Migraines

Migraines are a type of headache classified by a moderate to intense throbbing pain associated with nausea, vomiting, light and/or sound sensitivity, and can be preceded by an aura. An aura is seen as visual or sensory disturbances such as light flashes, localized blindness, numbness, or pins and needles sensation. An aura typical arrives prior to the onset of the migraine. A migraine is usually classified by how severely the pain impacts daily function and how often these attacks occur. Some people find the most benefit from staying away from loud noises or bright lights when they have a migraine and may even need to call out of work and cancel plans. When this happens more than two to three times a month, it is usually a concern and a neurologist should be seen to consult on treating and managing the migraines. Migraines with or without aura can be treated in a variety of ways including prophylactic (preventative) treatment or with abortive therapy. 

The most common version of abortive therapy is the Triptan class of medications. These drugs include sumatriptan, naratriptan, rizatriptan, and others. Triptans work by activating specific serotonin receptors on cranial blood vessels which leads to a reduction of inflammation and constriction of the blood vessels, overall leading to a relief of the migraine. The triptans are available as an injectable, a tablet, or a nasal spray. The major side effects seen are dizziness, fatigue, nausea, and vomiting. In 2019, two new abortive therapies were introduced in the United States, Ubrelvy and Nurtec. Both of these new medications are Calcitonin-Gene Related Peptide (CGRP) inhibitors. This means they work by blocking a specific peptide only found in the central nervous system. By blocking this peptide, neural inflammation and pain signal transmission are greatly reduced. Ubrelvy is available as an oral tablet and Nurtec is available as an orally disintegrating tablet. The side effects seen with these medications are nausea and vomiting. 

Prophylactic treatments come in a variety of options. The most common options are now the use of injectable CGRP inhibitors. Medications such as Aimovig, Emgality, and Ajovy are once monthly subcutaneous injections that a person can self administer. These medications have very few side effects other than injection site redness and soreness and are largely effective at preventing most migraines. Similar to the oral CGRP inhibitors, these injections only work at the site of the specific neurons in the Central Nervous System (CNS) and help to prevent migraines before they even start. Other preventative methods include medications like topiramate, amitriptyline, or valproate. These medications have a variety of uses including seizure disorders, depression, anxiety, and migraine prevention and are generally well tolerated. Selecting an option is dependent on whether or not the patient is comfortable administering an injection or not, and is a decision usually made between the prescribing neurologist and the patient.

This content was originally provided by James Gorman PharmD candidate 2021.