AAN 2022 | New treatments for migraine: who, what, and when?

Yes, it was a great session. We had a lot to cover. So there’s been several new treatments that have come out over the last few years. We really have had a focus on the CGRP calcitonin gene-related peptide category of treatments. There have been preventive treatments and acute treatments in this category. Prevention has really focused first on these monoclonal antibodies, which are injectable treatment options that are used to prevent migraine in adults, though I do believe they are under investigation in the pediatric realm. So it’s going to be very exciting next few years to see how these work in children as well.

We have had the advent of small molecule tablet formulation of CGRP medications that have also come to market for prevention and acute use in adults as well. And this has really changed the paradigm of treatment for adults, where you now have an acute treatment that doesn’t cause medication overuse headache. And we’re starting to have these conversations with patients where it’s like treat when you actually have the smallest symptom of migraine.

And even at this meeting, there were abstracts being presented that talked a lot about when you’re having a migraine attack, even though this small molecule category called gepants have evidence that shows that they can work at moderate to severe pain, that the earlier you treat and, in fact, if you treat with mild pain, shows that efficacy can be much better. This, we already understand that anytime migraine starts, the earlier you treat, the better the chance of getting rid of the migraine faster. Patients inherently understand that, but we’ve really trained them to be very fearful of treating early because of medication overuse headache.

And now, we’re starting to have these conversations about, well, if you’re using a gepant, we’re not as worried about medication overuse headache. And the more often you use them, the less likely that’s a problem. And in fact, the better you treat acute migraine, the less likely you’re going to convert into chronic migraine. And so we’re really perhaps able to shift that paradigm early on, and maybe we can start to prevent disease progression in a very different manner than the idea of prevention by starting a daily medication.

So again, these conversations are looking different in clinic, and it’s some of what we’re starting to now try to educate people about. Well, we’ve talked so much about medication overuse headache. Now, the paradigm is starting to shift and we even have evidence that the monoclonal antibodies work with medication overuse headache. So perhaps we should treat early as opposed to focusing on medication overuse headache is bad.

And so in these courses, that’s a lot of the conversations have been about, we have these new treatments. When do we use them? We have consensus statements that I think people haven’t recognized come out. How do you use a newer medication versus an older medication? Older medications are still very effective, but they do have side effects. So when’s the right time to choose which drug? How do you make these decisions in clinical practice? How do you dialogue about them?

And our course was a lot about that, that dialogue, that conversation, but also the fact that it’s not just CGRP. There’s a whole wealth of new treatments in the pipeline. And so there was conversations about PACAP and endocannabinoids and the delta receptors and μ receptors and how we’re moving away from μ and we’re looking at delta and kappa receptors for pain management and looking at treatment in migraine. And we’re looking at glutamate, and there’s all these other receptors that are playing a role. And there’s actually very active research in these areas as well.

So that might be maybe a decade away before we see that, but it is important to realize that there’s more research in place and there’s more treatment options that might be coming. And I think that’s very important to also take that dialogue back to patients who are very anxious if something doesn’t work. Well, is that it? This is it. This is the new category of treatments and we’re done. We’re not going to feel better. But that realization that, no, there’s other treatments that are being studied, it’s very important because this doesn’t mean it’s the only option for you, that there’s going to be future targets that are under investigation. And that’s actually very important for clinicians to know that as well.