William B. Young, MD, FAHS, FAAN, FANA
Professor, Department of Neurology and Co-Director, Inpatient Program, Headache Center, Thomas Jefferson University, Philadelphia, Pennsylvania
Migraine is the second leading cause of disability worldwide, impacting an estimated one billion people globally.
In the last five years a new wave of treatments have come to market in the United States, and some in other places in the world, that have revolutionised migraine treatment.
Six of these new treatments are medications that work by controlling the effects of the pain molecule called calcitonin gene-related peptide (CGRP). Four of the treatments are injectable or intravenous preventives that are given either every 28 or 84 days, and two treatments are for acute usage at the start of a migraine attack. In addition, another acute treatment is available that works differently, on a subtype of the serotonin receptor. Finally, there are a handful of neuromodulation devices that can be used to prevent or treat migraine attacks.
Let’s go through these new treatments.
CGRP migraine preventive medicines
- Erenumab was the first of the new class of preventives. It takes out the receptor of the CGRP molecule so it can no longer make nerve cells more responsive to pain signals.
- Fremanezumab was second. It directly neutralises the CGRP molecule so it can’t stimulate pain nerves to become hyperactive.
- Galcanezumab was next. It works similarly to fremanezumab.
- Eptinezumab is the last of these medicines to come to market. It is given intravenously, and kicks in very quickly.
Compared to previous migraine preventives, these medicines are at least as effective, with astonishing few side effects by comparison. While they are not effective for some people, they are strongly helping some patients who don’t respond to other preventive medicines. The first three are given via injection pens and the fourth is given as an intravenous infusion.
Patients with migraine deserve to live a better life, and these new innovations for migraine treatment can help provide needed care and relief to millions of people with migraine.
CGRP migraine acute medicines
- Ubrogepant was the first of the new acute migraine medicines. It works similarly to erenumab focusing on the CGRP receptor, but is taken at the beginning of a migraine attack instead of preventively.
- Rimegepant came next and it works similarly to ubrogepant. Rimegepant can also be taken every other day as a migraine preventive.
These new acute medicines are making life better for many migraine patients. They prevent the pain nerve from becoming overactive and have astonishingly few side effects. Another small molecule CGRP medicine called atogepant will hopefully soon come to the U.S. market as another preventive option.
Ditan acute medicine
- Lasmiditan works similar to how the standard of care triptan class of medicines work, but it doesn’t have the same cardiovascular contraindications. Note that it can cause dizziness, and people should not drive for twelve hours after a dose, so there are some limitations to its use, although it is often effective.
In the U.S. there are five neuromodulation devices that have been cleared by the FDA for the treatment of migraine. They can be used on different parts of the head and body, and they work to disrupt pain signals associated with migraine. The side effects of these devices are much lower than we see for medicines, so they are a great tool to have in the migraine treatment toolbox.
We are in a promising new era with treatments that are now revolutionising migraine care. Patients with migraine deserve to live a better life, and these new innovations for migraine treatment can help provide needed care and relief to millions of people with migraine.