Migraine sufferers have new options for taming the painful condition that affects more than 30 million people in the United States.
This year, the U.S. Food and Drug Administration has approved three injectable drugs — Emgality, Ajovy and Aimovig — to help prevent the disabling headaches by blocking activity related to a molecule that plays a role in migraine attacks.
“We’re having a whole new host of very important migraine preventive medications; it’s really an exciting time, no question about it,” said Dr. Vincent Martin, president of the National Headache Foundation. “These are some of the greatest advances that we’ve ever had in the headache field, so far.”
The trio of new medications is designed to ward off a migraine with a monthly — or sometimes quarterly — injection, often self-administered.
But “it’s a smaller injection than even your flu shot,” said Dr. Brian Plato, a Louisville neurologist who will be speaking at Norton Healthcare’s Neuroscience Expo next month in Louisville.
For those who choose quarterly injections of Ajovy (fremanezumab-vfrm), three separate shots are required every three months. Like the other two drugs, it’s also available as a single monthly shot.
Keep in mind, however, that two shots may be required, instead of single shots, with these drugs sometimes, such as during the first administration, or if you’re prescribed a certain dose, such as 140 mg of Aimovig.
The drugs are “very effective and they have low side effects, so when you take those two together, that makes them a very desirable preventive therapy for many people,” said Martin, who’s also director of the University of Cincinnati Headache and Facial Pain Center.
But cost could be an issue for some people since “the medicines are still fairly expensive” and insurance coverage varies, Martin said. Typical costs are $575 a month or $1,725 quarterly. But some discounts are being offered. For example, certain patients with commercial insurance can get Emgality (galcanezumab-gnlm) free for up to 12 months, according to the product website.
In general, to obtain the drugs, patients may find they have to meet certain criteria, such as having failed multiple other treatments, and may be limited to only certain kinds of doctors, depending on their insurance plan, Martin said.
During a migraine attack, lasting four to 72 hours, sufferers experience intense pulsing or throbbing pain, usually in one area of the head, and also may experience nausea, vomiting and sensitivity to light and sound, according to the National Institute of Neurological Disorders and Stroke. Sometimes, it is preceded by an aura or visual disturbance, such as flashing lights, zigzag lines or temporary loss of vision.
“You hear a lot of people refer to them as these ‘sick headaches,’ where they just would be sort of incapacited for a period of time,” said Plato, who’s with the Norton Neuroscience Institute. ” … The majority of patients that I see have between 15 and 30 days per month of headache.”
There are various different types of drugs available to treat acute migraine headaches, but “being a headache doctor, I really like the concept of preventing the headaches before they ever come on,” Martin said. “Once the headaches come on, even if you treat it very well with Imitrex or some other drug, you still have to endure the pain and other symptoms of a migraine.”
Historically, doctors have turned to drugs like antidepressants, anti-seizure medications and blood pressure medicines “as sort of like our mainstay of treatment options,” Plato said. But “those medicines have a lot of side effects and they weren’t really created specifically to treat migraine.”
According to a technical backgrounder from the National Headache Foundation, the highly anticipated drugs, which are also referred to as monoclonal antibodies, interfere with calcitonin gene-related peptide (or its receptors) that are involved in the transmission of pain and the resultant reaction of tissues and blood vessels. The molecule is commonly referred to as CGRP.
Aimovig (erenumab-aooe) was the first of the new CGRP-thwarting drugs to come on the scene this year. It won FDA approval in May, followed by Ajovy and Emgality in September.
“CGRP is involved in nerves talking to each other in signaling pain, so during migraine pain CGRP levels rise and then when you take a medicine to stop the migraine attack, the CGRP levels go back down,” Plato said. “So it was apparent to researchers that this is something that if you could block its activity, you might actually be able to alter the course of migraine for individuals.”
The mechanism of action varies by drug. For example, Aimovig “blocks the target for CGRP, so basically this antibody goes in and it blocks where CGRP would do its work,” Plato said. “Ajovy attaches to CGRP itself and blocks it from going and binding to its receptor.”
The drugs are generally well-tolerated and have “a better side effect profile than most of the medications out there,” including topiramate, a preventive medication that can lead to memory loss and kidney stones, Martin said.
The most common side effects with the new drugs are injection site reactions, such as pain and redness. Constipation also can be an issue with Aimovig.
Hypersensitivity reactions, such as rash, also have been reported among some users of migraine drugs, such as Emgality.
And Martin noted that long-term side effects of these drugs aren’t known and patients are likely to still need another drug to treat breakthrough headaches.
In terms of lifestyle choices that might help, Martin recommends that migraine sufferers maintain a consistent bedtime and wake-up time; eat regularly without fasting for lengthy periods; minimize stress; not get overextended; learn relaxation techniques; and minimize caffeine and alcohol consumption.
Also, take note of the weather. “The change in barometric pressure may act as a triggering event for people who suffer from headaches and migraines,” Plato said recently on the Norton Healthcare website. “In addition to barometric pressure changes, bright sunlight, extreme heat or cold, sun glare, high humidity, dry air and windy or stormy weather can also have a significant impact.”
Public Education Event
What: 2018 Neuroscience Expo
When: Starts at 8 a.m. Nov. 3
Where: Kentucky International Convention Center, 221 S. Fourth St.
Why: This free event will educate the public about treatments and support for headaches, epilepsy, multiple sclerosis, Parkinson’s disease, essential tremor, Alzheimer’s disease and other forms of dementia, and neuromuscular disorders. There also will be information for caregivers and life-skills workshops for coping with neurological conditions.
How: Register online or call (502) 629-1234.