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Emerging Strategies for Migraine Therapy

Emerging Strategies for Migraine Therapy

  • In a review of current pharmacologic strategies to prevent and treat migraine headaches, the authors of an article on recent advances in migraine therapy also look at novel acute and preventive treatments strategies.[1] Here’s a quick overview of what’s new—and what may be coming. 

  • Among the novel acute and preventive treatments:

    . Calcitonin gene-related peptide antagonists (gepants) – these monoclonal antibodies do not have a vasoconstrictive effect and are able to target specific migraine mechanisms. May be suitable for patients with vascular disease.

    . Serotonin 5HT1F agonists (ditans) – activation of 5HT1F receptors decreases the expression of c-Fos, a marker of neuronal activation, without having vascular effects.

  • Novel acute and preventive treatments(2)

    . Glutamate receptor antagonists – glutamate, released from neurons expressing 5HT1B/1D/1F receptors in the trigeminal ganglia, is implicated in both migraine and migraine aura pathophysiology. There are three glutamate receptor subtypes: N-methyl-d-aspartate (NMDA), α-amino-3-hydroxy-5-methyl-4-isoazolepropionic acid (AMPA), and kainate. Some glutamate antagonists have shown efficacy in migraine without aura. 

  • Among the novel acute and preventive treatments:

    . Neuromodulation – differing results have been found using occipital nerve stimulation and spinal cord stimulation

    . Neurostimulation – supraorbital transcutaneous stimulation has been shown to provide effective migraine prophylaxis and may be considered a valid option for patients who cannot or who will not take daily medicines, or who have low migraine frequency and /or intensity. 

  • Novel acute and preventive treatments (2)

    . Single-pulse transcranial magnetic stimulation – several handheld devices have been approved for the acute migraine therapy. These include The Spring TMS is FDA approved for migraine with aura in patients aged ≥18 years; it should not be used for more than one treatment in 24 hours. GammaCore, a handheld device for acute and preventive migraine therapy, generates an electrical signal to deliver transcutaneous vagal nerve stimulation (VNS). VNS can suppress high glutamate levels in the trigeminal nucleus caudalis, which may be the pain-blocking mechanism of non-invasive VNS.

    . Sphenopalatine ganglion stimulation – because of the reported preventive effect in cluster headache, trials are exploring efficacy as means of preventing migraines.

  • Appropriate migraine treatments can also be identified by considering the following:
    . The level of attack frequency and disability
    . The suitability of acute therapy in the single patient
    . The possible inefficacy of non-pharmacological therapy or the patient’s unwillingness to use such approaches
    . The presence of specific migraine forms
    . The presence of medical or psychiatric comorbidities.

  • Take Home Messages
    . Consider individual patient response, tolerability, patient preference, and clinical aspects when deciding on appropriate migraine treatment.
    . Introduce measures that can reduce biological tendency to headaches.
    . Set realistic expectations about what can be achieved with migraine treatments.

  • Reference
    1. Antonaci F, Ghiotta N, Wu S, et al. Recent advances in migraine therapy. Springerplus. Epub 2016 May 17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4870579/

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