The Changing Treatment Landscape for Acute Migraine - Episode 9

Acute Migraine Treatment Goals

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The American Headache Society (AHS) Guidelines and the evolution of treatments for acute migraine are outlined.

Robert Cowan, MD, FAAN: The American Headache Society has established criteria for how to best manage headaches, and they have looked specifically at what criteria should be used in assessing how well a given medication works for acute treatment. That is a medication that would be taken at the onset of symptoms of headache. Within that, there are a number of classifications that have been used, such as triptans, anti-inflammatories, combination analgesics, butalbital-containing medications, opioids, and now the new class of CGRP antagonists. 

There have been a number of advances in treating acute migraine recently. In fact, we’ve gone from famine to feast in the past several years. A little historical background is that in the early 1990s—that’s 30 years ago—we got our first exposure to triptans. Over those 10 years, about 7 or 8 triptans or triptan combinations, came to market. Those revolutionized how we approach migraine, because for the first time we were able to actually provide a treatment for migraine per se, rather than a painkiller or an antinausea medication. That was quite revolutionary. We also used anti-inflammatories, either in combination with triptans or alone, and then we used medications to treat other symptoms associated with migraine.

Calcitonin gene-related peptide, which we’ll call CGRP because it takes too long to say every time, will be the next big change in acute treatments. That is, with the exception of the medication called lasmiditan, which came out a couple of years ago and is actually a serotonin 1F receptor agonist, so it is related to the triptans. The CGRP antagonists are the first novel treatments to come out for the acute management of headache, and that’s been a dramatic change, along with the advent of a number of devices for acute treatment which have come to market in recent years as well.