In a review published in The Lancet, researchers discussed current pharmacological and non-pharmacological therapies for treating migraines, as well as emerging strategies.
Pharmacological therapy is the mainstay in the treatment toolbox for migraines. The International Headache Society defined successful treatment as resolving pain and / or resolving secondary symptoms (such as nausea, vomiting, phonophobia, and photophobia) within 2 hours of taking a drug.
In addition to the traditional pharmacological options of acetaminophen (acetaminophen), nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, ergot alkaloids, and additional antiemetics, gepants and ditans have recently been approved for use.
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Planted are low molecular weight calcitonin gene-related peptide receptor antagonists. Currently 2 pants have been approved. Ubrogepant has been found to relieve migraine pain within 2 hours at a dose of 50 mg in 22% of patients with moderate to severe headache. Rimegepant had similar results (21%) with the 75 mg dose.
The approved Ditan is called Plasmiditan. In the study, 32% of patients with moderate to severe headache had pain relief within 2 hours of taking 200 mg. Because this drug interferes with driving ability, patients should be advised not to operate a vehicle or machine for 8 hours, which means it may not be a suitable option for many patients.
Trials are currently underway with 3 additional drugs. Two gepants, atogepant and rimegepant, were found to be superior to placebo in phase 2b / 3 studies, but require additional evaluation of efficacy, tolerability and safety. Pituitary adenylate cyclase activating polypeptide (PACAP) is a signaling molecule; An anti-PACAP monoclonal antibody is currently in phase 1 of the test, but a similar monoclonal antibody has failed phase 2.
Pharmacological prevention strategies have been recommended by the European Headache Federation for patients who experience 2 or more seizures per month, have impaired quality of life, and who have failed or overused acute drugs. Current options include antidepressants, antihypertensive drugs, anticonvulsants, flunarizine, onabotulinum toxin A, and anti-CGRP (calcitonin gene-related peptide) monoclonal antibodies. The review authors warned that in most cases the clinical trials for many of these options were inadequate and poorly designed.
The non-pharmacological options of neuromodulatory devices, bio-behavioral therapies, nutritional modulation, physical therapy, sleep modulation, and acupuncture can be used alone or in combination with pharmacological options.
In general, migraines are heterogeneous and symptoms vary from patient to patient. Physicians should prioritize educating patients about the disease itself and any treatment options to fully understand the patient’s preferences and ensure adherence to treatment.
The review authors concluded that while new mechanisms for relieving migraine symptoms have been developed, the biological basis of the disease is poorly understood. A better understanding of migraine biology is likely to improve patient-centered precision medicine strategies.
Disclosure: Some review authors have stated links with biotech, pharmaceutical, and / or device companies. For a full list of the authors’ information, see the original reference.
reference
Ashina M., Buse DC, Ashina H. et al. Migraines: Integrated Approaches to Clinical Management and Emerging Treatments. Lancet. 2021; 397 (10283): 1505-1505. 1518. doi: 10.1016 / S0140-6736 (20) 32342-4
