Lingering Unmet Needs in Acute Migraine Treatment


Despite the explosion of preventive medications for migraine, a large need for acute care remains.

Dr Richard Lipton

Richard B. Lipton, MD, the Edwin S. Lowe Chair in Neurology at the Albert Einstein College of Medicine, and director of the Montefiore Headache Center

Richard Lipton, MD

In 2018 alone, migraine care has gained a handful of incredibly efficacious and helpful therapies for prevention of an otherwise debilitating condition.

Although physicians such as Richard B. Lipton, MD, have welcomed these new therapies into the therapeutic arsenal with open arms, they understand that patients will still require acute relief. Additionally, this need often leads to other issues, such as treatment with opioids and the development of medication overuse headache.

Thus, the Edwin S. Lowe Chair in Neurology at the Albert Einstein College of Medicine and director of the Montefiore Headache Center provided some insight into the needs that linger despite the introduction of calcitonin gene-related peptide (CGRP) inhibitors into the fold of treatment.

Lipton tied this assessment into the recently announced positive results from a couple of trials examining the safety of a member of another newly developed class of migraine therapies: the gepants. With Allergan recently reporting these positive results for its agent, ubrogepant, the therapeutic landscape looks bright, according to Lipton.

NeurologyLive: What is the main takeaway for the clinician community from these results with ubrogepant?

On the acute treatment side, there are really 3 major areas of unmet need in my view. One area of unmet need is that all the triptans are really effective drugs, but they don’t work in everybody. We need treatments that can be given to patients who don’t respond well to triptans—and by the way, there’s emerging evidence that people who fail on triptans for migraine more than a one-third of them are given opioids. We know opioids make migraines worse for long-term, so that is a piece of evidence of unmet need for people that don’t do well on triptans.

The second issue is that triptans have cardiovascular contraindications in their labeling, and those cardiovascular contraindications mean that some people, who would otherwise be good candidates for triptans, can’t get them, and even larger groups of people don’t get them because of worries about cardiovascular safety. This drug provides a safe alternative to triptans that can be used in people with cardiovascular contraindications to triptans.

Then, the third issue is a bit more speculative. Many of the drugs we use to treat migraine, if overused, make migraine worse. That’s true for triptans, that’s certainly true for opioids, that’s true for some analgesic combination products. The hope is that these CGRP small-molecule receptor blockers won’t cause medication overuse headaches. One reason to hope that is that this mechanism works in acute treatment of migraine and preventive treatment of migraine. Erenumab binds CGRP receptors and is FDA-approved for migraine prevention. Allergan has another gepant, another drug in this class, called the atogepant, and that drug, in phase 2 has been an effective preventive treatment for migraine. The hope is this class of medications may allow us to treat migraine acutely without fear of medication overuse. More data is required to determine if the drug will live up to that hope. I’m pretty optimistic about it, for what that’s worth.

If ubrogepant gets FDA approval, what are the potential implications?

Acute treatment is always about rapidly relieving pain, restoring function, not producing nuisance side effects, and not producing long-term harm. The therapeutic armamentarium is much bigger now than it was in the early 90s, prior to the approval of triptans, but still, there’s a lot of unmet need out there. This drug answers unmet needs for acute treatment that I certainly feel every day in my practice.

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