Expert Perspectives: Advances in the Management of Acute Migraine - Episode 6

Recent Approvals for Acute Migraine

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Expert physicians consider the recent treatment approvals for the management of acute migraine, and how the shift in expectations outcomes has impacted treatment selection.

Wade M. Cooper, DO: One of the most exciting things about migraine is the new tools we have at our fingertips. In the last 3 years, we‘ve seen tremendous breakthroughs in our science and understanding of migraine, and this has yielded incredible treatment options for our patients. You may have heard about the CGRP [calcitonin gene-related peptide] monoclonal antibodies. These are medications that got approved in the spring of 2018, and have dramatically changed the landscape of migraine, as well as cluster headache, in the United States.

As an example, we know that in this country, about 1 in 1000 people have multiple sclerosis [MS]. We also know that about 1 in 1000 people in the United States are on a CGRP monoclonal antibody for prevention of headache. The same number of people with MS in the entire country are on the preventive CGRP monoclonal antibodies; it’s rapid adoption.

What also spilled out from that is an understanding of acute therapies, so that the CGRP concept is applied to acute therapies. Instead of focusing on the 5-HT1B and D receptors of serotonin, which is where triptan-class medicines work, now we’ve got agents that focus either on the CGRP inflammatory cascade that can turn off this spike of headache on the inflammation piece and not worry so much about serotonergic transmissions. Or we‘ve got this new medication called lasmiditan, which works specifically on the 5-HT1F receptor, a receptor that’s specifically spared by most triptans out there, and has some benefits to it, not only because it doesn’t affect blood vessel constriction, but also because it has got some targets centrally in the nervous system.

Amaal J. Starling, MD: There have been some shifts in the clinical trials and even the primary end points that the FDA is requiring for the acute treatment trials. One of those is looking at this concept of the most bothersome symptom. I really appreciate that this is an end point in clinical trials because migraine is not just a headache. Migraine is not synonymous with the term head pain. There are so many other disabling symptoms in migraine. Based on the clinical trials, we see that many people have indicated that one of their most bothersome symptoms is photophobia, and nausea. 

I appreciate that this is now an end point, and that this has been able to translate and allow that conversation to take place in the clinic, too, as an expectation we have of these medications that I can discuss with my patients. That not only do I, and also should the patient, expect that these acute medications address their pain, but we are also looking for these medications to address the migraine attack and all that comes with it. I think this is a good shift in the field of headache medicine, in the research world, as well as in the clinical world, and the patient advocacy world, that we should all be expecting more from our medications. And patients should be expecting more from not only their medications but from their headache treatment providers.