The Migraine Patient Journey: Episodic Migraine and CGRP Inhibitors - Episode 14

Injectable Therapies for Migraine 

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Jill Dehlin, RN, a patient with migraine, talks about her experience receiving a subcutaneous injectable CGRP inhibitor, and neurologist Jessica Ailani, MD, explains what she counsels her patients on when prescribing a newer injectable treatment. 

Philippa Cheetham, MD: Jill, when did you first start taking one of the CGRP [calcitonin gene-related peptide] inhibitors yourself?

Jill Dehlin, RN: In November of 2018, I began taking a CGRP medicine. I had joint replacement surgery, and I had heard that there was a theoretical risk of delayed healing. That is why I put it all off. Otherwise, I would have jumped right on the bandwagon because I knew that these were coming down the pipeline. I recently had hip replacement surgery, and I’m still on that same CGRP drug, and I did not have any problem with healing. I wish that I had done things differently, but I did learn something that way.

Philippa Cheetham, MD: To clarify for our viewers, you’re on this medication for prevention.

Jill Dehlin, RN: Yes, I’m on a CGRP injection. I give myself the injection monthly, subcutaneously. Then, if I have a breakthrough migraine, I will take my gepant, and that usually makes me pretty functional. It does not always make the pain go away; sometimes, like today, I do not really have head pain, but I had all those other symptoms of migraine.

Philippa Cheetham, MD: Obviously, you are using the injection for prevention. Had you been using injection medications in an acute episode prior to that?

Jill Dehlin, RN: As Dr Ailani said, some people have hypertension when they use the triptans. I’m one of those folks. I can remember, just as you did, the first time I used the injectable sumatriptan, I couldn’t figure out how to get the thing open. I’m not just all thumbs, but it is not very good packaging for people who are cognitively impaired in a migraine attack, so that is my answer.

Philippa Cheetham, MD: That’s quite stressful for patients, isn’t it? Yes, you’re having a very bad migraine, but for many patients the thought—especially for patients who have no connection with the medical profession—of experiencing an acute attack and having to inject yourself with a medicine that may have quite scary adverse effects on the packaging is rather scary. Dr Ailani, do you find that patients get to the point where they say, “I’ll try anything, give me that needle,” or is it a bit of a sell to try to convince patients that injectable medication, either as acute or preventive medication, is the right way forward?

Jessica Ailani, MD: When it comes to acute treatment, I think that when a patient has a terrible attack, they will come in and they’ll say, “I will do anything.” As a physician, I often would not talk about injectables until I started to understand that the injectable triptan—sumatriptan is the only injectable triptan—works within 15 to 20 minutes and the pill can take up to 2 hours. The minute you start to discuss that with patients, it is surprising how many are like, “Yes, OK, give me the injection because that is a huge time difference.” It can have significant adverse effects for some patients but no adverse] effects for others. It is one of these tricky things. You have to know how a patient responds, often to oral sumatriptan, to have a good sense of whether they are going to experience significant adverse effects to sumatriptan delivered subcutaneously.

As for the injectable medications for migraine prevention, I would say that the majority of my patients who have never used an injection before have absorbed this idea without even blinking. Occasionally, I’ll have a patient who’s like, “Wait, wait, what, an injection?” I have to remember it’s only monthly, so then they are like, “Oh, that’s fine, but I have to do it myself?” Then, we show them that it is an autoinjector. It is a button you push. It is really simple to do, and then they are not as anxious about it, especially after the first or second time they do it. If they are responders and they have good response, it is not even a question.

Philippa Cheetham, MD: Thank you for watching NeurologyLive® Cure Connections®. If you enjoyed the program, please subscribe to our e-newsletter to receive upcoming programs and other great content right in your inbox. Thank you so much.

Transcript Edited for Clarity