Options include calcitonin gene-related peptide antagonists, ergotamine, hormone therapy, lasmiditan, and triptans.
Migraine headaches are characterized by recurrent episodes of pulsating or throbbing pain on one side of the head, often accompanied by nausea, vomiting and/or sensitivity to light and sound.
The pain comes from the activation of nerve fibers in the walls of the vessels of the meninges.1 If left untreated or treated unsuccessfully, the pain can last for hours to days and can be moderate to severe and often debilitating.1
Adults and children can suffer from migraines. Women are 3 times more likely to have migraines than men.
Migraines usually occur in the morning upon waking. Some patients experience migraines at predictable times, such as before a menstrual cycle or at the end of a particularly stressful week. In some patients, migraines occur in stages.
Migraine Stages
prodrome. Hours or days before a migraine, many people experience symptoms such as bloating, changes in appetite, constipation, diarrhea, fatigue, mood swings and severe thirst, in addition to sensitivity to light, smells and sound.2
Aura. Aura usually starts gradually over 5 to 25 minutes. Aura usually lasts less than an hour. These symptoms arise from the nervous system and may involve changes in smell, taste, and touch; difficulty speaking; a heaviness in the arms and legs; numbness on 1 side of the body; ringing in the ears; and vision changes.2
Attack. The actual migraine attack usually gets worse with physical activity and can last a few hours or several days.2
post dream. After a migraine attack, patients often feel confused, exhausted and weak. This may take a day or more.2.3
Causes
Migraines have a genetic component to them. Four out of five migraine sufferers have a family member who suffers from the same condition. If 1 parent has migraine, a child has a 50% chance of getting it too. That number jumps to 75% if both parents suffer from migraines.2
Having other medical conditions increases your risk of developing migraines. These include anxiety, bipolar disorder, depression, epilepsy, and sleep disorders.2
triggers
Everyone has different triggers that can trigger migraines. These include alcohol; chocolate; food additives, such as monosodium gluconate or nitrates; hormonal changes; medications, such as vasodilators; tension; tobacco; too little or too much caffeine; too little or too much sleep; and weather changes.2
Therapy
While there is no cure for migraines, treatment focuses on relieving symptoms and preventing additional attacks. Some tips for non-medical symptom relief may include drinking fluids; placing a cool compress or ice pack on the back of the neck, forehead, or top of the head; and rest with eyes closed in a cool, dark, quiet environment.3
Lifestyle changes can help prevent migraine headaches. Some of these include logging triggers to avoid them in the future, stress management techniques, and weight loss.
However, often medical intervention is required. Usually, the sooner treatment starts after the onset of a migraine, the better it will work.
OTC pain relievers containing acetaminophen, aspirin, caffeine and/or ibuprofen often work well. Of course, products containing aspirin should not be given to patients under the age of 19 because of the risk of Reye’s syndrome.
If patients take these OTC pain relievers more than 2 days a week, they should be referred to a doctor, who can prescribe a product to better manage the migraines.2
Many patients experience nausea and sometimes vomiting with migraines. Doctors will often prescribe medications to control nausea, such as metoclopramide, ondansetron, or promethazine, to help resolve this symptom.2
Triptans are FDA-approved, first-line drugs used to treat migraines.
Triptans reverse the vasodilation that causes migraines by selectively binding to the vascular serotonin receptor 5-HT1B. They also selectively bind to the neurogenic and central serotonin 5-HT1D receptors, inhibiting the activation of the trigeminal nerves. This also results in a blockage of the transmission of pain signals to the brain.4
Triptans are available in multiple dosage forms, including nasal sprays, oral tablets, orally disintegrating tablets, and subcutaneous injectables.4
Triptans can cause coronary vasoconstriction, dizziness, and nausea, as well as a group of side effects (AEs) called “triptan sensations,” including chest tightness, flushing, neck pain, paresthesia, and tingling.4
Ergotamines are also used to treat migraines by selectively binding to and activating the serotonin receptor 5-HT1D, and they work similarly to triptans. Ergotamine also binds to alpha-adrenergic receptors, stimulating vascular smooth muscle, resulting in vasoconstriction.5
Side effects of ergotamine are many and range from relatively benign symptoms such as dizziness, drowsiness and xerostomia to severe symptoms including arrhythmias and decreased blood flow.5 Therefore, ergotamine derivatives have fallen out of favor as first-line treatments for migraines.
Lasmiditan is the first FDA-approved “ditan” used to treat migraines. Lasmiditan has a strong affinity to bind to 5-HT1F serotonin receptors, which are involved in pain signalling. These receptors are located both centrally and peripherally. Unfortunately, the mechanism of action of ditans is not clearly understood.6
Side effects of lasmiditan include central nervous system depression, impaired driving ability, headaches related to overuse, and serotonin syndrome.6
Calcitonin gene-related peptide (CGRP) antagonists block the effects of CGRP, a small protein located in the trigeminal nerve.
This blockade results in inhibition of neurogenic inflammation, inhibition of pain signals and inhibition of vasodilation without causing vasoconstriction.7.8
The most common side effects of CGRP antagonists are constipation and injection site reactions. Less commonly, these drugs can cause new or worsening constipation and hypertension with serious complications.7
Hormone therapy can be used for patients who experience migraines around their menstrual cycle.
Additional forms of treatment that may be considered include acupressure, acupuncture, biofeedback, chiropractic care, cognitive behavioral therapy, craniosacral therapy, and massage.2
Since each individual’s migraine is different, it is obvious that not every available drug will work in all cases. Pharmacists can help patients determine which drugs may work for them and inform them about how the drugs work and their possible side effects.
About the author
Kathleen Kenny† PharmD† RPh, has over 25 years of experience as a community pharmacist. She is a freelance clinical medical writer based in Homosassa, Florida.
Reference
1. Headaches: Hope Through Research. National Institute of Neurological Disorders and Stroke. Updated April 18, 2022. Accessed May 11, 2022. https://www.ninds.nih.gov/health-information/patient-caregiver-education/hope-through-research/headache-hope-through-research
2. Migraines. Mayo Clinic. July 2, 2021. Accessed June 1, 2022. https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201
3. Migraines. Medline Plus. Accessed May 11, 2022. Updated May 5, 2021. https://medlineplus.gov/migraine.html
4. Triptans. National Library of Medicine. October 30, 2021. Accessed May 12, 2022. https://www.ncbi.nlm.nih.gov/books/NBK554507/
5. Ergotamine. National Library of Medicine. May 6, 2022. Accessed May 12, 2022. https://pubchem.ncbi.nlm.nih.gov/ compound/ERGOTAMINE
6. Reyvow. Accessed May 12, 2022. https://www.reyvow.com/
7. Nurtec. Accessed May 12, 2022. https://www.nurtec-hcp.com/rimegepant.
8. Aimovig. Prescribing information. amgen; 2021. Accessed May 12, 2022. https://www.pi.amgen.com/-/media/Project/Amgen/Repository/pi-amgen-com/aimovig/aimovig_pi_hcp_ english.ashx