Guest Commentary: Migraine treatment updates from American Headache Society meeting

A host of new migraine-specific therapies were reviewed during this year’s American Headache Society Annual Scientific Meeting. The treatments that are receiving the most attention are those that target calcitonin gene-related peptide.

Among anti-calcitonin gene-related peptide therapies, there are three monoclonal antibodies for migraine prevention that have been available for some time: erenumab (Aimovig; Novartis, Amgen), fremanezumab (Ajovy, Teva Pharmaceuticals) and galcanezumab (Emgality, Eli Lilly and Co.). A fourth one — eptinezumab (Vyepti, Lundbeck) — is also now available. There is a lot of excitement in the field surrounding these treatments, which are delivered once a month or once every 3 months as a subcutaneous injection, or with eptinezumab, intravenously.

Real-world evidence of anti-CGRP therapies

Some of the results presented during the virtual meeting examined the real-world experience with these therapies and build on the primary outcome measures that were initially reported with the clinical trials. The real-world experience is validating in that, for some patients, these treatments are spectacularly effective and can be life-changing not only in terms of the reduction in the frequency and severity of the attacks, but also in terms of disability associated with the attacks. It is gratifying to see these results.

There has also been a focus on safety. The longer we have our hands on these treatments, the more comfortable we feel using them, but some potential side effects are emerging that were not widely reported in the clinical trials. Overall, though, the long-term safety data are looking quite positive. Another key point discussed at the meeting is that the monoclonal antibodies are effective even in patients who have failed multiple other preventive treatments which, for those of us in headache practice, account for the majority of patients we see. But even primary care physicians are accustomed to treatment failures with migraine patients, which has caused an understandable sense of frustration with migraine management. The fact that these treatments are working well in this population is particularly rewarding. In some ways, it is not surprising given that this class is among the few migraine-specific treatments that are available. Most other migraine preventive therapies were developed for other indications such as BP medications, antidepressants and antiseizure medications. Because these monoclonal antibodies were actually developed as a treatment for migraine is probably partly why they are so effective in patients who may not have done as well on other treatments.

Small molecules are another new approach to targeting calcitonin gene-related peptide (CGRP). These are more traditional medications that are taken as pills. There are two that are now approved by the FDA: rimegepant (Nurtec ODT, Biohaven Pharmaceuticals) and ubrogepant (Ubrelvy; Allergan). There was data demonstrating their effectiveness as acute treatments, as well as data about their tolerability. These are a very interesting, new therapeutic option.

With regard to CGRP-targeted therapies, the overall message is that they are working. They do not work for everybody, unfortunately, but they have the potential to transform the management of migraine.

Novel treatment approaches

An additional area of interest is new delivery methods of established treatments. We have triptans, for example, or ergotamine preparations that can be used as acute therapies. There has always been a push to develop new formulations of these, as well as novel intranasal delivery mechanisms. These are currently in progress, and there were multiple reports of those at the meeting.

Finally, there were a number of studies on neuromodulation devices, which are devices that deliver electrical or magnetic stimulation to different regions and can be applied by the patients themselves. This represents a nonpharmacological approach to migraine therapy.

Incorporating migraine treatments in practice

The take-home message here is that we have a much broader set of both acute and preventive treatments that we can offer to patients with migraine. Many of these treatments have not hit primary care yet because they are still in the realm of the neurologist. However, it is important for PCPs to know that they are out there, to become more familiar with them and to eventually start incorporating them into practice. These are generally well-tolerated approaches that PCPs should be quite comfortable prescribing. They represent a quantum change from the therapies of the past, as they are very specific therapies targeting fundamental mechanisms of migraine.

Given how common migraine is, how disabling it is and how much of a significant public health issue it represents, PCPs should stay aware of what is going on in the understanding and treatment of headache disorders. These are exciting times for headache medicine. Keep staying tuned! The American Headache Society will continue providing results that will be useful in clinical practice.