Migraine-specific Medications Research Articles

Understanding the real-world treatment patterns for patients with migraine-specific acute medications in Ontario, Canada

Understanding the real-world treatment patterns for patients with migraine-specific acute medications in Ontario, Canada

Real-world Treatment Combinations of Migraine-specific Prescription Medications (P11-12.006)

<h3>Objective:</h3> To describe how prescription medications for migraine are combined in real-world toolkits and how intranasal (IN) treatments fit into these toolkits. <h3>Background:</h3> While migraine may be adequately controlled with monotherapy in some patients, combination therapy is not uncommon. Little is known about the current prevalence and composition of combination toolkits. <h3>Design/Methods:</h3> Medical and prescription claims for migraine patients were analyzed from an open US-based medical and prescription claims dataset (IQVIA LAAD) from November 1, 2015–July 31, 2022. Inclusion required ≥1 ICD-10 migraine diagnosis and ≥1 prescription fill in the 3 months prior to July 31, 2022 (L3M) for ≥1 of the following classes: triptan, lasmiditan, CGRP receptor antagonist (gepant), CGRP monoclonal antibody (mAb), and dihydroergotamine (DHE). L3M fills were analyzed by class and by route of delivery for triptans and DHE. <h3>Results:</h3> 1,329,668 patients were included. Of these, 184,095 (13.8%) filled prescriptions in ≥2 studied classes. Four combinations accounted for 96.9% of multi-drug toolkits: triptan + mAb (n= 75,918; 42.2%), mAb + gepant (n= 45,138; 25.2%), triptan + gepant (n= 43,148; 24.1%), and triptan + mAb + gepant (n= 14,106; 7.9%). IN medication was included in 28,314 (2.1%) patient toolkits; IN-triptans (n= 24,683) were observed 6.6× more frequently than IN-DHE (n= 3,732). Of toolkits containing IN medication, 11,942 (42.2%) combined IN medication with non-IN medication(s). The most frequent such IN/non-IN combinations were with oral triptan (n= 6,675; 55.9%), mAb (n= 4,791; 40.1%), gepant (n= 4,174; 35.0%), or ≥2 non-IN medications (n= 3,400; 28.5%). <h3>Conclusions:</h3> More than 1 in 8 patients using migraine-specific prescription medications used a toolkit combining multiple classes. Patients using IN medication were more likely than the overall included population to use a combination toolkit and frequently combined medications across classes or in the same class with different routes of delivery. <b>Disclosure:</b> Dr. Mohajer has received personal compensation for serving as an employee of Qral Group, LLC. Gilbert J. L’Italien has received personal compensation for serving as an employee of Biohaven Pharmaceuticals. Gilbert J. L’Italien has received stock or an ownership interest from biohaven pharmaceuticals. Ms. Harris has received personal compensation for serving as an employee of Biohaven Pharmaceuticals. Ms. Harris has received stock or an ownership interest from Biohaven Pharmaceuticals.

Observational Analysis of the Costs Associated with Acute Treatment of Breakthrough Migraine Attacks in Medicaid Patients Using Preventive Therapies.

Medications for preventive treatment of migraine reduce migraine frequency, usually measured by a reduction in monthly migraine days (MMD), but generally do not eliminate the need for acute treatment. To assess the economic impact of treatment-related reductions in frequency, methodological guidance recommends capturing cost differences along the spectrum of MMD. Characterize monthly migraine medication costs along the spectrum of MMD for patients using calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) for prevention. Medicaid State Drug Utilization Data (SDUD) were used to identify formulations and per-unit costs for oral, intranasal, and parenteral migraine-specific medications for acute and preventive treatment used by fee-for-service (FFS) Medicaid enrollees in 2020. National drug codes of relevant therapies were used to match SDUD to formulation characteristics including substance, route of administration, and branded/generic marketing status. Mean per-unit cost and the formulation's share of total prescriptions were estimated. Monthly medication costs were modeled based on formulations' per-unit costs and frequency of acute medication use during clinical trials of CGRP mAbs. In the SDUD, there were 563,338 prescriptions for migraine-specific acute medications; triptans accounted for 97.37%. Triptan formulations prescribed were 83.78% oral tablet, 10.89% orally disintegrating tablet, 2.60% intranasal, and 2.73% parenteral. Dihydroergotamine accounted for < 1% of total prescriptions and had the highest per-unit cost ($443.50, branded intranasal). There were 97,119 prescriptions for CGRP mAbs, the majority for erenumab (45.73%) or galcanezumab (45.24%). Modeled monthly acute and preventive medication costs ranged from approximately $550 in patients with the fewest MMD treated with oral triptans to > $1500 in patients with the most MMD treated with dihydroergotamine. In consideration of the migraine-specific acute medications used in FFS Medicaid 2020, for patients using CGRP mAbs for prevention, medication costs may vary significantly with the number of breakthrough attacks treated per month and the type of migraine-specific acute therapy used.

Acute Medication Use in Patients With Migraine Treated With Monoclonal Antibodies Acting on the CGRP Pathway: Results From a Multicenter Study and Proposal of a New Index.

IntroductionAssessing the impact of migraine preventive treatments on acute medication consumption is important in clinical evaluation. The number of acute medication intakes per each monthly migraine day (MMD) could provide insights on migraine burden and represent a new proxy of treatment effectiveness in clinical trials and real-life studies. We evaluated the effect of monoclonal antibodies acting on calcitonin gene-related peptide (CGRP) pathway on the consumption of migraine acute medication in real-life.MethodsIn two headache centers in Prague (CZ), we included and followed up to 6 months consecutive patients treated with MoAbs acting on CGRP (erenumab or fremanezumab). For each month of treatment, we reported monthly drug intake (MDI) in doses of any medication, migraine-specific (MS), and non-migraine-specific (non-MS) medications, and computed a ratio between MMDs and MDI, i.e., Migraine Medication Index (MMI) for MS and non-MS medications.ResultsWe included 90 patients (91.1% women) with a median age of 47 [interquartile range (IQR) 42–51] years; 81 (90.0%) treated with erenumab and 9 (10.0%) with fremanezumab. Median MMDs decreased from 11 (IQR 8–14) at baseline to 4 (IQR 2–5) at Month 3 (p < 0.001 vs. baseline) and 3 (IQR 2–6) at Month 6 (p < 0.001 vs. baseline). Median MDI decreased from 15 drug intakes (IQR 11–20) at baseline to four drug intakes (IQR 2–7) at Month 3 (p < 0.001) and four drug intakes (IQR 2–7) at Month 6 (p < 0.001).The corresponding MDIs for MS medications were 10 (IQR 6–14) at baseline, 3 (IQR 1–5, p < 0.001) at Month 3, and 2 (IQR 0–4, p < 0.001) at Month 6. Monthly drug intakes for non-MS medications were 4 (IQR 0–9) at baseline, 1 (IQR 0–3, p < 0.001) at Month 3 and at Month 6.Median MMI decreased from 1.32 (IQR 1.11–1.68) at baseline to 1.00 (IQR 1.00–1.50, p < 0.001) at Month 3 and 1.00 (IQR 1.00–1.34, p < 0.001) at Month 6.ConclusionsWe confirmed that MoAbs acting on CGRP pathway decrease acute migraine medication consumption. We proposed a new index that can be easily applied in clinical practice to quantify migraine burden and its response to acute medication. Our index could help optimizing migraine acute treatment in clinical practice.

Medication-Overuse Headache: Results from a Pain Medicine Clinic Cohort

Background and Objective: Medication-overuse headache (MOH) is a common, disabling, and treatable cause of chronic daily headache. This study evaluates the characteristics of a cohort of patients with MOH seen in a pain medicine clinic. Methods: We conducted a retrospective study of consecutive patients seen by a neurologist in the pain medicine clinic at the University of California, San Diego. Demographics, headache diagnoses, and overused medications were extracted from clinical records from 83 patients ≥ 18 years of age where a diagnosis of MOH was entered into the electronic medical record September 12, 2017-March 30, 2020. Results: Opioids were the most overused medications (42/83, 50.6%) followed by caffeine-containing compounds (20/83, 24.1%), triptans (12/83, 14.5%) and non-steroidal anti-inflammatory drugs (10/83, 12.9%). Chronic migraine was the most common underlying headache syndrome (54/83, 65.1%), followed by secondary headache disorder (13/83, 15.7%) and tension-type headache (8/83, 9.6%). Men were more likely to be overusing opioids (OR 3.3, p = 0.026) while women were more likely to be overusing caffeine-containing compounds (OR 5.4, p = 0.041). Discussion and Conclusions: It is crucial for pain specialists to recognize MOH in the pain clinic setting. Opioid overuse headache is more common among men, likely in part due to migraine being underrecognized in men and therefore men not receiving migraine-specific medications. Caffeine-containing compound overuse is more common among women; these are over-the-counter (OTC) and often do not appear on patients’ medications lists. Pain specialists should specifically ask patients with headache whether they are using OTC caffeine-containing compounds.

Evaluation and treatment of headache associated with moyamoya disease - a narrative review.

Headache in patients with moyamoya disease is an under-addressed topic in the medical literature. Delay in the diagnosis of moyamoya disease or inappropriate treatment of headache could lead to devastating cerebrovascular outcome. With the evolving understanding of moyamoya disease, migraine pathophysiology, and various migraine-specific medications that have become available, it is crucial to provide an updated overview on this topic. We searched PubMed for keywords including moyamoya disease, moyamoya syndrome, headache in moyamoya, surgical revascularization, surgical bypass, migraine and moyamoya, and calcitonin gene-related peptide (CGRP). We summarized the literature and provide a comprehensive review of the headache presentation, possible mechanisms, the impact of various surgical revascularizations on headache in patients with moyamoya disease, and the medical management of headache incorporating novel migraine-specific treatments.Results and conclusion: The most common headache phenotype is migraine; tension-type headache, hemiplegic migraine, and cluster headache have also been reported. Most patients experience improvement of headache after surgical revascularization, though some patients report worsening, or new-onset headache after surgery. Given the complexity of moyamoya disease, careful consideration of different types of medical therapy for headache is necessary to improve the quality of life while not increasing the risk of adverse cerebrovascular events. More prospective studies are warranted to better understand and manage headache in patients with moyamoya disease.

PND51 Trends and Characteristics in Opioid Analgesic Use for Migraine in US Emergency Departments: Analysis of National Hospital Ambulatory Medical Care Survey 2007-2018 Data

Opioid analgesics are commonly prescribed for migraine management in emergency departments (ED) despite clinical guidelines warning against such practice. Despite several policies and guidelines that have been implemented to prevent unsafe prescription opioid use and opioid-related adverse outcomes in the United States (US), little is known about opioid use patterns among migraine patients. We aimed to examine the trends, patient, and visit characteristics in opioid use for migraine treatment in US ED settings. A cross-sectional study of 2007-2018 National Hospital Ambulatory Medical Care Survey data was conducted for adult visits (≥18 years) with a primary ED discharge diagnosis of migraine. To obtain sufficient sample sizes and reliable national estimates, we examined the data across 3 time periods: 2007-2010, 2011-2014, and 2015-2018. We used multivariable logistic regression to examine the trends in the use of opioid and non-opioid migraine medications including ergots/triptans, antiemetics, antihistamines, acetaminophen/non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and intravenous fluids, separately. There were 10.8 million migraine-related ED visits between 2007 and 2018. The majority of migraine-related ED visits with opioids were from patients aged <50 years (78.3%), female (84.7%), White (85.0%), and having severe pain (60.7%). Approximately 40% and 25% of migraine-related ED visits prescribed with opioids were paid by Medicaid and Medicare, respectively. Among migraine-related ED visits, a significantly declining trend was observed in opioids (2007-2010: 58.0%, 2011-2014: 49.5%, and 2015-2018: 36.0%; Ptrend<0.001). Conversely, increasing trends were observed in the following medications over time (all Ptrend<0.001): acetaminophen/NSAIDs (33.2% to 53.7%), antiemetics (43.4% to 64.1%), and corticosteroids (4.0% to 9.0%) from 2007-2010 to 2015-2018. Ergot/triptan use remained stable (10.0% in 2015-2018; Ptrend=0.55). Among migraine-related ED visits in the US, opioid analgesic use substantially decreased from 2007 to 2018, while acetaminophen/NSAIDs, antiemetic, and corticosteroid use increased significantly. Migraine-specific medications (i.e., ergots/triptans) were underutilized in ED settings.

Acute Migraine Treatment.

Migraine is a disabling disease of attacks of moderate to severe pain with associated symptoms. Every person with migraine requires treatment for acute attacks. Treatments can range from behavioral management and nonspecific medications to migraine-specific medications and neuromodulation. For many with migraine, having a combination of tools allows for effective treatment of all types of attacks. Over the past several years, four neuromodulation devices have been cleared by the US Food and Drug Administration (FDA) for treatment of acute migraine, and three medications with novel mechanisms of action have been FDA approved. They add to the arsenal available to people with migraine and focus on migraine-specific pathways to allow for precise care with fewer side effects. This article discusses acute migraine therapy, focusing on best-level evidence.

Naturalistic assessment of patterns and predictors of acute headache medication use among women with comorbid migraine and overweight or obesity.

Given the potential for obesity to complicate migraine treatment outcomes, there is a need to understand patterns and correlates of acute medication use among individuals with this comorbidity. Experience sampling methodology (ESM) was used to characterize patterns of acute medication use among those with migraine and overweight/obesity and to examine individual and momentary factors related to medication use (both migraine-specific and nonspecific medications). Women with migraine and overweight/obesity (N = 170) seeking behavioral migraine treatment completed questionnaires followed by 28 days of daily ESM headache diaries. Participants used medications to treat 71.9% of attacks, 20% of which were treated with migraine-specific medications. Participants were more likely to use medication in the context of longer and more severe attacks that started earlier in the day. Presence of aura and greater work-related pain interference uniquely related to migraine-specific medication use. Questionnaire-assessed factors were not related to medication use, although older age and higher educational attainment related to more frequent use. A substantial proportion of attacks were left untreated, suggesting unmet treatment needs in this population. Results also suggest that ESM-assessed factors are more salient correlates of medication use compared to questionnaires. Additional investigation of barriers to medication use is needed.

Editors' Note: Characterizing Opioid Use in a US Population With Migraine: Results From the CaMEO Study

Editors' Note: Characterizing Opioid Use in a US Population With Migraine: Results From the CaMEO Study

Reader Response: Characterizing Opioid Use in a US Population With Migraine: Results From the CaMEO Study.

Despite guidelines directing against the use of opioids in migraine management, this analysis by Lipton et al.1 reveals that more than 36% of patients surveyed have opioids available to them. These opioid users were more likely to have allodynia and vascular risk factors including diabetes, moderate-to-severe depression, anxiety, obesity, and high MIDAS scores, and they were more likely to be men. The data in this study demonstrate that those who use opioids are worse off in many domains, but the casual directions cannot be determined. Do opioids actually make migraine worse or do the most severe patients get prescribed opioids? Is the increased use of opioids a consequence of increased headache with high MIDAS scores, central sensitization, and allodynia? This leads to a debate on which came first, and it is likely that worsening headache came first,2 leading to initial opioid use. However, did the opioids subsequently worsen and escalate the situation? A controversial concept is whether opioids have a place in migraine treatment at all, given the new treatment options (Gepants and devices) because these have not been identified as causing medication overuse. Is the real issue a lack of education about alternative treatment options, resulting in patients becoming opioid users because of misdiagnosis and poor prescribing of migraine-specific medications?

Acute Care Treatment of Migraine.

Migraine is a chronic neurological disease involving the brain and its vasculature, typically characterized by recurrent attacks of moderate or severe throbbing headache, accompanied by sensitivity to light and sound, and associated with nausea, vomiting, and inability to move due to worsening of pain. About 30% of migraineurs have some type of aura, most often visual. Migraine attacks, if untreated or suboptimally treated, usually result in significant disability, requiring bed rest and resulting in poor quality of life. Increased frequency of attacks and overuse of acute care medication are significant risks for chronification, resulting in the transformation of episodic migraine into chronic migraine. We aim to review most acute care treatments for migraine. Current treatment options for migraine attacks were reviewed from the selected literature and combined with our clinical experience. Current acute treatment options for migraine attacks include over-the-counter analgesics, at times combined with caffeine, nonsteroidal anti-inflammatory medications, opioids, and migraine-specific medications such as triptans and ergots. In the near future, we will probably have 3 gepants (small-molecule calcitonin gene-related peptide [CGRP] receptor antagonists). The first one was just approved in the United States. A ditan acting as a stimulator of 5-HT1F receptors, was also just approved by the FDA. Stimulation of the trigeminal, vagal, occipital, and even upper arm peripheral nerves through electrical nerve stimulation devices and magnetic stimulation devices are available as alternative, nondrug treatment options. Several devices have already been FDA-allowed for treatment in the United States and/or approved elsewhere, and others will follow soon. Behavioral medicine techniques such as biofeedback training and mindfulness have been available for some time and are often helpful. A wide variety of acute care options to treat migraine are available, and others will soon be and will herein be described in further detail. Some medications have been approved by regulatory authorities in countries other than the United States, and some devices have been given a CE Mark in Europe.

Efficacy and safety of erenumab in women with a history of menstrual migraine

BackgroundWe performed a post hoc, subgroup analysis of a phase 3, randomized, double-blind, placebo-controlled study of erenumab for prevention of episodic migraine (STRIVE) to determine the efficacy and safety of erenumab in women with self-reported menstrual migraine.MethodsPatients received placebo, erenumab 70 mg, or erenumab 140 mg subcutaneously once monthly during the 6-month double-blind treatment phase of STRIVE. Women who reported history of menstrual migraine and who were ≤ 50 years old were included in the analysis. Endpoints were change from baseline in monthly migraine days (MMD) and monthly acute migraine-specific medication days (MSMD; among patients who took acute migraine-specific medications at baseline), proportion of patients achieving ≥ 50% reduction from baseline in MMD, and incidence of adverse events.ResultsAmong 814 women enrolled in STRIVE, 232 (28.5%) reported a history of menstrual migraine and were ≤ 50 years old. Of the 232 patients, 214 (92%) had a baseline MMD > 5, suggesting a high proportion of women with attacks outside of the 5-day perimenstrual window (2 days before and 3 days after the start of menstruation). Information on “migraine days” includes (and does not discriminate between) perimenstrual and intermenstrual migraine attacks. Between-group differences from placebo over months 4–6 for erenumab 70 mg and 140 mg were − 1.8 (P = 0.001) and − 2.1 (P < 0.001) days for MMD and − 1.6 (P = 0.002) and − 2.4 (P < 0.001) days for acute MSMD, respectively. The odds of having a ≥ 50% reduction from baseline in MMD over months 4–6 were 2.2 (P = 0.024) and 2.8 (P = 0.002) times greater for erenumab 70 mg and 140 mg, respectively, than for placebo. Erenumab had an overall safety profile comparable to placebo.ConclusionData from this subgroup analysis of women with menstrual migraine are consistent with data from the overall STRIVE episodic migraine population, supporting the efficacy and safety of erenumab in women who experience menstrual migraine.Trial registration: ClinicalTrials.gov, NCT02456740. Registered 28 May 2015.

Unmet needs in the acute treatment of migraine attacks and the emerging role of calcitonin gene-related peptide receptor antagonists: An integrative review.

Migraine is a prevalent and chronic disease associated with high rates of disability and significant financial and socioeconomic burden. Current acute treatments for migraine attacks include both migraine-specific (e.g., triptans, ergotamines) and nonspecific (e.g., nonsteroidal anti-inflammatory drugs) medications; however, significant unmet treatment needs remain. The authors sought to characterize the nature and drivers of unmet treatment needs in the acute treatment of migraine attacks and describe emerging migraine-specific treatments, that is, calcitonin gene-related peptide (CGRP) receptor antagonists. PubMed searches were conducted using search terms for studies of unmet migraine treatment needs and CGRP receptor antagonists. Additionally, studies presented at recent headache-focused congresses were included. Forty percent of people with migraine report at least 1 unmet treatment need. Many people are unable to use migraine-specific or nonspecific agents because of contraindications, precautions, and tolerability issues. Disease burden (disability, headache severity/frequency) remains high even in those receiving migraine-specific medications. The oral CGRP receptor antagonists, ubrogepant and rimegepant, demonstrated efficacy in reducing migraine pain, migraine-associated symptoms, and disability, with a low adverse event profile, similar to placebo. The availability and use of CGRP receptor antagonists may help reduce the extent of unmet needs in the treatment of migraine attacks, resulting in more patients receiving treatment and better outcomes for people with migraine. Nurse practitioners are well positioned to increase rates of migraine diagnosis/treatment (another key unmet need), using consensus guidelines to guide their approach.

Changes in Acute Migraine-specific Medications After Initiating Erenumab: Results from a Real-world Retrospective Cohort Study in the United States (1685)

Changes in Acute Migraine-specific Medications After Initiating Erenumab: Results from a Real-world Retrospective Cohort Study in the United States (1685)

Persistent post-traumatic headache attributed to mild traumatic brain injury: Deep phenotyping and treatment patterns.

To investigate clinical characteristics and treatment patterns in persistent post-traumatic headache attributed to mild traumatic brain injury. A total of 100 individuals with persistent post-traumatic headache attributed to mild traumatic brain injury were enrolled between July 2018 and June 2019. Deep phenotyping was performed using a semi-structured interview while allodynia was assessed using the 12-item Allodynia Symptom Checklist. In 100 subjects with persistent post-traumatic headache, the mean headache frequency was 25.4 ± 7.1 days per month. The most common headache phenotype was chronic migraine-like headache (n = 61) followed by combined episodic migraine-like and tension-type-like headache (n = 29) while nine subjects reported "pure" chronic tension-type-like headache. The most frequent trigger factors were stress, lack of sleep, and bright lights. A history of preventive medication use was reported by 63 subjects, of which 79% reported failure of at least one preventive drug, while 19% reported failure of at least four preventive drugs. Cutaneous allodynia was absent in 54% of the subjects, mild in 23%, moderate in 17%, and severe in 6%. The headache profile of individuals with persistent post-traumatic headache most often resembled a chronic migraine-like phenotype or a combined episodic migraine-like and tension-type-like headache phenotype. Migraine-specific preventive medications were largely reported to be ineffective. Therefore, there is a pressing need for pathophysiological insights and disease-specific therapies.

Ubrogepant for the treatment of migraine

ABSTRACT Introduction Migraine is a neurovascular disorder involving neurogenic inflammation and transmission of trigeminovascular nociceptive pathways mediated by Calcitonin Gene-Related Peptide (CGRP). Several small molecules antagonizing the CGRP receptor have been developed as migraine-specific acute medications. The CGRP receptor antagonist ubrogepant, also known as MK-1602, has been recently evaluated in phase III clinical trials for clinical efficacy and long-term safety as an abortive migraine treatment. Areas covered This paper discusses the pharmacodynamics, pharmacokinetics, clinical efficacy, safety, and tolerability profile of ubrogepant for the acute treatment of migraine with or without aura. Expert opinion Ubrogepant, a selective CGRP antagonist belonging to the gepants family, has been evaluated in large short- and long-term Phases 2 and 3 clinical trials aimed to assess clinical efficacy and safety as acute migraine medication. It did not significantly affect liver function and was not associated with other serious adverse events. Long-term non-serious adverse events were similar between placebo and ubrogepant. The efficacy was evaluated in large placebo-controlled studies and ubrogepant 50 mg and 100 mg was superior, even if the therapeutic gain seems to be low. Nevertheless, the favorable safety profile compared to other abortive drugs makes ubrogepant a promising option for the acute treatment of migraine.

Poor patient awareness and frequent misdiagnosis of migraine: findings from a large transcontinental cohort.

Although migraine is the second most disabling condition worldwide, there is poor awareness of it. The objective was to assess the awareness of migraine and previous diagnostic and therapeutic consultations and treatments in a large international population of migraineurs. This was a multicentre study conducted in 12 headache centres in seven countries. Each centre recruited up to 100 patients referred for a first visit and diagnosed with migraine. Subjects were given a structured clinical questionnaire-based interview about the perceptions of the type of headache they suffered from, its cause, previous diagnoses, investigations and treatments. In all, 1161 patients completed the study. Twenty-eight per cent of participants were aware that they suffered from migraine. Sixty-four per cent called their migraine 'headache'; less commonly they used terms such as 'cervical pain' (4%), tension headache (3%) and sinusitis (1%). Eight per cent of general practitioners and 35% of specialists (of whom 51% were neurologists and/or headache specialists) consulted for migraine formulated the correct diagnosis. Before participating in the study, 50% of patients had undergone X-ray, computed tomography and/or magnetic resonance imaging of the cervical spine and 76% underwent brain and/or cervical spine imaging for migraine. Twenty-eight per cent of patients had received symptomatic migraine-specific medications and 29% at least one migraine preventive medication. Although migraine is a very common disease, poor awareness of it amongst patients and physicians is still an issue in several countries. This highlights the importance of the promotion of migraine awareness to reduce its burden and limit direct and indirect costs and the risk of exposure to useless investigations.

Pharmacokinetics and pharmacodynamics of new acute treatments for migraine

ABSTRACTIntroduction: Recommended medications for the acute treatment of migraine encompass triptans, nonsteroidal anti-inflammatory drugs (NSAIDs), and analgesics. While it is true that triptans have been the first successful mechanism-driven treatment in the field, recently, new targets involved in migraine pathogenesis have emerged and new drug classes have been studied for migraine attack therapy.Areas covered: Pharmacodynamics and pharmacokinetics of the new acute treatments of migraine (i.e. ditans, gepants, and glutamate receptor antagonists), considering also marketed drugs in new formulations and administration routes.Expert opinion: Research on the administration routes of marketed drugs was performed in order to improve, in accordance with basic pharmacokinetics parameters, the speed of action of these medications. Similar to the triptans, the new acute treatments are migraine-specific medications, acting on the trigeminovascular system, albeit with different mechanisms. Although available data do not conclusively indicate the superiority of a class over the others, the pharmacodynamics explains the peculiar tolerability and safety profile of different drug classes emerging from clinical trials. Further studies are needed to investigate the possibility of combining different drug classes to optimize the clinical response and the potential role of the novel drugs in medication-overuse headache.

Erenumab in the prophylaxis of migraine: a profile of its use

Erenumab (Aimovig®, erenumab-aooe), a fully human monoclonal antibody (MAb) calcitonin gene-related peptide (CGRP) receptor antagonist, is the first MAb approved for the prophylaxis of migraine in adults. Erenumab is subcutaneously administered and has a convenient once-monthly/every-4-week dosing regimen. In patients with episodic or chronic migraine, erenumab is effective and generally well tolerated, significantly reducing the frequency of migraines and the use of migraine-specific medications during weeks 9–12 and months 4–6 relative to placebo. Erenumab also displays efficacy in numerous subgroup analyses, including in patients with episodic or chronic migraine with prior prophylactic treatment failure and/or patients with a history of aura. Although the efficacy and tolerability profiles of erenumab remain to be determined in specific populations (for example, in patients with major cardiovascular disease), it is a promising candidate for alleviating the widespread personal, societal and economic burdens that are presently associated with migraine.