Migraine treatments

Mij said:
A new medication, approved by the F.D.A. just over a year earlier, called ubrogepant or Ubrelvy, had been effective for many. The drug blocks a protein that promotes the inflammation in the brain that is thought to initiate the process that produces migraines. When taken at the very start of the symptoms, it can stop the episode in its tracks.
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That's interesting Mij. Lots of us get migraines, has anyone tried this drug?
 
Hutan said:
That's interesting Mij. Lots of us get migraines, has anyone tried this drug?
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Im waiting for this drug to come to the U.K. I’m pretty sure it’s an acute medication that works on anti CGRP pathways?

The good news is that there are already some preventative anti CGRP injection medications available in the U.K in headache clinics. Ajovy, Aimovig etc. They cost around £300 a month privately (which is why I haven’t been able to access them even though they are the meds I need!), but are free in some NHS clinics. Getting access on the NHS also requires jumping through several hoops.

https://www.healthline.com/health/migraine/cgrp-migraine#how-its-taken
 
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Bumping this thread, with two fairly recent papers reporting higher levels of CGRP in people with fibromyalgia, and the treatment inhibiting CGRP receptors. Interesting to read that account of a person whose migraine involved post-exertional symptoms up thread.
 
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If you suffer from migraines, you’ll have no doubt tried everything to try and avoid them.

From countless painkillers, beta-blockers, and trips to the GP, to so-called hacks like the daith piercing, different remedies work for different people.

And now, the NHS is backing a new medication that could help the one in seven Brits – mostly women – that suffer from the debilitating pain.

The drug comes in the form of a medicated wafer, which dissolves under the tongue.

Known as Rimegepant, which is to be taken every other day, it will only be available to adults who have already tried at least three other preventative drugs, and still have migraines on four to 15 days of every month.

It works by stopping a protein that causes severe pain being released around the brain. There are injections that target the same protein, but this is the first oral option.

It’s been backed by the National Institute of Health and Care Excellence (NICE) which makes decisions on which drugs can be offered in England.
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A new NHS backed wafer could help thousands of migraine sufferers (msn.com)
 
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Rimegepant for the treatment of migraine, 2022

Abstract
Migraine is a common form of primary headache, affecting up to 1 in every 6 Americans. The pathophysiology is an intricate interplay of genetic factors and environmental influence and is still being elucidated in ongoing studies. The trigeminovascular system is now known to have a significant role in the initiation of migraines, including the release of pain mediators such as CGRP and substance P. Traditional treatment of migraine is usually divided into acute and preventive treatment. Acute therapy includes non-specific therapy, such as NSAIDs and other analgesics, which may provide relief in mild to moderate migraines. 5-HT1 agonists may provide relief in severe migraine, but are not universally effective and carry a significant side-effect profile with frequent redosing requirement. Prophylactic therapy may reduce the occurrence of acute migraine attacks in selected patients, but does not completely eliminate it.

More recently, CGRP antagonism has been studied and shown to be effective in both abortion and prevention of migraine. Novel medications, targeting CGRP, divide into CGRP antibodies and receptor antagonists (gepants). Rimegepant, a second-generation gepant, has shown efficacy in several clinical trials in treating acute migraine. Ongoing trials are also evaluating its role in migraine prophylaxis, and results are promising. It is also generally safer for use than existing options, does not appear to increase the chance of developing chronic migraines, and carries a very tolerable side effects profile. It is a part of a growing arsenal in migraine treatment, and may present the silver bullet for treatment of this disease.
 
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If you're one of the millions of people suffering with migraine, potential good news is in the pipeline. A new drug, which has been shown to reduce attacks by half, could soon be available.

The pill, which is called Atogepant, appeared to slash the volume of participant's attacks from eight to four a month in study trials.

Now licensed by the Medicines and Health Products Regulatory Agency (MHRA), the Daily Mail reports that experts predict it will soon be available for widespread prescription, pending approval from the National Institute For Health and Care Excellence (NICE).

Atogepant is understood to work by blocking the impact of the calcitonin gene-related peptide, (CGRP) which is the protein that triggers migraine attacks.

Professor Peter Goadsby of Kings’ College Hospital discovered the existence of CGRP in the eighties. He has said that this new drug could be be ‘life-changing’ for migraine sufferers.

‘While the migraines themselves are incredibly painful, the worst part of the condition is the unpredictability. Something as simple as going out for a coffee with friends becomes difficult,’ he said.

Currently, more than 5.6 million people in the UK have episodic migraines. A migraine attack is a recurring, throbbing pain which tends to last from a few hours to days. Other symptoms of a migraine involve nausea, vomiting and light or sound sensitivity.

Fingers crossed that once Atogepant is approved, patients will see an improvement on accessing treatment via the NHS.
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New drug thought to cut migraine attacks by half could be available within months (msn.com)

eta:another article with more info


'Life-changing' tablet that tackles common illness could be available in UK by Christmas (msn.com)
 
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I found this recent paper useful in understanding these recent medicines for migraine:
Calcitonin Gene-Related Peptide Receptor, 2023, Rashid and Manghi
CGRP receptor antagonists and monoclonal antibodies against CGRP and its receptor are medications used in the management and treatment of migraine, which is the sixth-highest cause worldwide of years lost due to disability as per the Global Burden of Disease Study (2013). This activity describes the indications, actions and, contraindications for these drugs as a valuable agent in the prophylaxis and acute management of migraine and cluster headaches. This activity will highlight the mechanism of action, monitoring, adverse events, relevant interactions, and other key elements in the clinical setting as relates to the essential points needed by members of an interprofessional team managing the care of patients with migraines.
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Calcitonin gene-related peptide is a 37-amino acid neuropeptide and a potent vasodilator produced by neurons in both the central and peripheral nervous systems.[1] The receptor for this neuro-peptide is a complex heterodimer containing a class B G-protein coupled receptor called CLR (calcitonin receptor-like receptor).

In the central nervous system, researchers observed that a raised level of blood and salivary levels of CGRP occur in patients with headache disorders such as migraines and cluster headaches and neuralgias such as trigeminal neuralgia, chronic paroxysmal hemicranias, and even rhinosinusitis. Levels are elevated during a migraine attack and between migraine attacks in patients with chronic migraines. Also, CGRP from exogenous infusions was shown to trigger migraine attacks.[2] Later studies showed that CGRP released in the trigeminal neurons was associated with the release of vasoactive neuropeptides and vasodilation of the cerebral vasculature, thus playing a role in the pathogenesis of migraine.
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CGRP was also shown to have cardio-protective action in pathological conditions, as demonstrated in rodent models of different cardiovascular diseases. Studies in humans have also demonstrated that CGRP decreases afterload and increases inotropy, cardioprotective in heart failure. However, there are no drugs developed to date that take advantage of this effect on the cardiovascular system.[4]

Similarly, newer studies find that CGRP is also involved in several other physiological/pathological phenomenon such as peripheral nerve regeneration, Alzheimer's disease, vascular tone of mesenteric arteries, and pregnancy. However, no drugs have been developed which take advantage of these effects of CGRP.
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It's interesting to think how the raised blood CGRP in people prone to migraines might also be related to orthostatic intolerance and PEM. Interesting also that it might be related to peripheral nerve regeneration, and that it can be cardio protective.

I think there could be an interesting study there to track CGRP levels in people with ME/CFS who get migraines. It would be good to know if these medicines for migraine help with ME/CFS symptoms.
 
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I have suffered from migraine for 40 years and severe ME for 30 years. I am eligible for a trial of rimegepant as a prophylactic medicine and wonder if anyone else has tried it.


Also has anyone tried botulinum toxin?
 
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obeat said:
Also has anyone tried botulinum toxin?
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I tried botox by a doctor with a very good track record of success for it and it had zero effect. Apparently it doesn't work for some people the first time and effects only show up on the second set of injections, which should be about three months later, but I wasn't able to get those.

I tried botox for my migraines because it was rated 8/10 in Dr Alexander Mauskop's optimistically titled book, 'The End of Migraines'. :) He was one of the first neurologists to use it for migraines, and thinks it's underutilised. You can read about it on his clinic's website here.

FWIW, he rates rimegepant at 7/10 in his book. The edition I have is dated 2021, so I don't know if there's recent evidence on either of these treatments that would affect his ratings.
 
obeat said:
Also has anyone tried botulinum toxin?
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I have never tried botulinum toxin but I've always thought it sounded terrifying. Would it be used to inject migraine sufferers in the head?

I've only seen it used (on TV) for two different problems - smoothing out wrinkles on the face and how it can cause the face to become expressionless until it wears off, and secondly it is used to inject young children who become phobic about defecating so they hold it in all the time.
 
Arnie Pye said:
I have never tried botulinum toxin but I've always thought it sounded terrifying. Would it be used to inject migraine sufferers in the head?

I've only seen it used (on TV) for two different problems - smoothing out wrinkles on the face and how it can cause the face to become expressionless until it wears off, and secondly it is used to inject young children who become phobic about defecating so they hold it in all the time.
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You might like to read the link to Dr Mauskop's work in my above post and I think it will set your mind at rest! You get injections in the scalp, mainly, loads of them. I barely felt a thing (very fine needle) and it was over very quickly. Because it's not your face getting injected (apart from your forehead a bit, IIRC), you don't end up expressionless.
 
I had my second round of botox for chronic migraine last month (given at 3 month intervals). I had to fail 3x oral preventatives and have >15 migraine days a month to qualify for it on NHS. It's not prescribed for episodic migraine and I'm unsure how effective it would be for that. I suffered with episodic migraine for 30 years before the transformation to chronic, they're related but chronic feels like a different beast to me.

I have seen a sustained reduction in migraine days from roughly 5 days per week before botox down to 2 days per week now. The second dose hasn't appeared to have reduced that frequency further, though I am noticing a further drop in migraine severity and can now fully kick a migraine the same day with triptans.

I get the feeling that the injectable monoclonal antibody anti-CGRP treatments (Erenumab + others) are a more effective preventative than the oral gepants. I will be trialling the mAbs in due course but also plan to try rimegepant for acute as I find triptans pretty unpleasant to take.

Arnie Pye said:
I have never tried botulinum toxin but I've always thought it sounded terrifying. Would it be used to inject migraine sufferers in the head?.
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Yes - most follow the PREEMPT trial and administer ~30 injections across the hairline, brow, above the ears, back of head & shoulders. Quite different to cosmetic use, I find it hard to frown now and perhaps have a few less wrinkles on my forehead but no obvious visual difference.
 
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