Developing Solutions to Address Acute Care Challenges in Migraine

November 20, 2018

The director of the MedStar Georgetown University Hospital Headache Center shared her interest in the pipeline and the ongoing search for biomarkers in migraine.

Jessica Ailani, MD

With the recent approval of calcitonin gene-related peptide (CGRP) inhibitors for the preventive treatment of migraine, much of the headache specialist community has turned its attention toward the continuing need for acute care.

One of those specialists is Jessica Ailani, MD, the director of the MedStar Georgetown University Hospital Headache Center, in Washington, DC. A pair of exciting classes of therapies in development include the Gepants and the Ditans, both of which are being assessed for their impact on aborting migraines. As well, a number of neuromodulating devices have shown the ability to relieve patients of attacks.

To discuss her interest in the pipeline and the ongoing search for biomarkers in migraine, Ailani spoke with NeurologyLive in an interview.

NeurologyLive: Is there anything of particular interest to you in the pipeline?

Jessica Ailani, MD: The 2 acute classes that, looking at in the future, are very exciting are the Gepants, which are the CGRP antagonists—small molecules working near the receptor sites—and then the Ditans. Lasmiditan is up for probable approval, hopefully, in the next year. That's a 5-HT1F receptor agonist. Those are very exciting because they're tangible. We see the evidence that they are working in patients with migraine. They seem to be tolerated pretty well and their mechanism is slightly different than what we have right now, so I think that's something to be really excited about.

We also have all these neuromodulation devices that I find to be exciting because you can modulate the nervous system without causing, really, any significant adverse effects, and many of them are used for acute treatment of migraine. You have the vagal nerve stimulation, transmagnetic stimulation, and your transcutaneous device that can sit on the forehead. This has a button you press when you're using it acutely for migraine attack, and this really speaks to patients. The idea of a hands-on device that they have control over during a migraine attack, that they can use and abort the migraine attack, usually within minutes. It really speaks to the patient. What's disturbing is that insurance companies have been really far behind on getting these items approved, so sometimes there can be a bit of a cost effect that can be limiting on our ability to get this out to all our patients.

Are there any challenges devices are helping to overcome in migraine?

Absolutely. One of the places we're using devices in practice is particularly in our chronic migraine population that has to use medications often. We're trying to limit that because of the danger of overuse of medication, and also, when we keep using acute medications, this isn't really what they're meant for. There could be potential long-term adverse effects to using these medicines every day, so having options that allow the patients to treat in between what they consider their severe or major attacks is extremely helpful. I don't have to worry about medication overuse with these devices because they've become known to be very safe. We'll advise the patients that at the start of attack to use the device, and if it's not getting better, layer in the medicine. If there's a chance you're going to end up using less and less acute medication, that brings that value of the device really high up the patient’s list.

Many times, we'll hear this when we're using devices that, “I find it helpful. It doesn't take care of the very severe attacks, but I'm definitely using less acute medication,” and, “At the end of the month, I still have some acute medication left and I'm a little bit less worried about hoarding these medicines or waiting until that really bad migraine and then not having enough medication.” The value of that is tremendous to these patients. They get a sense of security that they can have confidence that they'll have enough medicine to treat their severe attacks in a given month.

Are there any biomarkers being explored in migraine?

We do have a large registry called the ARMR [American Registry for Migraine Research], where there are certain sites that are putting patient information in with patient permission. We're able to collect bio-samples from these patients if they agree, and the hope is to see if we can find any kind of marker of disease. Now, we have information about what meds these patients are using, so is it possible that we'll be able to identify that the patients that respond to this treatment have this marker, or patients that respond to this treatment have this marker. That's really the hope of our field as we keep moving forward, that we'll be able to expand this registry to such a point, that we achieve enough samples, that we can find if there's any particular biomarkers that predict disease progression, disease state, and also response to particular treatment options. The hope is, with time, we're going to be able to answer that question.