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DEAR MAYO CLINIC: I’ve dealt with migraine attacks for years. So has my mom. I typically manage by using over-the-counter pain medication that includes caffeine as soon as my symptoms begin. Then, if my migraine doesn’t improve, I use a prescription triptan medication. But my headache days have been increasing, and my doctor suggested I try a newer preventive migraine medication. Can you please explain more about medication options?
ANSWER: Migraine is a neurologic disorder. The severe pain of migraine typically is on one side of the head but may be on both sides. Symptoms also may include nausea, vomiting, sensitivity to light and sound, difficulty speaking, or visual disturbances known as aura with flashes of light or blind spots. Attacks may last hours or days, and they can make work, school or other daily activities difficult.
Migraine is common, especially in women. It’s also hereditary. Migraine attacks can be triggered by multiple causes, from weather to wine. Some lifestyle changes and treatment options can help you manage the disease of migraine.
Overall, migraine treatment consists of preventive and acute therapy. Preventive therapy is a medication people take regularly to reduce the frequency and severity of headache. Acute therapy is the medication people take as needed for migraine attacks.
Calcitonin gene-related peptide (CGRP)-targeting therapies are a newer class of medications. The protein CGRP exists in several body systems, including the brain and nervous system. It’s involved in transmission of pain signals, the dilation of blood vessels and some inflammation-like responses. Multiple studies have shown that CGRP plays a key role in causing the pain of migraine-related symptoms.
The CGRP treatments help prevent or reduce migraine attacks by stopping CGRP from doing its job of dilating brain blood vessels and signaling pain in the nervous system. These therapies led to a treatment paradigm shift targeting CGRP.
Evidence suggests that CGRP-targeting therapies are more tolerable with less side effects and can be as effective or more effective than traditional first-line oral medications, including topiramate, beta-blockers such as propranolol, or amitriptyline.
Real-world studies also reported CGRP-targeting therapies can be effective in achieving 50% reduction in monthly headache days even if patients previously have tried multiple migraine preventive medications.
There are two main types of CGRP medications:
- CGRP monoclonal antibodies: Used as migraine prevention, these antibodies attach to the CGRP protein and neutralize them directly. By doing so, they can decrease the frequency and severity of migraine. These medications include erenumab, galcanezumab, fremanezumab and eptinezumab.
People also can use another as-needed medication for acute treatment of headache, meaning they take the medication when they experience a migraine attack.
- CGRP receptor antagonists: Used primarily to treat acute migraine attacks, these medications prevent CGRP from binding to receptors and triggering the pain and other symptoms of a migraine. These include ubrogepant, rimegepant, atogepant and zavegepant. However, atogepant and rimegepant also can be used for migraine prevention.
The most important thing is for patients to work with their healthcare professional to find the correct medications or other treatment that’s right for them. What works for one patient will not necessarily be appropriate for another. Some medications are not safe during pregnancy.
Also, discuss with your healthcare professional the risk of medication-overuse headaches that can occur when medications stop relieving pain and begin to cause headaches.
Remember, nonmedication measures also can help people cope with migraine, including:
- Maintain regular healthy habits of eating, sleeping and exercising.
- Relax in a dark, quiet room.
- Apply hot or cold packs to the neck or head.
- Try a small amount of caffeine.
- Manage stress.
Chia-Chun Chiang, M.D., Neurology, Mayo Clinic, Rochester, Minnesota