New Migraine Guidelines Aim to Help Patients Beat the Pain

Migraines are a profoundly disabling condition affecting more than 37 million people in the US alone.¹ Historically, the available treatments were not specifically designed for the condition. Instead, they were repurposed from treatments for other ailments. These first-line treatments often included antihypertensives, antiseizure medications, and antidepressants. Although these medications were beneficial for some patients, they were not explicitly targeted toward the unique mechanisms underlying migraine attacks.²

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The advent of calcitonin gene-related peptide (CGRP) inhibitors represents a groundbreaking development in the management of migraines. Unlike previous treatments, CGRP inhibitors are designed to specifically address the underlying pathophysiological processes involved in migraines. These processes include inflammatory and nociceptive mechanisms that contribute to the intense and debilitating pain experienced during a migraine attack.² The introduction of CGRP inhibitors has marked a significant shift in migraine management, offering a more targeted approach to treatment.

CGRP inhibitors come in 2 main classes: monoclonal antibodies and small molecule receptor antagonists, also known as gepants. The monoclonal antibodies include medications such as erenumab (Aimovig; Amgen Inc), fremanezumab (Ajovy; Teva Pharmaceuticals USA, Inc), galcanezumab (Emgality; Eli Lilly and Company), and eptinezumab (Vyepti; Lundbeck Seattle BioPharmaceuticals, Inc). These drugs specifically target and inhibit the CGRP peptide, which plays a crucial role in migraine pathogenesis. Alternatively, the gepants, which include rimegepant (Nurtec; Pfizer Inc) and atogepant (Qulipta; AbbVie Inc), are small-molecule drugs that block the CGRP receptor, preventing CGRP from exerting its effects.²

Initially, the American Headache Society (AHS) recommended CGRP inhibitors as second-line treatments. The organization based its recommendation on the understanding that these newer therapies should be used only after patients had tried at least 2 other classes of medications. The rationale behind this approach was to ensure that the newer, often more expensive treatments were reserved for cases in which traditional treatments had proved ineffective.³

However, the 2024 revision of the AHS guidelines marks a significant shift in this approach. The updated guidelines elevate CGRP inhibitors to first-line treatment options for both chronic and episodic migraines. This change underscores the importance of early intervention and reflects a growing body of evidence supporting the effectiveness and safety of CGRP inhibitors. Early intervention with CGRP inhibitors is associated with enhanced personalized care, improved quality of life, and potential reductions in overall health care expenditures. By recommending CGRP inhibitors as first-line therapies, the AHS aims to provide patients with access to treatments that target the root causes of their migraines rather than relying on medications not originally designed for this purpose.³

The AHS guidelines address several practical considerations in migraine management, including the importance of early intervention to prevent the progression to chronic migraine and the necessity for individualized treatment plans based on patient specific factors. The reclassification of CGRP inhibitors to first-line status allows for direct access to targeted migraine therapy, bypassing the need to trial other medication classes that may be associated with significant adverse effects. Additionally, clinical trial data have shown that CGRP inhibitors have higher adherence rates, indicating their efficacy and tolerability. Conversely, a stepwise treatment approach may result in suboptimal management due to difficulties accessing effective preventive treatments.³

The administrative and logistical burden on patients and health care providers significantly increases when a treatment is not classified as a first-line option, necessitating trials of alternative medications before initiation. Recent AHS guidelines aim to enhance the accessibility of CGRP inhibitors, potentially alleviating this burden. By incorporating CGRP inhibitors as firstline treatments for migraine prophylaxis, insurance plans may adjust their formularies, potentially reducing the need for prior authorizations and minimizing delays in therapy initiation.

Cost considerations are critical in clinical decisionmaking for migraine prevention and treatment. Traditional migraine medications may be more cost-effective than targeted therapies such as CGRP inhibitors; however, it is essential to consider the direct and indirect costs associated with a patient’s migraine treatment. Clinical evidence suggests that CGRP inhibitors might offset some costs associated with traditional therapies, including expenses related to acute treatment, adverse effects, and emergency visits. Despite these potential cost offsets, CGRP inhibitors are generally more expensive than conventional treatments, which could limit their accessibility for some patients.³

As the field of migraine treatment evolves, the AHS position statement represents a significant step toward personalized care by designating CGRP inhibitors as first-line therapies, thereby eliminating the need to trial nonspecific preventive medications. This shift is anticipated to enhance medication accessibility and improve patient outcomes. The impact of this change on insurance formularies and the requirement for prior authorizations for CGRP inhibitors will be closely observed. Pharmacists play a crucial role in migraine management, and the updated guidelines position them to advocate for optimal treatment plans and provide clinical and financial support to patients considering CGRP inhibitors.

REFERENCES

1. The facts about migraine. American Migraine Foundation. March 28, 2019. Accessed August 8, 2024. https://americanmigrainefoundation.org/resource-library/migraine-facts/

2. Helmer J. CGRP inhibitors for migraine. WebMD. February 9, 2023. Accessed August 8, 2024. https://www.webmd.com/migrainesheadaches/cgrp-inhibitors-for-migraine

3. Charles AC, Digre KB, Goadsby PJ, et al. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: an American Headache Society position statementupdate. Headache. 2024;64(4):333-341. doi:10.1111/head.14692