Acute and Preventive Therapy for Migraine - Episode 2
Experts in the management of migraine discuss the prevalence of individuals taking acute migraine therapy and enumerate the various classes of agents available.
Neil Minkoff, MD: Dr Dodick, could you lead us a bit in the discussion of the different classes of agents used for migraine treatment?
David W. Dodick, MD: Yes. We talked about the difference between acute and preventive treatments. If we look at the classes of treatments available for acute treatment, let's review medications first. They're broadly divided into 2 groups. One is migraine-specific acute treatments. These are drugs that have been developed and approved specifically for the treatment of migraine. Some of them have also been approved to treat other headache disorders like cluster headache.
Then there's the other group of nonspecific medications. These are, broadly speaking, analgesics like non-steroidal anti-inflammatory drugs. There are also simple analgesics, like acetaminophen, and sometimes combination analgesics that contain acetaminophen, aspirin, and caffeine, for example.
For about the past 29 or 30 years, we've had migraine-specific triptans available. There are 7 triptans available. Some of them are in different formulations. They can be taken by tablet or as a nasal spray. One of them can be taken as an injection.
Over the past year, there are 2 new classes of migraine-specific acute treatments that have been approved. One class is called the gepants. That's the suffix of the name of some of these drugs. Rimegepant and Ubrogepant are 2 gepants which have been approved for the acute treatment of migraine. Then, there's another class called the ditans, of which there's only 1. That is called Lasmiditan. We now have 3 different classes of acute migraine-specific medications.
I should also note that there are devices that have been approved for the acute treatment of migraine. There's a transcutaneous electrical nerve stimulation device. That is placed over the forehead. There's a vagus nerve stimulator that's placed over the neck. There's a remote neuromodulation device that's placed over the arm. Finally, there's a transcranial magnetic stimulation device that emits a magnetic impulse. There are nonmedication acute treatment options for migraine, as well.
Neil Minkoff, MD: Wow. There's a lot to weed through there, right?
David W. Dodick, MD: Yes.
Neil Minkoff, MD: There are several different types and the fact that they are changing. We'll get back to these a bit, in terms of understanding who should get which therapies and that sort of thing. But I wanted to take a step back for a second.
Dr Stephens, you're looking at this across a large membership. It’s not just the patients who have headache, but patients across the whole spectrum of all the different diseases. What are you seeing, in terms of prevalence and use of acute migraine treatments? What is your goal in trying to manage these when you're looking at it from a population base point of view?
Kevin Stephens, Sr., MD: That's a very good question. The first thing we find is that typically, it's in females, as we mentioned before. We find that it's not a 100% —18 to 44. It's found in about 10% of men in the same age group. It’s 2 to 3 times more common in women than in men.
No. 2, as we get over the age of 75, it's present in about 5% of people. There are fewer migraines in the elderly group. We have a subset of the population, particularly young, reproductive-aged women, with the most burden. They have many duties in the home—picking up kids, work, etc. It can be very problematic.
A couple of principles we really try to get the momentum so that they can reduce emergency department use and admissions. Many times, they have to function. When we have migraines, they can be really debilitating, as we’ve said. It's really important to us to be aggressive and proactive, rather than reactive.
Neil Minkoff, MD: When you're looking at someone in your membership, do you push patients away from acute treatment into prophylaxis? Or are you reacting to what their prescribing or managing physician is recommending?
Kevin Stephens, Sr., MD: Typically, we allow the physician to make the decision. It’s a physician-patient interaction. We really try not to disrupt the physician-patient interaction with rules, guidelines, and those types of things. We follow national guidelines for utilization, but we like to keep the patient and provider as a guide so that we can do what's best for the patient. They all are different. They have different triggers. They have different reactions with the medications. It's a very complex disease. One size does not fit all.