Over the past several decades our understanding of migraine and other headache disorders has dramatically improved and so did the therapeutic approaches. In the late 1980s - early 1990s a new neuropeptide – calcitonin gene-related peptide (or simply CGRP) was discovered and linked to migraine and cluster headaches and eventually became known as one of the key “ingredients” of a migraine and cluster headache disorders. We now know that CGRP levels increase in plasma during migraine and cluster headache attacks producing changes in blood vessels as well as in the central and peripheral nervous system producing migraine pain as well as associated symptoms such as sensitivity to light, sounds, etc. If we could modulate the impact that excess of CGRP has on our body we would be able to reduce migraine and cluster headache frequency, severity, and overall improve treatment outcomes.
We now have great options that help us not only to stop or abort an ongoing migraine or other headaches attack (acute medications) but also to reduce the frequency of headache episodes that you may experience (prophylactic medications) and accomplish all of it by affecting migraine-specific mechanisms (such as CGRP).
CGRP monoclonal antibodies: We now have 4 FDA approved CGRP monoclonal antibodies that effect either CGRP receptor (Aimovig) or CGRP molecule (Emgality, Ajovy, and Vyepti). These medications are administered monthly or quarterly (depending on the specific medication) and may provide relief as soon as within weeks after the first dose.
Botox (onabotulinumtoxinA): Botox has been FDA approved for chronic migraine prophylaxis in 2010 and has become a standard of care for all patients with chronic migraine. It takes only a few minutes to perform Botox treatment in our office and this procedure needs to be repeated every 3 months (or only 4 times per year!). Most patients start noticing headache improvement within weeks after the first treatment.
Traditional pharmacotherapy options include antiseizure medications, blood pressure medications, antidepressants among others.
CGRP receptors antagonist (gepants): We now have two FDA approved acute medications that block CGRP receptor and provide rapid headache relief (Ubrelvy and Nurtec ODT)
Serotonin receptor agonists (ditans) - we now have an FDA approved oral medication called Reyvow that helps to stop an ongoing migraine attack.
Triptans: This class of medication consists of 7 different drugs: sumatriptan, almotriptan, eletriptan, rizatriptan, zolmitriptan, naratriptan, and frovatriptan. They are all similar yet different and we can help you chose the one that will work best for you.
Ergotamine-containing medications: “ergots” was the first class of medications specifically approved for migraine treatment that we continue to use even today and this class includes Migranal (dihydroergotamine), Ergomar (ergotamine), etc.
Nonsteroid anti-inflammatory medications (NSAIDs) and Cox 2 inhibitor: two representatives in this group have been FDA approved for migraine treatment: Cambia (diclofenac potassium) and Elyxyb (celecoxib oral solution).
Parenteral (injectable) therapy: Occasionally, for more refractory headaches that did not respond to the above options we may use injectable medications or even discuss hospitalization to help abort an intractable headache cycle.
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