US Pharm. 2020;45(3):11-12.

A Debilitating Headache

Migraine is a specific type of headache often described as a throbbing pain that can occur on one or both sides of the head and can sometimes be debilitating. Migraine is prevalent, occurring in approximately 28 to 30 million Americans, three-quarters of whom are women. Most people have their first migraine during their teenage years or as young adults, with the highest prevalence occurring between ages 25 and 55 years. Scientists are still unsure of the exact cause of migraine. Researchers are working to understand the role of serotonin levels in the brain, hormones, and heredity in the development of migraine disorder.

Auras May Signal an Attack

Migraine can be mild, moderate, or severely painful and is often debilitating. Migraine is sometimes accompanied by visual changes (aura) just before the pain begins, nausea or vomiting, and sensitivity to bright lights or sounds. Sensations of numbness or tingling may be felt in an arm or leg. Migraine pain can worsen with physical activity, which is why many patients find some relief resting in a dark, quiet room. Untreated, migraines can last from a few hours to several days.

Environmental Migraine Triggers

Certain events or environmental factors trigger migraine. They include certain foods, stress, intense exercise, too much or too little sleep, changes in hormone levels in women, and environmental changes such as glaring light, strong scents, or changes in the weather. When migraine first begins, it is helpful to keep a headache diary: a recording of when, where, and how the migraine started; how long it lasted; what circumstances surrounded the headache; and what medication helped relieve the pain. Often, a pattern of events or environmental factors associated with the headache emerges from this diary, which may help to avoid future episodes.

Prevention Is Paramount

Preventing migraine attacks before they happen and rapidly treating headache pain are the cornerstones of treatment. For those suffering from migraine several times a month, preventive medication can lessen the severity and length of symptoms and cut down on the number of attacks. Several medications, such as antihypertensives, anticonvulsants, and antidepressants, have been shown to reduce the frequency of attacks and their severity. Hormone therapy is often beneficial for women who suffer migraines related to hormone levels.

Calcitonin gene-related peptide antagonists are the newest group of medications approved for the prevention of migraine. This class of drugs will grow over time. Still, the currently available agents include erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality). They are given monthly by injection. Another, more recently approved, medication for preventing migraine is injection of onabotulinumtoxinA (Botox), given approximately every 12 weeks.

Relieving Acute Pain

Acute migraine medication is taken on an as-needed basis as soon as symptoms appear to stop a migraine as quickly as possible. Acute treatment can be used alone for those who have infrequent or mild migraine or in combination with preventative medications. Mild or infrequent migraine can be effectively managed with OTC pain relievers such as acetaminophen or ibuprofen. Overuse of medicines such as aspirin and ibuprofen, however, can lead to ulcers and bleeding in the gastrointestinal tract.

For more severe migraine, prescription medications that treat migraine pain might be warranted. One such medication is triptans (sumatriptan and rizatriptan), which work by blocking pain pathways in the brain.

Two newer agents that have recently been approved for the acute treatment of migraine are lasmiditan (Reyvow) and ubrogepant (Ubrelvy). Lasmiditan can have a sedative effect and cause dizziness, so people taking it are advised not to drive or operate machinery for at least 8 hours. In addition, lasmiditan should not be taken with alcohol or other drugs that depress the central nervous system. Ubrogepant side effects include dry mouth, nausea, and excessive sleepiness, and it should not be taken with potent CYP3A4 inhibitor drugs.

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