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What Are Some Migraine Medications

Nurtec Odt And Gepants For Migraine Prevention

The CGRP mAbs have been a major step forward for migraine prevention. However, up to this point, we still have not had an oral pill that has been engineered and created purely and only for migraine prevention .

 

That was until now, with development of the gepants . On 5/27/21, Nurtec ODT made history as the first and only FDA approved medication for BOTH abortive and preventive migraine treatment simultaneously, and the only option with this flexibility and is discussed in greater detail here!

 

The perspective behind this is that migraine is a fluid and variable disease, fluctuating between periods of episodic migraine , and other periods of chronic migraine . So, having a medicine that can function as both types of treatment, depending on what type of phase the migraine is in opens up an entirely new flexible treatment paradigm and approach which we have never had up to this point.

 

So essentially, taking Nurtec ODT every other day could be used as an ongoing daily preventive strategy when the migraine is in a high frequency to chronic migraine phase. If it evolves back into a lower frequency episodic migraine pattern, it can then just be used abortively only when needed for a migraine attack.

 

 

Atogepant is the 2nd gepant that will be used as a daily preventive pill only and is pending FDA approval, but is anticipated soon.

 

Selective Serotonin Reuptake Inhibitor Antidepressants

Depression and migraines often go hand in hand, as mood changes are commonly associated with migraine attack, so much so that premonitory depression is sometimes shown to occur before a migraine, ostensibly warning the sufferer of an episode. Id say we deal with mood issues at least 50% of the time in migraine patients, maybe more, mentioned Dr. Charles in the summit interview. Luckily, if doctors find episodic periods of depression in migraine sufferers, they can test whether the mental complications disappear after acutely treating the migraine first.

While SSRI antidepressants, or selective serotonin reuptake inhibitors, have been shown to be effective in the treatment of depression, their role in migraine is a long, rocky road. The current medical hypothesis is that a deficiency of serotonin is somehow involved in migraine; triptans, prescription-strength migraine treatment, activate a set of serotonin receptors in the brain. One would think that SSRIs, which look to increase serotonin, would help migraine, but it is not as simple as high serotonin is good and low serotonin is bad, explained Dr. Charles. These drugs react differently in each patient, and may deliver the opposite effect intended, leading to migraine.

Over The Counter And Abortives

1. Three Over The Counter Products Are Approved

Thats right three. Only three OTC products are currently on my list of migraine medications because they are approved by The USFDA to specifically treat migraines. These are:

  • Excedrin MigraineĀ®
  • Advil MigraineĀ®
  • Motrin Migraine PainĀ®

The ingredients for Excedrin combine: acetaminophen, aspirin and caffeine. It is recommended for reducing migraine pain and the accompanying symptoms.

Both Advil and Motrin contain ibuprofen. They are recommended to treat headaches and the associated pain.

This is what drugs.com says about Motrin Migraine Pain: “This medicine may cause life-threatening heart or circulation problems such as heart attack or stroke, especially if you use it long term.”

Always discuss the side effects with your doctor before you take anything, or the pharmacist. Remember Non-steroidal anti-inflammatory agents or NSAIDs carry risks too, even though you can get them over the counter.

I never found any of these OTC combinations by themselves to help reduce my severe migraine pain. Not even a little bit!

It was not until I combined ibuprofen with the triptan Naramig that I found effective relief from the attacks and symptoms.

Please work with your doctor on finding a combination that works for you.

2. Abortive Medications

Here is the approved A-Z list of migraine medications called Triptans, with my accompanying results.

My research reveals these are all potent serotonin 5HT1 agonists:

  • Almotriptan
  • Frovatriptan

Can I Still Use My Cgrp Mab With The Covid

This hasnt been a reported issue thus far. There is no current evidence for an interaction between the Covid-19 vaccine and CGRP mAbs, the same as any other vaccine. This has also been stated by the American Migraine Foundation. Patients receiving CGRP mAbs were not excluded from the Covid-19 vaccine trials. There is no evidence at this time that these treatments cannot be used along with receiving Covid-19 vaccination, nor do they need to be delayed or timed any differently in relation to receiving Covid-19 vaccination.

 

Most physicians feel that there should theoretically be no interaction or contraindication to receiving either of these treatments in relation to Covid-19 vaccination because they are entirely different proteins with different mechanisms of action. The Covid-19 vaccine stimulates the immune system to form antibodies against the virus, should you encounter it. The CGRP mAbs do not have any significant influence on the immune system .

 

Rarely, the immune system of some patients can form neutralizing antibodies against the CGRP mAbs, and this can weaken the effectiveness of these treatments in their ability to decrease migraine frequency and severity. However, this rarity really has nothing to do with the mechanism and how the Covid-19 vaccine works. So, it is not felt that the Covid-19 vaccine will lessen the effectiveness of these treatments, nor will these treatments lessen the effectiveness of the Covid-19 vaccine.

 

 

FIRST, LETS DECIDE WHERE TO START:

Diagnosis And Patient Assessment

New migraine drugs promise relief  but at a steep price ...

    Migraine has well-established diagnostic criteria  . Good evidence supports the use of the POUND mnemonic for migraine diagnosis  . Assessment aims to confirm diagnostic criteria, evaluate for alternative explanations, identify comorbidities that could complicate management ,  and document the baseline pattern and severity of episodes. A variety of conditions can present as headache, most of which can be identified by the history and physical examination . The only indications for ancillary testing are to identify causes of secondary headaches or comorbid conditions.,  Table 4 lists red flag symptoms that indicate the need for neuroimaging and/or urgent referral.,

    International Headache Society Diagnostic Criteria for Migraine Headache With and Without Aura

    Migraine without aura

    *Recurrent disorder manifesting in headaches with reversible focal neurologic symptoms that usually develop gradually over 5 to 20 minutes before onset of the headache and last for less than 60 minutes. Headache with the features of migraine without aura usually follows the aura symptoms. Less commonly, headache lacks migrainous features or is completely absent .

    Adapted with permission from Gilmore B, Michael M. Treatment of acute migraine headache . Am Fam Physician. 2011;83:272.

    International Headache Society Diagnostic Criteria for Migraine Headache With and Without Aura

    Migraine without aura

    POUND Mnemonic for Diagnosis of Migraine

    Clinical features:

    POUND Mnemonic for Diagnosis of Migraine

    Can Painkillers Like Acetylsalicylic Acid Or Acetaminophen Help

    NSAID painkillers have been shown to effectively relieve migraine pain. The most commonly used painkillers in Germany are acetylsalicylic acid , diclofenac, ibuprofen and acetaminophen . Research has shown that these drugs are effective in treating migraine:

    • Without painkillers, migraine pain disappeared within two hours in about 10 out of 100 people.
    • With painkillers, it disappeared within the same time in about 20 out of 100 people.

    In other words, the pain was gone in an extra 10 out of 100 people two hours after taking the medicine. Another 20 out of 100 people can expect some pain relief. The effectiveness of a drug will depend on things like the severity of the migraine and the dose used.

    Effectiveness of painkillers

    Dose taken for a migraine attackMaximum daily dose for adults
    Acetylsalicylic acid
    4,000 mg

    Migraine Prevention Drugs: Types Benefits And More

    There are many preventive migraine drugs available. Some examples include angiotensin converting enzyme inhibitors, anticonvulsants, beta blockers, and calcium channel blockers.

    Not every medication is right for every person, so individuals should always speak to a doctor to determine which migraine prevention method is best for their needs.

    The following article discusses some medications for migraine prevention, their benefits, and more.

    ACE inhibitors help relax blood vessels and veins. This can help lower blood pressure, which can be helpful in preventing migraines.

    However, these drugs may not be the best choice for preventing migraines.

    According to a 2019 study review, ACE inhibitors can be effective in reducing the number or frequency of headaches in people with migraines. However, due to the limited number of studies and small sample sizes, they may not be a good first choice for migraine prevention.

    However, the review also notes that people with comorbidities like high blood pressure may find it helpful as a first or second line of treatment for migraine prevention.

    Find out more about ACE inhibitors here.

    Doctors usually prescribe anticonvulsants or anti-epileptic drugs to people with epilepsy. Researchers believe these drugs can work by reducing or calming down activity in the brain.

    According to the American Migraine Foundation , doctors often prescribe these drugs to help prevent migraines.

    Learn more about beta blockers here.

    • magnesium
    • Riboflavin
    • Feverfew

    Articles On Migraine & Headache Prevention

    It’s the best situation: Stop a before it starts. To do that, your doctor may consider these types of prescription drugs.

    Beta-blockers. These relax your vessels. Theyre often prescribed to control blood pressure. For migraines, your doctor may suggest , , , , or timolol. Side effects include feeling depressed and having problems during sex.

    Botulinum toxin . A doctor can inject small amounts around your face and scalp every 3 months to keep migraines from happening. This treatment is approved only for people who have headaches at least 15 days a month. The more often you have migraines, the better Botox seems to help.

    Calcium-channel blockers. These include and verapamil . They ease the narrowing of your blood vessels and are also given to treat heart disease. Side effects can include and low blood pressure.

    . Your doctor may prescribe tricyclic antidepressants like or . Some people gain weight and feel very when they take these. TCAs can also cause severe problems if you have heart disease or are . Research suggests that selective serotonin and norepinephrine reuptake inhibitors such as and may also help prevent migraines.

    Creating A Migraine Treatment Plan

    Patients should meet with their health care provider to figure out which treatment options are right for them. An individual treatment plan will primarily depend on the frequency and severity of the patients migraine.

    If youre experiencing more than four migraines a month or if theyre very disabling, you should be on both a preventive and an acute medication for breakthrough attacks, Dr. Michael says. If youre experiencing a migraine once a month or once every few months, then you could consider just an acute medication.

    Dr. Michael says a patients complete medical history will also be taken into consideration. Some migraine medications cant be used when certain medical conditions are present, such as kidney disease and heart disease. In addition, Dr. Michael says patients should tell their doctor about any past allergies theyve had, as well as whether they are pregnant or plan on becoming pregnant.

    After a patient has been on a new treatment plan for at least two months, his or her health care provider can determine whether its working.

    Additional Information On Types Of Migraine Medications

    Warning: Triptans should not be taken with SSRI or SNRI antidepressants, it may lead to a life-threatening condition called serotonin syndrome.

    • Please visit our medication section of each drug within its class for more detailed information.
    • If your prescription medication isnt on this list, remember to look at MedicineNet.com drug information or discuss with your healthcare provider and pharmacist.
    • It is important to discuss all the drugs you take with your doctor and understand their effects, possible side effects and interaction with each other.
    • Never stop taking your medication and never change your dose or frequency without consulting with your doctor.

    Treating Migraine Headaches: Some Drugs Should Rarely Be Used

    Migraine attacks can last for hoursor even days. They can cause intense pain, nausea and vomiting. They can make you sensitive to light or noise and they can affect your life and work.

    To treat migraines, you may be given a prescription for an opioid or a barbiturate called butalbital. These are pain medicines. But you should think twice about using these drugs for migraine. Heres why:

    These drugs can make headaches worse.

    Using too much pain medicine can lead to a condition called medication overuse headache . Two kinds of pain medicine are more likely to cause MOH:

    • Drugs containing opioidssuch as codeine , morphine , Hycodan or oxycodone .
    • Drugs containing butalbital .

    They are not as effective as other migraine drugs.

    There are other drugs that can reduce the number of migraines you have and how severe they arebetter than opioids and butalbital. Even in the emergency roomwhere people with severe migraines often ask for opioidsbetter drugs are available, including triptans.

    They have risks.

    Opioids and butalbital can cause serious withdrawal symptoms if you stop taking them suddenly. People who use high doses for a long time may need to be in the hospital in order to stop using them.

    Opioids, even at low doses, can make you feel sleepy or dizzy. Other side effects include constipation and nausea. Using them for a long time can lower your sex drive and cause depression and sleep problems.

    Which drugs are good for migraines?

    Limit the use of all pain medicines.

    Can The Preventive Cgrp Mabs Be Used With The Cgrp Abortive Gepant Medications

    Can I use Aimovig with Nurtec ODT? Can I use Aimovig with Ubrelvy? Can I use Emgality with Nurtec ODT? Can I use Emgality with Ubrelvy? Can I use Ajovy with Nurtec ODT? Can I use Ajovy with Ubrelvy? Can I use Vyepti with Nurtec ODT? Can I use Vyepti with Ubrelvy? These are very common questions. Unfortunately, there arent many studies so far to clarify this, although Im sure these questions will be studied and clarified in the near future. The gepants and the CGRP mAbs have much different structures, molecule sizes, and metabolism.

     

    So theoretically, it would make sense that using an abortive CGRP medication on top of a CGRP preventive medication would give synergistic benefit. Using a CGRP preventive medication targeting the CGRP protein and a CGRP abortive medication targeting the CGRP receptor seems like a very sensible idea. Similarly, using a CGRP preventive medication targeting the CGRP receptor combined with a CGRP abortive medication also targeting the CGRP receptor would make a lot of sense too. In fact, there are some limited studies which provide evidence that these medications used together do work better and are safe.

     

     

     

    What Are The Side Effects Of Nurtec Odt And Ubrelvy

    Migraine Triggers: A Functional Medicine Approach

    The side effect profile of the gepants is minimal and similar to placebo. The most common side effects of gepants are very low risk of nausea for Nurtec ODT and low risk of nausea and mild sedation with the higher dose of Ubrelvy. Side effects are discussed in more detail .

     

    In addition, there is no interaction with using them and triptans, NSAIDs, or other acute meds in case they happen to be taken close together.

     

    Compared to other abortive medications such as the triptans and NSAIDS, these medications are not associated with medication overuse headache , which is great! They also have no addiction potential.

     

    Compared to the triptans and ergots, these medications are NOT contraindicated in patients with stable cardiovascular or peripheral vascular disease or risk factors because they do not cause vasoconstriction of the arteries, which is a HUGE benefit.

     

    Triptans are also contraindicated in patients with visual snow, persistent migraine aura, and migrainous stroke . However, gepants are felt to be safe for these patients, as well as those with hemiplegic migraine and migraine with brainstem aura . There are many patients who have been stuck without safe options since they have been unable to use standard therapies such as triptans due to other medical problems such as heart disease. So, we finally have a safe alternative for them, which is a highlight of these medications.

     

    Treatment Of Menstrual Migraine

    Abortive therapy for menstrual migraine is the same as for nonmenstrual migraine. Patients with frequent and severe attacks may benefit from short-term, perimenstrual use of preventive agents . Patients with menstrual and nonmenstrual migraine who are receiving continuous preventive therapy and experiencing breakthrough menstrual migraine headaches may benefit from perimenstrual elevation of the dose of the preventive medication.

    Patients who do not respond to standard preventive measures may benefit from hormonal therapy. Perimenstrual estrogen supplementation with estradiol may be beneficial. A study by De Leo et al of oral contraceptive use in women with menstrual migraine without aura found that a regimen of 24 ethinyl estradiol/drospirenone pills and 4 inert pills was more effective than a regimen of 21 active pills and 7 inert pills.

    Complementary And Alternative Treatments

    Interest in the use of complementary and alternative medicine by headache patients is widespread. A 2002 survey showed that more than 85% of headache patients use CAM therapies and 60% felt they provided some relief. Overall, more than 70% of patients who use CAM do not tell their doctors about it.

    Some CAM techniques have good scientific evidence of benefit and have been proven by studies to be effective in preventing migraine. Biofeedback and behavioral therapy should be part of the standard of care for a difficult migraine patient.

    Good studies have demonstrated the effectiveness of the herb butterbur in preventing migraines. A guideline from the American Academy of Neurology and the American Headache Society recommends offering butterbur to patients with migraine to reduce the frequency and severity of migraine attacks . Patients on butterbur require monitoring of liver enzymes.

    The AAN/AHS found moderate evidence of effectiveness for riboflavin , magnesium, and feverfew. A 3-month, randomized, controlled trial of high-dose riboflavin found that riboflavin was superior to placebo in reducing attack frequency and headache days.

    A variety of other CAM techniques are not bolstered by solid scientific data, but they may be perceived to be of benefit to patients. Techniques that some patients use for headache relief include the following:

    • Body work – Eg, chiropractic, massage, and craniosacral therapy )

    • Nutritional/herbal supplements – Eg, vitamins and herbs

    • Biofeedback

    Cgrp Medications Used To Prevent Migraine

    Preventive migraine treatments are used to lessen the frequency and/or severity of migraine attacks. Preventive treatments include a variety of daily pill medications, neuromodulatory devices, herbal and natural supplements and vitamins, yoga and meditation, acupuncture and acupressure. All of the medications used for migraine prevention have always been adopted from other specialties. In other words, these were medicines made for other purposes , but eventually some were also found to be useful for migraine prevention.

     

    There has never been a medicine engineered and created purely and only for migraine prevention. However, that changed in 2018 when the migraine preventive landscape changed abruptly and significantly. The 1st medication class designed purely and only for migraine prevention become available, called the CGRP monoclonal antibodies . There are currently 4 CGRP mAb treatment options. They are Aimovig , Emgality , Ajovy , and Vyepti .

     

    These medications either target the CGRP receptor , or the CGRP protein . The result of blocking the CGRP protein or CGRP receptor prevents the CGRP pathways of pain from turning on, as discussed above and . Clinically, some patients tend to respond better to the CGRP receptor blockade, whereas others tend to do better with binding the CGRP protein itself. There is not really any data on this in terms of who may respond to which type of CGRP mAb target, but Im sure it will be studied further eventually.

     

     

    What Are The Side Effects Of The Cgrp Mabs

    Compared to most other medications used for migraine prevention historically, the side effects of the CGRP mAbs are very low. The most common side effects reported are mild upper respiratory infections and minor injection site reactions. Aimovig has a slightly increased risk of constipation and possible mild increase in high blood pressure for some patients. These have little to no drug interactions and do not affect the liver or kidneys. Data show no immunological , cardiovascular, or neurological safety concerns of significance.

     

    Taking Preventive Migraine Medicines

    It is important to discuss the side effects of each preventive medicine with your doctor when deciding which medicine to take, and for these side effects to be monitored.

    You will often start of a low dose and gradually increase. This can help to minimise side effects.

    It can take six to eight weeks to see any impact from the medication. Ideally, you should take a preventive for three months to assess if it has had an effect on your migraine.

    Drugs and new treatments for migraine are changing all the time. If you are on long term medication you should ensure that your treatment is regularly reviewed by your doctor.

    Triptans And Ergot Alkaloids

    The 2 categories of migraine-specific oral medications are triptans and ergot alkaloids. The specific ergot alkaloids include ergotamine and dihydroergotamine . The specific triptans include the following:

    • Sumatriptan

    • Eletriptan

    • Frovatriptan

    Although the triptans share a common mechanism of action, they differ in the available routes of administration, onset of action, and duration of action. Routes of administration include oral, intranasal, subcutaneous, and intramuscular. Transdermal patches have proved effective for the delivery of sumatriptan, and one such product has received FDA approval. The sumatriptan iontophoretic transdermal system was approved by the FDA in January 2013 for the acute treatment of migraine with or without aura in adults. The single-use patch also treats migraine-related nausea. In phase 3 trials involving 800 patients, the patches safely and effectively relieved migraine pain, migraine-related nausea, sonophobia, and photophobia within 2 hours of activation.

    The FDA approved a low-dose intranasal sumatriptan powder for migraine in January 2016. The product consists of 22 mg of sumatriptan powder and is the first breath-powered intranasal medication delivery system to treat migraines. Approval was based on data from phase 2 and phase 3 trials, reference data on the use of sumatriptan, and safety data from more than 300 patients.

    Treatment For Pregnant And Breastfeeding Women

    In general, migraine treatment with medicines should be limited as much as possible when you’re pregnant or breastfeeding.

    Instead, trying to identify and avoid potential migraine triggers is often recommended.

    If medicine is essential, your GP may prescribe you a low-dose painkiller, such as paracetamol.

    In some cases, anti-inflammatory medicine or triptans may be prescribed.

    Speak to a GP or your midwife before taking medicine when you’re pregnant or breastfeeding.

    Page last reviewed: 10 May 2019 Next review due: 10 May 2022

    Who Is A Good Candidate For The Cgrp

    Migraine Medication

    Headache specialists would say pretty much everybody with migraine. The initial populations that were using them were in headache specialty practices and they were people who had tried multiple other therapies in the past and failed them, either because of lack of efficacy or because of side effects.

    Even in those individuals who had tried three or five or 10 different therapies, there were still positive results with the new CGRP-targeted medications. Headache specialists’ experience validates what has been published in clinical trials, which is that previous treatment failures with other preventive therapies do not predict failure in response to these newer medications. The success rate may actually be higher in those who have failed other treatments in the past.

    Can The Cgrp Mabs Be Used With Botox For Chronic Migraine

    The answer is yes. Insurance companies often present various hurdles to using preferred treatment options . One common issue for patients with chronic migraine who are receiving Botox injections is that most insurance companies will now make the patient choose between Botox or the CGRP mAb. There is of course no good scientific basis for this, other than the company doesnt want to pay for both.

     

    Actually, there is evidence that using Botox with the CGRP mAbs works better together than with either individually. An abstract presented at the American Headache Society Annual Scientific meeting in June 2020 showed that in patients with chronic migraine and a baseline frequency of 25.7 days per month, the frequency dropped to 14.8 days with Botox, and 9.1 days with Botox plus a CGRP mAb.

     

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