Migraine Medication: Guidance Just Published

In her autobiography Karla Cornejo Villavicencio, writes about her migraine in a way that all migraine sufferers can identify with. We are dismissed. We are just a medical puzzle and our pain is minimised.

At the first hint of a migraine with aura I take a triptan. Aura for me is scintillating scotoma (flashing black spiders in my vision) and numbness down my right side. I know that if I have more than 4 triptans in a month I run the risk of getting a medication overuse headache. So I save them for “special occasions.” If I have a regular migraine, I take two paracetamol, two ibuprofen. I put liniment on my neck. I put Vicks VapoRub on my face. I take Magnesium and vitamin B, I have a few pieces of Kendal Mint Cake (pure sugar). I use a TENS machine on my neck. If I can, I have a nap. Migraines steal days from me. I can’t think when my head is pounding and I am not unique. Over one billion people get migraines.

Some people have chronic migraine which is more than 15 headache days per month. Some are low, medium or high - episodic migraine sufferers. For a very long time it has been standard practice to treat us with repurposed medication. This might be why you are taking antidepressants, blood pressure, epilepsy or dizziness medication. Or. You may have tried one or all of these medications and stopped because of the side effects.

This table shows the medications that are usually prescribed for migraine - both non specific and specific.

and there's more:

It comes from a fantastic review of migraine treatment published in the Lancet.

The specific migraine medications listed are CGRP targeting therapies.

So. What are CGRP targeting therapies?

Here’s a super quick video I made to explain how these medications work

https://vimeo.com/1064333382

If you’re not a video person, essentially: a new generation of drugs have been specifically engineered to target migraine through reducing CGRP production. Calcitonin gene-related peptides are small proteins that act dial neuron activity up or down. They appear in high concentrations during a migraine. These medications work better and have fewer side effects than the older repurposed medications.

Returning to the Lancet article, take a look at this marvellous table:

This is a proposed optimal approach to migraine prevention. It starts with 6 months of CGRP medication for episodic migraine; and adds 6 months of Botox for chronic migraine. It recommends a review at 6 months and trying a different CGRP medication if necessary. At the next review if CGRPs are not helping then it recommends adding a repurposed medication along with non pharmacological treatment. Examples of these are CBT, mindfulness, or neuro-modulation.

There is also an assumption that treatment would include headache education around the influence of hormones, stress, sleep and diet. The use of a headache diary to help patients recognise patterns and track progress would also remain standard practice.   

Botox injections are migraine medication?

OnabotulinumtoxinA is also used to help prevent chronic migraine it is thought that injections might block CGRP release in the sensory nerve fibres. The standard protocol (PREEMPT study protocol) requires that you have injections at all of these sites (25-40 injections 3 times a year)

This is quite expensive at £650 a time! However, clinicians don’t always follow the exact protocol. Through experience and patient feedback some doctors are injecting lower doses in fewer areas. I can’t find the paper that I read where the researchers only injected the temporals muscles (around the ears) so that they could have a placebo group. Their subjects still had a reduction in migraine despite the smaller area.

This just adds to the conclusion that migraines are hard to treat. There will always need to be trial and error. There are new treatments on the horizon though and the current migraine specific medications are much better than the repurposed ones. Thank you so much Daniele Martinelli, Roberto De Icco, Haidar M Al-Khazali, Sait Ashina, Hans-Christoph Diener, Freda Dodd-Glover, Maria Teresa Goicochea, Bronwyn Jenkins, Antoinette MaassenVanDenBrink, Mi Ji Lee, Aynur Özge, Mario Fernando Prieto Peres, Patricia Pozo-Rosich, Francesca Puledda, Simona Sacco, Todd Schwedt, Gisela M Terwindt, Cristina Tassorelli for writing such a comprehensive review.