Newer migraine therapies may yield fewer side effects
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Advanced therapies for the treatment of migraine events could provide more benefits with fewer side effects, according to findings published in the Journal of Neuro-Ophthalmology.
Kathleen B. Digre, MD, department of ophthalmology and visual sciences, Moran Eye Center, University of Utah, analyzed the new methods of treating migraines that can be used by neuro-ophthalmologists.
“Migraine is very common – more common than diabetes and asthma combined,” Digre wrote. “It affects almost 20% of women and 10% of men and will account for a large number of people visiting a neuro-ophthalmology clinic.”
Digre researched the literature using the term “migraine” related to the terms “treatment,” “evidence-based,” “calcitonin gene-related peptide (CGRP) inhibitor or antibody,” “electrical stimulation” and “vagal nerve stimulation.”
In addition to standard, well-described and evidence-based therapies for the acute treatment and prevention of migraines there were many new treatments that have received FDA approval.
Medication currently used to treat acute migraines include ergots, triptans and NSAIDs, Digre wrote. However, all of these drugs are contraindicated in coronary artery disease, uncontrolled hypertension and Prinzmetal angina because of their unwanted vasoconstrictive properties.
New medications called gepants (ubrogepant [Allergan] and rimegepant [Biohaven]) are currently in clinical trials with an anticipated release in 2020-2021, Digre said. The gepants are expected to expand the reach of migraine-specific therapies as they may be an alternative to triptans because there is no evidence that gepants cause vasoconstriction.
Digre wrote that while there may be good evidence that various classes of drugs are useful in incidence prevention such as anti-CGRP monoclonal antibodies, the monoclonal antibodies represent specific therapies for episodic and chronic migraines. Concerns about short-term side effects, their potential for long-term use and cost may lead to hesitation for use as a first-line preventive medication.
Four new neuromodulation devices have received FDA clearance: a noninvasive vagus nerve stimulator (gammaCore), a transcranial magnetic stimulator (SpringTMS), a superorbital stimulator (Celafy) and a remote electrical neuromodulator (Nerivio), Digre wrote.
The noninvasive vagus device blocks connections from the vagus nerve to the trigeminal system, possibly lowering glutamate levels, while the transcranial magnetic stimulator may block cortical spreading depression.
The transcutaneous superorbital nerve stimulator is a noninvasive approach that delivers electrical stimulation to the superficial branch of the trigeminal nerve, Digre wrote. The remote electrical neuromodulation, which consists of an arm-worn device, is controlled by cell phone with 45 minutes of stimulation intended to inhibit pain pathways.
In addition to the four approved devices, there are others still under investigation, Digre wrote.
“Keeping up with this rapidly evolving field is important in reducing disability from the common disease of migraine,” she said.
Editor's note: This article was updated to indicate the most current brand name of Theranica's Nerivio.
Perspective
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Debora M. Lee Chen, OD, MPH, FAAO
We’ve all seen patients who have migraines, and we already know about their go-to treatments: NSAIDs, triptans and combination medications for acute attacks, along with beta-blockers, tricyclics and anticonvulsants (eg, topiramate) for prevention. This article provides an optimistic pharmacologic overview of what is new.
For acute management, I was encouraged to see more targeted drugs like gepants (expected release between 2020 and 2021) and ditans. These have fewer side effects than triptans and are great alternatives for patients unable to use triptans due to vascular disease. For prevention, anti- CGRP monoclonal antibodies and neuromodulation devices seem like promising treatments with similar efficacy and fewer side effects. Neuromodulation devices can even treat some cluster headaches in addition to migraines but are unfortunately contraindicated in patients with other implanted devices like pacemakers.
That said, this update would have been more comprehensive if it included nonpharmacological approaches. These techniques also play an integral role in migraine management. However, there was no mention of any identification of new triggers (including ocular triggers such as eyestrain), factors like diet and sleep, or the role of behavioral treatment in reducing migraines.
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