Migraine attacks have often been managed with older medications originally developed for other conditions. The landscape of treatment is changing as scientific understanding has led to a new generation of therapies. These newer options are designed to target the underlying processes of a migraine, providing tailored approaches for both stopping attacks and reducing their frequency.
A New Approach to Migraine Treatment
A breakthrough in migraine therapy is identifying the role of a protein called Calcitonin Gene-Related Peptide (CGRP). During a migraine, nerves release CGRP, which causes blood vessels to expand and promotes inflammation in the brain’s coverings. This peptide acts as a pain messenger, transmitting signals through the trigeminal nerve, responsible for sensation in the face and head.
The release of CGRP is believed to sensitize nerve endings, making them hyper-responsive to stimuli like light and sound. This process creates a cascade effect, where the initial release of CGRP triggers further inflammation and pain signaling, perpetuating the migraine attack. Most new migraine medications are designed to interrupt this CGRP pathway.
These treatments work by either blocking CGRP from attaching to its receptors or by binding to the CGRP protein itself. By intercepting this pain messenger, the medications can stop the inflammatory cascade and pain transmission that define a migraine. This targeted approach is a shift from many older treatments.
Medications for Acute Migraine Attacks
Two new classes of oral medications are available for stopping a migraine attack: Gepants and Ditans. These are taken as needed at the onset of symptoms to relieve headache pain, nausea, and sensitivity to light and sound.
Gepants, including drugs like ubrogepant and rimegepant, are small-molecule CGRP receptor antagonists. They work by blocking the CGRP receptor, which can halt an attack and alleviate symptoms within a couple of hours.
A different class of acute treatment is the Ditans, with lasmiditan as the primary example. Lasmiditan is a selective serotonin 5-HT1F receptor agonist. Activating this receptor is thought to impede CGRP release, suppressing the trigeminal nerve system without the blood vessel constriction of older triptan medications, making it a suitable alternative for those with cardiovascular risk factors.
Preventive Migraine Treatments
For individuals with frequent migraines, the focus shifts to prevention. A primary approach for prevention involves CGRP monoclonal antibodies, designed to reduce the frequency and severity of migraines over time.
These treatments are laboratory-created proteins administered via injection on a monthly or quarterly basis. Some medications, like fremanezumab and galcanezumab, bind directly to the CGRP protein, while another, erenumab, blocks the CGRP receptor.
By consistently targeting the CGRP pathway, these antibodies lower the baseline level of CGRP activity, making the nervous system less susceptible to migraine triggers. Studies show these treatments can reduce the number of monthly migraine days for people with both episodic and chronic migraine. One medication, eptinezumab, is administered intravenously every three months.
Considerations When Choosing a New Medication
The side effect profiles for these newer medications are distinct from older therapies. Gepants and Ditans may cause nausea, sleepiness, or dizziness. Lasmiditan carries a warning to avoid driving for at least eight hours after taking a dose due to potential sedation.
For injectable CGRP monoclonal antibodies, the most common side effects are reactions at the injection site. Some patients may experience constipation or increased blood pressure with erenumab.
Choosing a medication requires a discussion with a healthcare professional. A doctor will assess a patient’s migraine patterns, frequency, health, and treatment history to recommend the most suitable option.
It is important to consider the practical aspects of these treatments. As newer drugs, they can be more expensive than older generic medications. Insurance companies may require prior authorization or for a patient to have tried other treatments before covering the cost.