A new era in migraine and headache care

By Kevin Lenaburg

Providing new hope for people living with migraine disease

The past few years have seen more advances in migraine and headache treatment than occurred in the past three decades combined. We now have entirely new classes of medicines for both the acute and preventive treatment of migraine. We also have new devices that stimulate different nerves and can safely be used in combination with medicines.

Migraine is a disease that operates on many different pathways and expresses with widely different symptoms and severity levels across people. The many new types of treatment create incredible new opportunities for more effective disease management. With so many new options for clinicians and patients to choose from, here is a quick snapshot of all the recent innovations.

Acute medicines are taken when someone feels a migraine attack coming on. The earlier a patient recognizes the looming migraine and takes the acute treatment, the more effective these medicines are in thwarting the full-blown migraine. These types of treatments are called “acute” or sometimes “abortive” or “rescue medicines.”

Gepants – These are the newest entrants in the calcitonin gene-related peptide (CGRP) class of treatments. The gepants are small molecules that bind to the CGRP receptor and block the cascade reaction of a migraine attack. The gepants act differently than triptans (an older class of acute migraine medicines) and they do not cause vasoconstriction, so they may be an effective option for people who can’t safely use or aren’t helped by triptans:

  • Rimegepant (Nurtec) – A fast-acting orally disintegrating tablet (ODT) that comes in packs of eight 75 mg tablets.
  • Ubrogepant (Ubrelvy) – A pill that comes in packs of 10 at either the 50 mg or 100 mg strength levels.

Ditans – This new class of acute migraine treatment works in a similar manner as triptans, but without causing the vasoconstriction that makes triptans not a good option for patients who have cardiovascular risk factors. Ditans act on the trigeminal system and they can be effective in stopping an oncoming migraine attack.

  • Lasmiditan (Reyvow) – This is currently the only ditan and is available as 50 mg, 100 mg, and 200 mg oral tablets.

Preventive medicines are taken on a regular schedule to reduce the frequency of migraine attacks experienced by the patient.

Calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) – A relatively new class of medications that is the first preventive therapy in decades specifically designed to prevent migraine attacks. Those with migraine disease produce more of the CGRP peptide (or protein). These medications alter the CGRP molecules or receptors, thus limiting their impact and reducing the initiation of migraine attacks. There are currently four different approved CGRP mAbs:

  • Erenumab (Aimovig) – Binds to and blocks the CGRP receptor. Available as a monthly injection in either 70 mg or 140 mg strength doses.
  • Framenazumab (Ajovy) – Binds to the CGRP peptide and blocks the connection with the receptor. Available as a monthly 225 mg injection or quarterly as three 225 mg injections.
  • Galcanezumab (Emgality) – Binds to the CGRP peptide and blocks the connection with the receptor. Available as a monthly 120 mg injection (following an initial loading dose of two 120 mg injections). Note that this particular CGRP has also been approved for the prevention of episodic cluster headaches. The treatment protocol for cluster headaches differs from migraine in that it involves three 100 mg injections taken monthly until the end of the cluster period.
  • Eptinezumab (Vyepti) – Binds to the CGRP peptide and blocks the connection with the receptor. Available as a quarterly IV of either 100 mg or 300 mg.

Neurostimulation devices are designed to tone down pain signals to prevent or stop migraine attacks. Each device engages different nerve systems that are known to affect migraine (visual, trigeminal, vagal and nerves in the brain). The devices are often used in combination with medicines. 

  • Allay lamp – This green light causes less of an increase in migraine pain than light of similar strength of different wavelengths (colors).  For some people it will reduce migraine headache pain.
  • Cefaly – This device is placed on the center of the forehead and it stimulates the trigeminal nerves. Cefaly is approved for both the acute and preventive treatment of migraine.
  • gammaCore – This device is applied to either side of the neck and it delivers stimulation to the vagus nerves. gammaCore is FDA-approved for the acute and preventive treatment of pain associated with migraine, as well as for those with cluster headache.
  • Nerivio Migra – This device is worn on the upper arm and it provides electrical pulses that moderate the pain response. The device is controlled by an app on the user’s smartphone and it is approved for the acute treatment of migraine. It activates a different pain control mechanism than the Cefaly device.
  • sTMS – This device is held against the back of the head and it delivers pulses to the transcranial nerves. sTMS is approved for both the acute and preventive treatment of migraine in individuals aged 12 and older.  •

The U.S. Pain Foundation  does not endorse any specific modalities. This list is intended to outline some of the available treatment options so patients may research and discuss with their doctors.

Kevin Lenaburg is the Executive Director for CHAMP (Coalition For Headache And Migraine Patients). He has 15 years of professional experience in health care advocacy and communications. He also has personal experience in the headache disease area as the caregiver for a loved one with disabling chronic migraine disease.