Recent Advancements in Migraine Therapies Provide Opportunity for Pharmacist Intervention

Migraine prophylaxis and treatment was a topic of interest at the March 29, 2020, virtual symposium held in conjunction with the American Pharmacists Association Annual Meeting. Paul Mathew, MD, DNBPAS, FAAN, FAHS, and Jeffrey Fudin, PharmD, FCCP, FASHP, FFSMB, presented a comprehensive overview of migraine headache, evolving therapies, and the opportunity for pharmacist intervention.

Dr Mathew began the symposium with an overview of headache classification. Notably, headaches are an alarm system for the head that warns a patient when something might be wrong. Primary headaches are where there is an intrinsic miswiring of the alarm system, with the most commonly identified ones being migraine, cluster, and tension-type headaches. He then went on to discuss the 2 types of migraine (with and without aura), specifically their diagnostic criteria, which includes their associated presentations and symptomatology.

He also discussed the pathophysiology of migraine, and how after patients are subjected to enough stimuli, it will trigger cortical spreading depression. After that, activation of the trigeminovascular system can lead to central sensitization, which involves light and sound sensitivity, and the throbbing disabling pain component of a migraine.

Management of migraine headaches includes nonpharmacologic (eg, trigger avoidance) and pharmacologic (eg, abortive and preventive) therapies. Triptans are the cornerstone of abortive therapy but may not be appropriate for all patients. When pharmacologic agents are used for an acute migraine, taking the abortive agent early during a migraine is usually more effective.

Also, patients need to be warned about the risk of medicationoveruse headache and notable offending agents, as these can lead to rebound headaches and decrease efficacy of preventive medications. Preventive agents are used in patients who have severe decreases in quality of life, high frequency of headaches, or contraindications and/or adverse effects from or overuse of acute agents. Traditional treatment with preventive medications includes agents such as antiepileptics, calcium channel blockers, β-blockers, tricyclic antidepressants, and botulinum toxin injections.

The symposium then switched over to Dr Fudin, who discussed recent advancements in pharmacologic therapies for migraines: calcitonin gene-related peptide (CGRP) antagonists, CGRP receptor antagonists, and a serotonin (5-HT1F) receptor agonist. CGRP inhibitors block neurogenic inflammation, decrease arterial dilation, and inhibit pain transmission. Currently, there are 4 monoclonal antibodies that antagonize CGRP or its receptor (erenumab, fremanezumab, galcanezumab, and eptinezumab) approved for prevention of migraine in adults. These injectable agents are administered monthly or every 3 months depending on the agent and may reduce monthly headaches by up to eight per month. Adverse effects vary by agent, although injection-site reactions are the most common.

Dr Fudin also discussed 2 oral agents, ubrogepant and rimegepant, which are recently approved CGRP receptor antagonists indicated for the acute treatment of migraine in adults. These agents have been shown to significantly stop pain within 2 hours post-administration. The most common adverse effect was nausea. Dr Fudin also discussed lasmiditan, which is an oral agent and a first-in-class 5-HT1F receptor agonist also recently approved and indicated for the acute treatment of migraine in adults. Lasmiditan met efficacy end points of freedom from pain and most bothersome symptom at 2 hours; the results were statistically significant with all 3 studied doses. The most common adverse effects were dizziness, fatigue, paresthesia, and sedation.

Dr Fudin then highlighted the role of community pharmacists in the management of patients with migraine, including patient identification, assessment of symptoms, screening for drug interactions, and patient counseling. Pharmacists play an essential role in helping patients appropriately treat their migraines and referring patients for additional evaluation when necessary. As the treatment paradigm evolves, pharmacists will be called upon for their expertise to assist clinician colleagues and patients to improve outcomes and quality of life for patients with migraine.

PAUL MATHEW, MD, DNBPAS, FAAN, FAHS, indicated, "Migraine is a highly prevalent and disabling disorder. The underdiagnosis and undertreatment of= migraine continue to be very problematic. Everybody with migraine should have an effective abortive therapy, and all patients with high-frequency or high-intensity migraine should also be offered preventive treatment.JEFFREY FUDIN, PharmD, FCCP, FASHP, FFSMB, noted, "Pharmacists have an important and compelling role specific to migraine therapeutics. This includes patient identification for newer therapies, assessment and mitigation of drug—drug/drug–disease interactions, extensive patient counseling and education, assessment of medication overuse and rebound headaches, complementary and alternative therapies, and trigger avoidance."