November 15, 2019
Newly Approved Medications for Migraines: The U.S. FDA approved three new medications with novel mechanism of action for migraine prophylaxis. The calcitonin gene-related peptide (CGRP) antagonists, erenumab (Aimovig®), fremanezumab (Ajovy®), and galcanezumab (Emgality®) were approved in 2018 for migraine prophylaxis.
The CGRP antagonist therapies were approved for migraine prophylaxis in adults because of its hypothesized role in mediating trigeminovascular pain transmission and vasodilation activity for neurogenic inflammation. Although these medications appear effective, more data are needed regarding their long-term safety as well as use in special populations. All three therapies are available in the United States.
March 6, 2018
CGRP Monoclonal Antibodies for Prevention of Migraine Headache: Calcitonin gene-related peptide (CGRP) is a neuropeptide involved in central and peripheral vasodilation and nociception; agents that inhibit the CGRP receptor or the ligand itself have been shown to decrease migraine headache frequency in studies lasting 3 to 6 months. Three CGRP monoclonal antibodies (mAbs) are under review by the U.S. FDA for prevention of migraine headaches: erenumab, fremanezumab, and galcanezumab. These macromolecules act preferentially in the periphery, with only small amounts crossing the intact blood brain barrier, reducing the potential for adverse CNS side effects experienced with current prophylactic drugs (eg, β-blockers, antiepileptic drugs). Their long half-lives also allow for once-monthly or possibly quarterly administration (albeit by subcutaneous injection), which may improve adherence. The results of long-term studies of 12 months or more are pending and will offer further insights into the prophylactic efficacy and safety of these novel agents.
CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK
For the chapter in the Wells Handbook, please go to Chapter 54. Headache: Migraine and Tension-Type.
Acute migraine therapies should provide consistent, rapid relief and enable the patient to resume normal activities at home, school, or work.
A stratified care approach, in which the selection of initial treatment is based on headache-related disability and symptom severity, is the preferred treatment strategy for the migraineur.
Strict adherence to maximum daily and weekly doses of anti-migraine medications is essential.
Preventive therapy should be considered in the setting of recurring migraines that produce significant disability; frequent attacks requiring symptomatic medication more than twice per week; symptomatic therapies that are ineffective, contraindicated, or produce serious side effects; and uncommon migraine variants that cause profound disruption and/or risk of neurologic injury.
The selection of an agent for headache prophylaxis should be based on individual patient response, tolerability, convenience of the drug formulation, and coexisting conditions.
Each prophylactic medication should be given an adequate therapeutic trial (usually 6 months) to judge its maximal efficacy.
A general wellness program and consideration of headache triggers should be included in the management plan.
After an effective abortive agent and dose have been identified, subsequent treatments should begin with that same regimen.