Migraine Update 2020

Understanding the role of the pain peptide CGRP has led to advances in treatment of migraine not seen since the triptans (Imitrex and others) were approved in the early 1990’s.

The “gepants” (Ubrelvy and Nuretec, with more to come) and the “ditans” (Reyvow) are starting to replace the triptans as acute treatment, owing to better safety and tolerability. Unlike the triptans, the gepants have no propensity for medication overuse as confirmed by the results of a preventative study with the soon-to-be released atogepant. Soon, patients will decide on their own which medication to use and how often to use it.

Monoclonal antibodies directed against CGRP have revolutionized preventative migraine treatment. They are injected or infused monthly or quarterly, and, like the gepants, have excellent safety and tolerability. They can be effective even in patients who have tried and failed multiple oral preventatives.

Primary headache disorders do not kill but they do cause great suffering and are finally getting some respect.

Adapted from Lancet Neurology January 2021.

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