Matthew Robbins on the Current Therapeutic Landscape of Migraine Treatment

August 20, 2018

Robbins discusses the exciting future of true designer drugs in the works for migraine prevention as well as the challenges that remain in the space.

Matthew Robbins, MD

With 3 CGRP monoclonal antibodies competing for FDA approval as potential treatment options for migraine, the future looks quite promising, but there are still many unanswered questions.

To discuss the current therapeutic landscape of migraine treatment, NeurologyLive spoke with Matthew Robbins, MD, Director of Inpatient Services at Montefiore's Headache Center, Chief of Neurology at Jack D. Weiler Hospital and Associate Professor of Neurology at Albert Einstein College of Medicine. Robbins also spoke to the misconceptions and stigmatization of migraine, and addressed the need for additional education and awareness of this neurological disorder.

NeurologyLive: What is the current therapeutic landscape of migraine treatment?

Matthew Robbins, MD: Migraine is a super common disorder, it affects in any given year 12% of the whole population. In the more severe form of migraine, which we generally call chronic migraine, is also extremely common, which is anywhere from 1% to 2% of the whole population. Migraine is an important disorder to recognize and treat because it tends to affect people when they’re most productive, in sort of the younger and middle years of life. Migraine is associated with a lot of comorbidities like cardiovascular comorbidities, psychiatry comorbidities and others, so the impact of migraine is really immense and more than we have ever imagined as we look into it more and more, so that really underscores why it’s so important to have effective treatments for migraine.

Up until recently, treatments for migraine are generally divided into acute and preventative medicines, acute medicines are treatments to take for an individual attack, and then preventative medicines are medicines or other treatments used on a daily basis or in some longer-term fashion to reduce how frequent and severe migraine attacks are. Up until recently, migraine preventative treatments were all borrowed from other disciplines, so migraine benefits were noted in people who were using anti-seizure medicines, anti-depressants, blood pressure medications, botulinum toxin, medicines that were not originally designed to treat migraine, but they were found to be useful for migraine. So only recently has that changed and finally, the science has caught up and given us some sort of true designer drugs to use for migraine prevention, so that’s been a very big advance.

Is there a one-size-fits-all treatment method?

MR: There’s certainly no cure for migraine, and for preventative treatments there’s generally no sort of personalized medicine to see which medicine might be the most effective for any individual patient. The way decisions are often made is to go by what other medical conditions the patient has and what the side effects might be for that individual medication to see what might be the most useful or the most well-tolerated, or the least poorly tolerated for that individual patient.

Are there any misconceptions about migraine?

MR: In migraine, there’s a lot of misconceptions. There’s the scientific misconception that was perpetuated by the medical community, that migraine is just a vascular disorder of the head where the aura phase of migraine is from blood vessels constricting and then there was reflex vasodilation which is why people got pain. So that misconception was fortunately disproven by facts and science. What we know is that migraine is a brain disorder and it’s an inherited neurological disorder that features a sort of over excitable brain that leads to frequent attacks of headache, but also many other symptoms.

I think a big part of the public is that migraine has been a highly stigmatized disorder, which has really limited our understanding of it. It’s very underrepresented in NIH research budgets and having migraine or chronic migraine is not included in the list of diagnoses where people can apply for disability or social security benefits, so there’s a lot of institutional discrimination against migraine too that leads to more stigmatization. Part of it is that in most people migraine might be sort of an occasional nuisance, but in many people, migraine is sort of a life consuming disease, so it’s really different in different people.

Can you talk about erenumab, or Aimovig, that was approved by the FDA in May?

MR: So far what it looks like is that insurance companies, and we don’t know about government insurance like Medicare or Medicaid, will likely only cover this medicine in people who have failed other medicines first—and this is largely because of its cost. There have been no comparative studies yet looking at Aimovig or any of the newer medicines that will come out eventually, compared to the old medicines. Some of the studies have looked at these medicines in people who have failed multiple other classes of medications and it’s showed that many other people get benefit from the medicines who failed other old medicines, but we don’t yet have any comparative studies against the old ones.

Where do these 4 CGRP monoclonal antibodies benefit?

MR: Alder, which has an intravenous medicine, would be different, but we don’t know if that would be more potent than the others. The medicine that came out already, erenumab or Aimovig, is an antibody to the CGRP receptor whereas the other 3 are antibodies to CGRP itself. We don’t know if blocking the receptor or the protein is going to be more effective, I think there haven’t been comparative studies. It could be that in some, it’s more important to block the receptor and others it’s more important to block the protein, and we don’t yet have tests to figure out which might be more important in each individual patient. There might be in the earlier stages trial and error and if you don’t respond to one, you might have to try a different one, which is what we already do in migraine with all the other medications anyway, it’s a lot of trial and error.

The newer medications, where they really benefit is in their tolerability and hopefully their safety and convenience because most of them are self-injections, once a month or once every few months. The newest medication that’s out, this Aimovig or erenumab, once every 3 months, is a self-injection, so that’s very convenient. The data from the trials don’t show that they are substantially better than old medicines, so in general for any migraine preventative treatment, 50% of the people get 50% better and that mark still seems to be true for these newer medicines too.

Do you have any advice for PCPs or internists that are treating patients with migraine?

MR: Nationally there are just too few neurologists, and especially too few headache specialists to see everyone in the country with migraine or even chronic migraine and so it’s a reality that PCPs have to be comfortable managing migraine, it’s just a reality because of the sheer overwhelming commonality of migraine in all people. I think the more educational initiatives, the more awareness, the more legitimizing of migraine as a real brain disease, the better recognition, and often that starts in medical schools and in training environments where migraine education should be prioritized when people are in medical school and residency.

Transcript edited for clarity.