants include:

• Ubrelvy (ubrogepant): This was the first gepant approved in December 2019 for the acute treatment of migraine, with or without aura in adults.

Side effects: Nausea is the most common side effect.

• Nurtec ODT (rimegepant): The second gepant approved in February 2020 for the treatment of acute migraine with or without aura in adults.

Side effects: Nausea is the most common side effect.

Ditans

do not constrict blood vessels and block blood flow, like triptans do. This makes them suitable for patients who have high blood pressure or have had, or are at a risk of, a stroke or heart attack.

• Reyvow (lasmiditan): This was the first ditan approved in the fall of 2019 for the acute treatment of migraine with or without aura in adults. It is not indicated for the prevention of migraine.

Side effects: Central nervous system depression, including dizziness and sedation. Patients are advised to not drive or conduct activities that need mental alertness for 8 hours after taking Reyvow. The drug may also cause fatigue and prickling sensation in the skin.

https://vimeo.com/560376498

Other migraine innovations

Migraine patients have alternative options that can reduce the frequency of migraine attacks and cluster headaches.

Neuromodulation

Non-invasive devices to alter signaling in the brain and nerves have been developed and can be used as an early treatment, with or without medicines. They can also help prevent migraine attacks. These devices are particularly useful in the more sensitive populations, such as pregnant women or adolescents, or among patients who have low tolerance for drug-based treatments.

FDA-approved neuromodulators:

• gammaCore: A hand-held unit for acute treatment in adults 18 and older
• sTMSMini: A hand-held unit for acute and preventive treatment in adults and adolescents over 12 years
• Cefaly: Three independent models for acute or preventive treatment, or both, in adults 18 and older

A majority of insurance companies do not cover these devices and others have certain restrictions in place, such as failure on 2 or 3 oral medications, before coverage approval, also known as step therapy. Contact your insurance provider for specific coverage benefits.

The Coalition for Headache and Migraine Patients (CHAMPS) has developed a financial assistance guide for patients who have been prescribed gammaCore.

Photobiomodulation (PBM)

A form of non-invasive light therapy, PBM could have the potential to reduce the inflammation and pain associated with migraine headaches. A very small 3-patient study found some positive effects of this treatment on migraine episodes and symptoms, but larger studies are needed to confirm the validity and sustained effects of PBM on migraine pain.

This article is intended for informative purposes only. Please consult your physician regarding changes to your treatment plan.

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Additional Resources

1. Mayo Clinic resource on migraine diagnosis and treatment: https://www.mayoclinic.org/diseases-conditions/migraine-headache/diagnosis-treatment/drc-20360207.
2. Information on new anti-CGRP drugs: https://americanmigrainefoundation.org/resource-library/what-to-know-about-the-new-anti-cgrp-migraine-treatment-options/.
3. FDA resource on new drugs for migraine care: https://www.fda.gov/drugs/news-events-human-drugs/new-drug-class-employs-novel-mechanism-migraine-treatment-and-prevention.

Financial assistance guide for new migraine treatments, both medicines and devices: https://headachemigraine.org/treatment-financial-assistance-guides.

This article cites quality content from other nonprofits, such as The Coalition for Headache and Migraine Patients and The American Migraine Foundation.

A well written article from Healthline about the insomnia and sleep practices in migraine patients: https://www.healthline.com/health/migraine/how-to-manage-sleep-related-fatigue-with-migraine

You might also be interested in:

How Step Therapy Results in Untreated Migraine by Eileen Brewer

Getting Access to the Migraine Care You Need by Dr. Huma Sheikh

Audiogram features CarmenRose Fiallo, patient, advocate, and member of Patients Rising’s Diversity, Equity and Inclusion Council

article updated 7/29/21 by Jim Sliney Jr.

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