Current State of Migraine Preventive Therapies
Dr. Steven Kosa is a distinguished Neurologist in North Kansas City, MO. Dr. Kosa specializes in diagnosing, treating, and managing disorders of the brain and nervous system. With expertise in handling complex conditions like epilepsy, multiple sclerosis, and migraines, Dr. Kosa employs advanced techniques and personalized... more
Today’s landscape of migraine treatment has significantly improved over the past couple decades and in particular over the past 5 years with the introduction of a new class of preventive and acute migraine-specific treatment options targeting CGRP (calcitonin gene related protein) which is involved in migraine formation. Migraine treatment focuses on therapies to prevent attacks and those that are taken acutely when an attack occurs. The post will focus on the developments in the migraine preventive therapy space.
Previously preventive treatments consisted of prescribing medications designed for other disease states such as anti-seizure, antidepressant or antihypertensive medications which could be effective but left a lot to be desired and were fraught with numerous side effects that had to be managed. Botox was the first “new generation” preventive therapy that received FDA approval in 2010 to treat chronic migraines which is defined as headaches on 15 days per month or more for 3 months with over half of those headaches being moderate severity or above consistent with migraines. While not being specifically designed to treat migraines, it was noted by people receiving Botox for cosmetic purposes, they were experiencing significantly less migraines which led to dedicated Placebo-controlled clinical trials evaluating the effectiveness of Botox in prevention of migraine showing positive results leading to FDA approval.
Then in 2018, the first CGRP (calcitonin gene related protein) blocking therapy targeting a specific protein found to be a major cause of migraine attacks with lab created antibodies that are injected subcutaneously. The first product approved by the FDA was Erenumab under the trade name Aimovig which was approved for prevention of both episodic migraine (less frequent headaches/migraines but still sufficiently disabling requiring preventive therapy) and chronic migraine prevention. Shortly thereafter, two more subcutaneous injectable products were similarly approved by the FDA which includes: fremanezumab under the trade name Ajovy and galcanezumab under the trade name Emgality.
The most recent FDA approved antibody therapy was approved for intravenous administration (eptinezumab under the trade name Vyepti) in 2020.
The most recent preventive medication advances are the “Gepant” class which are oral therapies to be taken daily (atogepant under the trade name Qulipta) or every-other-day (rimegepant under the trade name Nurtec). These are oral medications that block CGRP receptors blocking the activity of CGRP and can be used for both acute treatment and prevention3.
The above therapeutic advancements have led to significant improvement in the quality of both home and work life for migraine sufferers with very limited side effects unlike the prior therapies.
Other non-medication therapies have been or are under development using electrical or magnetic stimulation and can be effective for patients that either can’t take medications (pregnancy, lactation) or who have side effects to a lot of medications. These products have been welcome additions to the migraine treatment landscape.
Oftentimes, patients require a combination of the above treatments to get the most benefit, especially the patients who have been referred to a headache/migraine referral clinic where I practice given poor response to initial therapies or those who have difficulty with insurance coverage of the more expensive but more effective therapies that have less side effects.
Despite these advances, migraines remain underdiagnosed and undertreated, with many patients continuing to rely on over-the-counter and prescription non-specific acute treatment medications that can lead to medication-overuse headache (also known as “rebound headaches”) making it more likely the patient develops chronic migraines that are more challenging to treat. It is of the utmost importance that patients be properly diagnosed and placed on appropriate therapies to get the best results. The headache/migraine field continues to evolve with ongoing research aimed at improving patient outcomes and expanding the arsenal of treatments available to those suffering from migraines.
