June 2020: Emerging Abortive Therapies for Adults with Migraines

Key Points

  • There are serious economic impacts associated with migraines leading them to be considered a public health issue.
  • There are significant costs associated with emerging therapies for acute treatment for migraines.
  • By following the evidenced-based treatment recommendations provided by the American Headache Society, we can work together to improve patient outcomes and decrease costs.

Background

Migraines are quite common, affecting 39 million people in the United States.1 Migraines are often burdensome for patients as they can significantly impact a patient’s ability to function at work, school, home, and in social situations. Migraines have been found to be the 6th most disabling illness in the world.1 Migraines do not only affect the individual, but they are considered a public health issue as there are serious social and economic consequences associated. It is estimated that healthcare and lost productivity costs associated with migraines can reach up to $36 billion annually in the United States.1 As we see emerging therapies in this area, it’s important we weigh the risks versus benefits when thinking about the best course of action to treat migraines in adults.

…costs associated with migraines can reach up to $36 billion annually in the United States.1

Current Abortive Therapies for Migraines2-3

There are several medications currently available to acutely treat migraines. The choice often depends on the severity and frequency of headaches. Within the last few years, there have been two new drug classes brought to the market including calcitonin gene-related peptide (CGRP) antagonists and selective serotonin 5-HT1F receptor agonists. Before these new classes were available, the various categories and classes for abortive therapies included Non-steroidal Anti-inflammatory Drugs (NSAIDs), acetaminophen, combination analgesics (e.g. Excedrin®), corticosteroids, opioids, ergotamine, dihydroergotamine and selective serotonin 5-HT1FB,1D receptor agonists (commonly referred to as the “triptans”).

The Guideline Recommendations for Abortive Therapies2-3

The current pharmacological recommendations for mild-to-moderate acute migraine attacks include:

  • NSAIDs: aspirin, diclofenac, ibuprofen, naproxen
  • Nonopioid analgesics: acetaminophen
  • Caffeinated analgesic combinations (e.g. Excedrin®)

For patients with moderate to severe attacks or mild-to-moderate attacks that respond poorly to first line agents, it is recommended to use migraine specific agents including:

  • Triptans
  • Dihydroergotamine

All the agents listed above have established efficacy for treatment of acute attacks in adults. The emerging novel drug classes, including CGRP receptor antagonists and the selective 5-HT1F receptor agonist, have demonstrated efficacy for the acute treatment of migraine. However, it’s important to note that they are certainly more costly and have not yet shown to be clinically significantly more effective than the current recommended products. When taking this into consideration, it becomes apparent that the best place in practice for these new emerging therapies are for patients who meet one of the following criteria: 1) contraindication to triptans, or 2) failed to respond or failed to tolerate at least two oral triptans.3

Comparison of New FDA Approved Abortive Therapies4-7

CALCITONIN GENE-RELATED PEPTIDE (CGRP) ANTAGONISTS

Mechanism: Blocks receptors of calcitonin gene-related peptide, a vasodilator and pain sensitizer found to spike during migraine attacks

SELECTIVE SEROTONIN 5-HT1F AGONIST

Mechanism: Targets 5-HT1F receptor and proposed to decrease stimulation of trigeminal system and treat migraine pain without causing vasoconstriction

NOTE: There is currently no data available on safety or interactions of the new oral CGRP abortive therapies with the use of injectable CGRP antagonists.

Brief Summary of Therapies Available for Abortive and Prophylactic Therapy2-10

Abortive Therapies2-8

Prophylactic Therapy7,9-10

*Should be offered for short-term menstrual-related migraine prevention

General Treatment Principles for Acute Attacks

  • Encourage the patient to treat the migraine as early as possible to reduce the intensity and duration. If they wait, it is likely their migraine level of pain and duration will increase and become even more burdensome.
  • Ensure the treatment is tailored to both the individual and the attack. Ensure both the correct dose and formulation is provided as this can play a key role in patients who experience severe nausea and vomiting.
  • General rule of thumb is to have the patients limit use of acute therapies to typically a maximum of 2 to 3 days/week to avoid rebound headaches or migraines.
  • Don’t forget about the various non-pharmacological intervention’s patients can implement to reduce their risk of experiencing a migraine. These include identifying and avoiding triggers, ensuring adequate amount of sleep and stress management.

References

  1. Migraine Facts. Migraine Research Foundation. 2019. Available from: https://migraineresearchfoundation.org/about-migraine/migraine-facts
  2. AAN and AHS Update Guideline for the Treatment of Acute Migraine. Neurology Reviews. 2015 February;23(2):1-31.
  3. American Headache Society. The American Headache Society position statement on integrating new migraine treatment into clinical practice. Headache2019;59:1-18.
  4. Clinical Resource, Comparison of Triptans and Other Drugs for Acute Migraine. Pharmacist’s Letter/Prescriber’s Letter. March 2020.
  5. Negro A, Koverech A, Martelletti P. Serotonin receptor agonists in the acute treatment of migraine: a review on their therapeutic potential.
  6. Goadsby PJ, Wietecha LA, Dennehy EB, et al. Phase 3 randomized, placebo-controlled, double-blind study of lasmiditan for acute treatment of migraine. Brain2019;142:1894-1904.
  7. Lexicomp®. Hudson (OH): Wolters Kluwer Clinical Drug Information. c2020. Lexi-Drugs online. Available from: http://online.lexi.com/lco/action/home
  8. Acute migraine headache: treatment strategies. Mayans L, Walling A. Am Fam Physician. 2018 Feb;97(4):243-251. Available from: https://www.aafp.org/afp/2018/0215/p243.html
  9. Update: Pharmacologic treatment for episodic migraine prevention in adults. American Academy of Neurology. American Headache Society. 2012. Available from. https://www.aan.com/Guidelines/home/GetGuidelineContent/545
  10. Evidence-based guidline update: Pharmacologic treatment for episodic migraine prevention in adults. Silberstein S, Holland S, Freitag F, et al. Neurology. 2012 Apr;78(17):1337-1345. Available from: https://n.neurology.org/content/78/17/1337.long
About the author

PharmD, Ambulatory Pharmacy Practice Resident

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