Prime/MRx experts share clinical insights for migraine treatment

“Migraine is a disorder with recurrent attacks,” explained Dr. Garcia, a board-certified neurologist. “The frequency of attacks varies from patient to patient.” 

An attack consists of four phases including prodrome, aura, headache and postdrome. Though, Dr. Garcia clarified that not every patient experiences all the stages. 

According to the NHF, 70% of all migraine sufferers are cisgender women. It’s a condition that experts say is underdiagnosed and underutilizes prescription medications for treatment.  

Patients are generally diagnosed with the disorder based on clinical history, physical examination and diagnostic criteria. The headache is typically on one side of the head, throbbing or pulsating, with moderate to severe intensity. Additional symptoms can include sensitivity to light and sound, nausea and vomiting, which may last for hours to days. 

Experts have proposed many causes for migraine, but most think cortical spreading depression (CSD), activation of the trigeminovascular system, sensitization, serotonin and calcitonin gene-related peptide (CGRP) are involved. Environmental and genetic factors also play a role. 

Risk factors for the disorder include a family history of migraine, low socioeconomic status, acute medication overuse, obesity, asthma, depression and hypercalcemia. Migraine attacks may be triggered by environmental factors (such as loud sounds, lights and weather changes), lifestyle factors (such as diet and sleep) and ergonomic factors (such as improper work set-ups). Hormone fluctuations and the use of oral contraceptives may also trigger migraine attacks.  

“It’s important for these patients to keep a headache diary, and record information about the pain and associated symptoms they’re having daily,” Dr. Garcia said.  

“Treatments can be broken down into lifestyle modifications, non-drug therapy and drug therapy,” said Dr. Pappas, a board-certified neurologist. Treatment plans are individualized for each patient.  

Some patients find that lifestyle modifications like getting enough sleep, eliminating dietary triggers, staying hydrated and managing stress may help prevent migraine attacks. Supplements such as riboflavin, magnesium and CoQ-10 can be used for prevention too. Once a migraine attack is already in motion, resting in a dark space; ice packs; creams/oils with menthol camphor, lidocaine and/or peppermint oil; neuromodulation devices; exercise; acupuncture; and/or specialty glasses (rose-tinted/light-blocking) may help address migraine symptoms.  

Current pharmacologic treatments for migraine can be broken down into two classes: abortive and preventative. Abortive therapies aim to stop a migraine, while preventative therapies aim to prevent them — or at least lower their intensity and frequency. It’s important for migraine patients to talk to their doctor about the treatment options that work best for them.  

Abortive therapies include drug options such as analgesics, antiemetics, triptans, ergotamines, ditans and gepants. Preventative therapies include drug options such as angiotensin II receptor blockers (ARBs), angiotensin-converting enzyme (ACE) inhibitors, anticonvulsants, antidepressants, beta blockers, and onabotulinumtoxinA (Botox^®). A 2019 real-world study by Prime Therapeutics found that Botox has an annual cost of $6,300 per patient and less than half of new Botox users receive the four recommended treatments during the first year of therapy for chronic migraine prevention. Accordingly, Botox was associated with higher migraine-related costs and high drug waste.  

Recent advancements in migraine therapy involve blocking the calcitonin gene-related peptide (CGRP), a type of protein released around the brain that causes inflammation in the meninges and causes migraine pain. Studies have shown that heightened levels of CGRP are found during migraine attacks. Selective CGRP antagonists were first introduced in 2018, and a Prime Therapeutics study a year later found that the use of CGRP receptor blockers was associated with a reduction in opioid claims.

Other drugs currently under evaluation for the efficacy of treating migraine and migraine-adjacent symptoms include lornixicam, dihydroergotamine (DHE) nasal powder, droperidol (Inapsine^®), levetiracetam (Keppra^®), Eptinezumab-jjmr (Vyepti^®), cannabis, metformin (Glucophage^®, Riomet^® and Glumetza^®), and glucagon-like peptide 1 (GLP-1) agonists. An alternative pathway in development of migraine headaches involves the pituitary adenylate cyclase-activating peptide (PACAP). Many of the new drugs in study are focused on this peptide, its pathway and the hormones involved as targets of new therapies to treat migraine.