New drugs may help prevent migraines
Marcie Zeldin, 63, doesn’t remember when she experienced her first migraine. She recalls having severe headaches as early as childhood, but it wasn’t until her first pregnancy at age 26 that the dozen or so headaches she experienced each month were diagnosed as migraines, a chronic neurological disorder.
“It would feel like an ice pick going through my eye,” Zeldin says. “There was always a burning sensation and throbbing. There was nausea, vomiting and sensitivity to light, sounds and smells. I would have severe pain and be nauseous and miserable for a good 48 hours.”
The severity and frequency of migraine episodes vary for the more than 36 million Americans who suffer from them, says Merle L. Diamond, MD, president and managing director of the Diamond Headache Clinic in Chicago. For some, a severe headache might be accompanied by nausea and vision problems lasting multiple days.
Migraines are disabling, says Diamond, who has been Zeldin’s physician since 2011. “My patients call it a ‘time robber.’ They get a migraine and they might lose that day, maybe the next day. Disability is one of the hallmarks of migraine.”
For patients with migraines, finding the best treatment can be a frustrating process, plagued by trial and error. But a new class of preventive drugs, called anti-CGRP drugs, might offer a potential solution for patients who experience a debilitating number of migraines.
Cause unknown
Scientists aren’t sure what causes migraines. Those with a family history of migraines have a good chance of developing the condition, according to the Mayo Clinic, implying risk factors are largely genetic.
Three out of 4 people with migraines are women, according to the U.S. Office on Women’s Health. Migraines are tied to hormonal changes, meaning that the headaches females experience often worsen during periods, pregnancy and menopause.
Richard P. Kraig, MD, PhD, director of the Migraine Headache Clinic at UChicago Medicine, characterizes migraines as a “hyper-excitability” in the brain. Migraines are most often a response to environmental triggers, he says.
“The migraineur’s brain is more excitable than normal, kind of like a seizure disorder,” says Kraig, who co-founded the migraine care start-up Seurat Therapeutics. “But that doesn’t mean a life sentence to headaches. It means a life sentence to it being easier to trigger a headache. Lifestyle activities can clearly influence that excitability, so those are a first line of defense for many headache docs.”
Finding the right treatment
Migraine treatments range from basic lifestyle changes to prescription medications. There’s no universal treatment that works for everyone, so finding the best fit for each patient can be a challenge.
The first step a patient often takes is to adopt subtle lifestyle changes, such as avoiding select foods, drinks or smells that tend to trigger a migraine. Kraig encourages patients to walk outside for 20 to 30 minutes a day, citing research that walking in nature can reduce inflammation in the brain and kick-start an immune system response to repair myelin, which insulates nerve cells in the human body. Those with migraines tend to have damaged myelin, he says.
For patients who experience four or more severe headaches a month, physicians might prescribe daily medications such as beta blockers, a type of cardiovascular drug used to reduce migraine frequency. To ramp up treatment for patients with more than 15 migraines a month, a physician might recommend a series of Botox injections to the forehead and neck to block some of the pain pathways associated with the condition.
Unfortunately, medications aren’t successful for everyone. Part of the problem is that these drugs were originally developed for conditions like seizures, high blood pressure and depression. “These drugs take a long time to work and have some side effects, because they weren’t developed [specifically] for migraine,” Diamond says.
New preventive drugs
Since being diagnosed with migraines almost 40 years ago, Zeldin has tried a myriad of strategies to manage the condition, including antidepressants, anti-seizure medications, Botox and beta blockers. On a daily basis, she avoids avocado, blue cheese, gorgonzola cheese and wine, all of which tend to trigger her migraine episodes.
“I was still getting the migraines [while using these drugs], but I don’t know how many more I would have gotten had I not been on some of these preventives,” Zeldin says.
To try something new, in 2017 Zeldin enrolled in a year-long clinical trial for a preventive treatment targeting migraines.
The clinical trial tested a set of monthly shots that block the transmission of calcitonin gene-related peptide, or CGRP, a neurotransmitter that contributes to the painful symptoms a patient experiences during a migraine. It’s one of a few migraine drugs that recently went through clinical trials.
In May 2018, Amgen and Novartis released the anti-CGRP drug Aimovig, administered via a monthly injection.
It’s the first-ever prophylaxis developed for migraine. At least three other major pharmaceutical companies — Alder Biopharmaceuticals, Eli Lilly and Company, and Teva Pharmaceuticals — have similar medications in the final stages of clinical trials or waiting for approval from the Food and Drug Administration (FDA).
We’re about to have a revolution. We’re going to have the first drugs ever that have been developed for migraine.”
Early findings from the studies suggest a promising alternative for patients who haven’t yet found an effective migraine treatment, Kraig says.
“The potential is high for [anti-CGRP drugs] to be an exciting new method of treating migraine,” he says.
For patients like Zeldin who suffer from debilitating migraines multiple times a month, anti-CGRP drugs offer a promising new type of care. Zeldin says she had only three migraines during the year she participated in the anti-CGRP clinical trial compared to the eight to 12 a month that she had previously experienced.
Like with all clinical trials, physicians suggest treating these results with hesitancy. However, Diamond remains optimistic about the potential of this emerging therapy.
“We’re about to have a revolution, is what I like to say. We’re going to have the first drugs ever that have been developed for migraine,” Diamond says. “It will certainly give patients more choices.”
