Migraine: Expanding our Tx arsenal
Beyond tried-and-true therapies are new therapeutic targets on the horizon—giving you a bigger toolbox to help patients abort and prevent migraine episodes.
PRACTICE RECOMMENDATIONS
› Offer treatment with a triptan to adult patients with moderate-to-severe episodic migraine. A
› Consider prescribing topiramate, divalproex sodium, metoprolol, propranolol, or the herbal, Petasites hybridum, for the prevention of recurrent episodic migraine that has not responded to a reduction in headache triggers. A
› Add onabotulinumtoxinA injection to your therapeutic toolbox as an effective preventive treatment for chronic migraine (≥15 headache days a month for 3 months). B
› Recommend magnesium and feverfew as adjunctive preventive treatments for migraine. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
With better understanding of the pathophysiology of migraine, a host of novel anti-migraine drugs are on the horizon.
CGRP receptor antagonists. The neuropeptide CGRP, which mediates central and peripheral nervous system pain signaling, has been noted to be elevated during acute migraine attacks26; clinical trials are therefore underway to evaluate the safety and efficacy of CGRP receptor antagonists.18 These agents appear to be better tolerated than triptans, have fewer vascular and central nervous system adverse effects, and present less of a risk of medication overuse headache.18 Liver toxicity has been seen with some medications in this class and remains an important concern in their development.19
Phase 3 clinical trials for 1 drug in this class, ubrogepant, were completed in late 2017; full analysis of the data is not yet available. Primary outcomes being evaluated include relief of pain at 2 hours and relief from the most bothersome symptoms again at 2 hours.27
Selective serotonin-HT1f receptor agonists, such as lasmiditan, offer another potential approach. Although the exact mechanism of action of these agents is not entirely clear, clinical trials have supported their efficacy and safety.20 Importantly, ongoing trials are specifically targeting patients with known cardiovascular risk factors because they are most likely to benefit from the nonvasoconstrictive mechanism of action.28,29 Adverse effects reported primarily include dizziness, fatigue, and vertigo.
Strategies for managing recurrent episodic migraine
Because of the risk of medication overuse headache with acute treatment, daily preventive therapy for migraine is indicated for any patient with 30 :
- ≥6 headache days a month
- ≥4 headache days a month with some impairment
- ≥3 headache days a month with severe impairment.
Continue to: Treatment begins by having patients identify...
