Up to 40 million Americans suffer from migraine headaches, 75% of them women. Symptoms can include throbbing head pain, nausea, vomiting, sensitivity to light and sound, fatigue, and dizziness.
Sobering statistic: According to the World Health Organization, migraine is the second-leading cause of disability, with only back pain causing more downtime.
To prevent or relieve migraines (which can strike as often as every couple of days), doctors prescribe two types of drugs—preventive, to stop attacks before they start; and abortive, to stop attacks once they’ve begun.
Preventive drugs
Preventive drugs have plenty of problems. None of them were developed specifically to prevent migraines. Drug by drug, each was accidentally discovered to block migraines—which means they deliver a host of unwanted side effects. These problematic drugs originated for a variety of conditions:
- Beta-blockers, such as propranolol (Inderal) and timolol (Blocadren), are usually prescribed for hypertension. Common side effects include fatigue, lightheadedness, shortness of breath and, in migraineurs, low blood pressure.
- Anti-seizure drugs, such as topiramate (Topamax), are used for epilepsy. They can cause memory loss, osteoporosis, and hair loss. They can also cause birth defects—a big risk for premenopausal women.
- Antidepressants, such as amitriptyline (Elavil) and nortriptyline (Pamelor), can cause insomnia, weight gain, and loss of libido, as well as distressing withdrawal symptoms if you suddenly stop taking the medication.
- Botox is best known as the anti-wrinkle drug. For migraines, the dose is five to six times higher than that used for cosmetic purposes. It’s injected once a month in the back of the head, in the neck, and in the shoulders. Botox is the safest and most effective of the preventive drugs, but the U.S. Food and Drug Administration (FDA) has approved it only for chronic migraineurs who have 15 or more migraine days per month.
Because of the many downsides, only 20% of migraineurs who are prescribed preventive therapy stay on the drug long term.
New development
Twenty-five years ago, scientists discovered that a chemical called calcitonin gene-related peptide (CGRP) is released in the brain during a migraine. CGRP’s exact causative role in migraines isn’t yet understood, but it may stimulate the sensory nerves that cause or contribute to the pain.
After decades of research by drug manufacturers, with hundreds of millions of dollars invested, six CGRP-blocking drugs were approved by the FDA in 2019 and 2020. They’re proving to be reasonably effective and mostly safe in preventing migraines. About 30% of people who try them get good results—with one out of five of those experiencing dramatic relief (75% to 100% reduction in migraines), and one out of two experiencing a 50% reduction.
So far, CGRPs have been used by more than 300,000 migraineurs, with very few side effects. For some people, they work when no other drug does.
Here’s what you need to know about this new class of drugs and how they might work for you or your loved ones:
Current options
There are currently four preventive CGRP drugs on the market, with a fifth likely to be approved within the year. There are also two migraine-abortive CGRPs.
- The injectable preventive CGRPs. Three drugs, fremanezumab (Ajovy), erenumab (Aimovig), and galcenezumab (Emgality), are self-administered by a push-button device where you don’t have to see the needle. Aimovig and Emgality are injected once a month. Ajovy is injected either once a month or as a triple dose once every three months.
Sometimes, the results are cumulative: The second treatment is more effective than the first, and the third treatment is even better.
The three drugs have slightly different mechanisms of action. Aimovig blocks the CGRP receptor on cells, whereas Ajovy and Emgality block CGRP itself. While none of these drugs consistently works better than the others, in about 10% to 20% of cases, Ajovy or Emgality might work better than Aimovig. If you’re taking a monthly drug, try it for at least three months before giving up on it.
Warning: Some people develop constipation on Aimovig. In about 100 cases, the constipation was so severe that surgery was necessary to resolve the problem. If you have constipation, don’t take this drug.
- The intravenous preventive CGRP. Eptinezumab (Vyepti) is delivered intravenously at the doctor’s office once every three months. This might be the right drug for you if you don’t like injecting yourself and because there’s only one treatment every
three months. - The oral abortive CGRPs. Rimegepant (Nurtec) and ubrogepant (Ubrelvy) stop a migraine that’s starting. They are prescribed only if the gold standard for abortive drugs—the triptans, such as sumatriptan (Imitrex)—have failed.
- An oral preventive CGRP. Atogepant is a migraine-abortive drug that has not yet been approved by the FDA. It is currently in phase 3 clinical trials and may be FDA-approved sometime in 2021.
Here’s the rub: These drugs are very expensive—around $600 per treatment. Currently, they’re covered by insurance only after every other preventive drug has failed.
A different type of drug
Lasmiditan (Reyvow). This new migraine abortive drug was approved by the FDA in December 2019. Like the triptans, it works on serotonin receptors: Triptans work on 1B and 1D receptors, while Reyvow works on 1F.
Why this matters: Reyvow doesn’t cause vasoconstriction of blood vessels so, unlike Imitrex, it’s not contraindicated for people with cardiovascular disease.
If you have cardiovascular disease, don’t respond to a CGRP abortive drug, or have side effects from a triptan, this may be the abortive drug for you.
Caution: Reyvow can cause drowsiness. Don’t drive a car for eight hours after taking the drug.
Non-drug options
Nervio is a new, FDA-approved electro-stimulator that eased migraine pain in two out of three people who tried it in a clinical trial. Placed under the upper arm for 45 minutes at the first sign of a migraine, it generates a low-level electrical current that activates nerve fibers to block pain messages from reaching the brain.
A prescription product, it costs $99 for 12 self-care treatments. It isn’t covered by insurance. Many patients find it very effective when combined with an abortive drug such as Imitrex, and some find the device useful on its own to abort a migraine.
You can find out more about the Nervio device at https://theranica.com.
Lalay Lamp. This non-prescription lamp was invented by Harvard-based migraine researcher Rami Burstein, PhD. Knowing that migraineurs are affected by light, he studied each color in the spectrum, first in rats and then in people, to see which worsened migraine and which made it better. He discovered that green light was the only color that eased migraine—and created the green-generating Lalay Lamp.
How to use it: When you feel a migraine coming on, go into a room, close the shades, turn off all other sources of light (including your smartphone, computer, and TV screens), and spend an hour or two with the Lalay Lamp turned on. (It provides enough light to read or work.) The lamp costs $149. You can learn more at https://lalaylamp.com.
