What’s new for migraine in early 2021?

Although 2020 was overall a difficult year for most of us due to the COVID-19 pandemic, there were actually a number of really important breakthroughs in the migraine world. A whole new class of as-needed medications became available, as well as a safer triptan-like medicine, and new quarterly-dosed IV medication for migraine prevention.  And additional research is bringing even more treatment options around the corner.  Here is a quick summary of what's new:

Gepants 

Arguably the most important change in the migraine world occurred in 2018 when the first CGRP-antibody medications arrived. CGRP, also known as calcitonin gene-related peptide, is an inflammatory neurotransmitter that triggers migraine attacks.  In 2018, three injectable medications became approved for migraine prevention - and their method of action was to block CGRP so migraine would be less likely to happen. Their names are Aimovig, Ajovy and Emgality and all are used to prevent, rather than to treat, migraine attacks.  They are typically injected once monthly, and, on average, decrease migraine days by 4-8 days monthly. 

In 2020, two oral medications became approved to treat migraine attacks acutely.  They also block CGRP, but as small molecules rather than antibodies.  This is relevant, because they only last a few hours, up to a day, rather than the whole month, like the injectables.  Their names are Ubrelvy and Nurtec, and are considered less potent, but more tolerable, than the triptan class of migraine medications.  The main side effects of Ubrelvy and Nurtec are tiredness and dizziness, although those were rare. This class of medications is called the gepant class, because the generic names all end with “-gepant” (ubrogepant, rimegepant).

Two additional medications in the gepant family are current undergoing later stage trials.  The goal of those medications will actually be prevention - they will be daily oral medications to prevent migraines.  Observational studies looking at the use of Ubrelvy and Nurtec have actually found them to be somewhat helpful preventively if used a few times a week.  All of the oral preventive medications we currently have for migraine are really used for other conditions (high blood pressure, depression, epilepsy), these would therefore the only migraine-specific oral preventive medications. 

Reyvow

Triptan medications were first developed in the 1990s, and were the first medications created specifically for migraine.  Triptans are not for everyone though, and they do have a tendency to cause vasoconstriction - spasm of blood vessels throughout the body.  This is particularly troublesome for people who are at increased risk for vascular events like heart attacks, stroke or blood clots, and most physicians will advise these patients not to use triptans. 

Reyvow is a triptan-like medication that is approved for the acute treatment of migraine attacks and can be used safely in this population as well.  It targets a specific serotonin receptor that has no vascular effect, and does not cause vasoconstriction. The main side effects are dizziness and tiredness, which can be pretty significant, and there is a restriction on driving for 8 hours after taking the medication. 

Vyepti

Another CGRP-antibody medication that was recently approved is Vypeti.  This is a quarterly IV infusion similar to injections we mentioned earlier (Aimovig, Ajovy, Emgality).  Insurance authorization may only be available if you’ve previously two or three of the injectable medications.  

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