If you’ve ever had a migraine—almost 40 million people in the US suffer them regularly—you know that it is far more than a typical headache. Yes, there is intense, throbbing pain, typically on just one side of the head, that can last between four hours and three days. But a migraine can be accompanied by nausea and vomiting…dizziness…numbness in your arms, legs and/or face…and extreme sensitivity to light, sound and odors. You also may experience aura—a visual or other disturbance that signals a migraine is on the way.
Migraine runs in families and can be triggered by many things—stress… consumption of alcoholic and caffeinated beverages…caffeine withdrawal… eating aged and unpasteurized cheeses and cured meats…lack of or too much sleep…overexposure to the sun… changes in weather…and use of certain medications such as birth control pills. Thankfully, new treatments are available now and more are in development.
New medications: Doctors used to believe that migraine was simply caused by overdilation and constriction of blood vessels in the head. But new research shows that migraine involves a cascade of events in the brain, including activation of the trigeminal nerve—a large nerve in the skull that is responsible for sensation in the face and motor functions such as biting and chewing—and the release of calcitonin gene-related peptide (CGRP). It appears that CGRP irritates nerve endings in the brain and inflames and dilates blood vessels. This discovery has led to the development of new types of migraine-preventive medications…
CGRP monoclonal antibodies. One of the drugs in this class, erenumab (Aimovig), mimics the shape of CGRP and binds to the CGRP nerve receptors so that the peptide has no place to attach when it arrives at a nerve cell—this prevents pain. The other three drugs in this class—galcanezumab (Emgality)… fremanezumab (Ajovy)…and eptinezumab (Vyepti)—attach to CGRP itself, changing its shape so that it can’t fit into the receptor. Aimovig, Ajovy and Emgality can be self-administered monthly or quarterly via an autoinjector. Vyepti is administered intravenously every three months by a health-care provider.
Gepants. Also known as CGRP inhibitors, gepants work similarly to CGRP monoclonal antibodies, but they contain smaller molecules and so can be taken orally. Ubrogepant (Ubrelvy) and rimegepant (Nurtec) are taken as needed to stop migraine attacks. Recently, Nurtec received approval for use as a preventive treatment, too, meaning that it can be taken regularly during the month to help prevent migraine. Atogepant (Qulipta) also has received FDA approval for migraine prevention. Zavegepant is currently in clinical trials.
Ditans. Lasmitidan (Reyvow) is the first approved drug in the “ditan” family, another new class of medication for migraine treatment. Ditans are close relatives of triptans (see below) but are more selective in their effects on the brain—meaning that they work on different types of serotonin receptors than triptans. This allows them to have no effects on the cardiovascular system. Warning: Ditans are potentially sedating, so lasmitidan has been labeled a controlled substance with a restriction against driving for eight hours after you take it. This side effect limits the drug’s widespread use, but it may be helpful for people whose migraine attacks usually occur at night or awaken them from sleep.
Standard medications: Before CGRP inhibitors became available a few years ago, the class of drugs known as triptans was used to treat migraine. The first triptan—sumatriptan (Imitrex)—was approved by the Food and Drug Administration (FDA) in 1991. Others have since been released, including almotriptan (Axert), eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt) and zolmitriptan (Zomig). Depending on the triptan, these drugs are available as pills, injectables and nasal sprays. For some people, a single dose of a triptan can bring migraine relief within a few hours. But for 20% to 30% of people impacted by migraine, a second dose is needed.
Gepants vs. triptans: There are pros and cons for gepants and triptans…
Heart problems: Triptans may constrict blood vessels, which could cause heart attack or chest pain in people who have ischemic heart disease and/or poorly controlled high blood pressure. Gepants appear to be safer because they don’t narrow blood vessels.
Rebound headaches: Gepants aren’t as likely as triptans to cause rebound headaches from overuse of the medication.
Efficacy: Gepants often aren’t as effective as triptans—only about 20% of people impacted by migraine find complete relief within two hours after taking a gepant (versus 64% for injectable sumatriptan). But: Gepants are more likely to be effective when a migraine is already underway. Triptans, on the other hand, work best when taken at the very start of a migraine.
Nondrug treatments: There are a number of brain-modulating devices that have recently received FDA clearance for migraine treatment. They can be used safely by all people impacted by migraine and are particularly helpful for people who don’t find relief with medications or don’t want to take medications. These devices effectively eliminate head pain in 30% to 40% of sufferers within two hours of using them. Examples…
Cefaly Dual is a small device that is placed on the center of the forehead to prevent migraine as well as to stop an attack in progress. It delivers electric stimulation to small branches of the trigeminal nerve. It may take daily use for a few months to see a preventive benefit.
Nerivio is an armband device that you control via a smartphone app to stimulate nerves in the arm and indirectly address migraine pain. It also is being studied for migraine prevention.
Relivion is a headband that goes around the forehead to electrically stimulate nerve branches in the front and back of the head to treat headache pain.