Migraine treatments: latest innovations from Migraine World Summit

Introduction

I recently attended the annual Migraine World Summit 2023. This is an incredible event that brings together the worlds-leading migraine experts, doctors, and specialists. One of the talks I listened to focused on the recent developments in migraine treatments and therapies.

It was the interview of the world-renowned Dr. Stewart Tepper, the Director of Dartmouth Headache Center. He also serves on the executive board of directors for the American Headache Society and published over 460 papers on headache medicine. I thought this talk was amazing and brought cutting-edge innovation to every patient’s awareness. Below is a brief summary of the treatments mentioned in the talk with key points from the presentation.

NOTE: Since some of these treatments are not widely known among migraine patients, I made some sidebars to provide a basic description of what they are and how they work from reputable sources. None of this is healthcare advice or medical direction of any kind.

While not everyone knows about this event, everyone should have access to the latest developments. This post brings the innovation from Migraine World Summit to all of you.

IV CGRP as a migraine prevention treatment

Many key developments happened in the last four years in the field of migraine medicine. One of the new treatments discussed by Dr. Tepper was the intravenous infusion of CGRP monoclonal antibody medicine, called VYEPTI. This is the 1st and only FDA-approved preventive treatment for migraine delivered by intravenous (IV) infusion.

A quick sidebar for those not familiar with CGRP monoclonal antibody medicine group  

What is it? Calcitonin gene-related peptide antibodies (CGRP) and monoclonal antibodies (mAbs) are a new type of treatment for migraine. CGRP mAbs are the first preventive medicines specifically developed for the treatment of migraine.

What drugs are in this group? The first medications in this group that came to market were in subcutaneous injection form that can be self-administered by the patient once a month or so.

There are several medications in the injection group including:

• Aimovig
• Ajovy
• Emgality
• Then Vyepti was launched in the form of IV infusions.

Back to Dr. Tepper talk!

In his talk at Migraine World Summit Dt. Tepper discussed that these under-the-skin injectable monoclonal antibodies have a dramatic positive impact on patients in the reduction of migraine days. However, patients still may have migraines.

He talked about the new IV CGRP migraine treatment as a strategy to get a greater drop in headache days and improvement in quality of life for patients who had only a partial response to the injection of CGRP. He reported moving some of these patients to CGRP IV therapy versus under-the-skin injection.

He reported numerous advantages of IV CGRP therapy:  

• Fastest acting
• Prolonged effect
• Can be used as acute as well as preventative treatment
• Quarterly administration in 30 min or less
• Rare side effects

In studies, patients reported having 8 fewer migraine days per month on average. If you are like me, you are probably wondering how hard or easy it would be to get access to a treatment like this.

There were 3 ways that patients could get access to this migraine treatment:

• The infusion can be done right at the doctor’s office or clinic because some of them have infusion chairs
• You can get the infusion in one of the hospital infusion centers that your doctor has access to.
• Finally, you could get it through a home care option where a nurse can perform the infusion during a home visit.

The 1^st IV is best to be done in the doctor’s clinic so you can be monitored for any allergic reactions and side effects. Most headache clinics have infusion chairs.

To sum it up: CGRP therapies are one of the biggest innovations in the field of migraine treatments and therapies. They are worth discussing with your doctor. 

CGRP receptor antagonists or Gepants (Ubrelvy, Nurtec, Qulipta) as acute and preventative migraine treatments

Another cosmic shift in the migraine treatment landscape happened with the development and introduction of CGRP receptor antagonists, called gepants. In particular, the main events had to do with approval for some of these gepants to be used not only for acute migraine treatment but also for migraine prevention. Another highlight of the talk was a new gepant in a nasal spray form that is fast acting for acute migraine.  

A quick sidebar for those not familiar with CGRP antagonist medicine group

As I wrote in one of my recent posts about migraine medications, gepants are designed to specifically block the CGRP (calcitonin gene-related peptide) protein. This protein is believed to play a significant role in the development of migraine pain and inflammation during a migraine attack.

CGRP levels are higher during the migraine attack. These proteins are bombarding the sensory nerve endings causing migraine symptoms we are all too familiar with! CGRP antagonists block these proteins from attaching to the nerve endings, thus relieving pain, light & sound sensitivity, and nausea.

Which medications fall into this group?

• Ubrelvy (ubrogepant): Approved Dec 23, 2019
• Nurtec ODT (rimegepant sulfate): Approved Feb 27, 2020.
• Qulipta (atogepant):  Approved Sept 28, 2021

Nurtec ODT for episodic migraine prevention

Dr. Tepper talks about a great additional development that happened when FDA approved Nurtec ODT for the prevention of episodic migraine attacks. He discusses how the clinical trials conducted for Nurtec showed that the more the patients took Nurtec ODT the fewer headaches they had. That is how the idea of preventative use was derived. This is the opposite of developing a medication overuse headache.

Blocking the receptor every day or every other day will produce a preventative effect. After the studies for acute migraine treatment with Nurtec ODT were complete, the company performed a series of studies to evaluate Nurtec taken every other day for the prevention of migraine.

The subsequent published study included episodic and chronic patients who took it every other day for prevention. The results were great and the FDA then approved it for episodic migraine prevention. For those who have less than 15 migraines per month. This is truly exciting because this is the only migraine treatment that is FDA-approved for both – acute and preventive therapy of migraine.

Daily Qulipta for migraine prevention

You now have even more options for migraine prevention without worrying about medication overuse headaches. Qulipta (Atogepant) is a daily gepant that is FDA approved for the prevention of episodic migraine, i.e. less than 15 migraine days a month.

In addition to this indication, Dr. Tepper discussed that the doctors hope and anticipate the FDA approval of Qulipta for the prevention of all migraine – chronic, episodic, aura or no aura, with or without medication overuse migraine. Note: since this talk, Qulipta has been approved for the prevention of chronic migraines and migraines of any frequency!

Zavzpret (zavegepant) nasal spray for acute migraine treatment

The same company that makes atogepant, recently (May 2023) received FDA approval for a nasal spray gepant called Zavzpret (zavegepant).

Dr. Tepper discusses how this nasal spray could be particularly helpful for people with migraine who have vomiting and nausea accompanying their attack. I was really energized to hear when Dr. Tepper mentioned the oral tablet form of the same gepants is being studied for chronic prevention, but is not yet FDA-approved.

A new form of nasal DHE, Trudhesa for heard-to-treat migraine  

DHE as a treatment for acute migraines has been around for some time. But it was ridden with issues like cost, and inconsistent drug delivery because the nasal spray was hard to administer. I can attest to it as a patient who experienced the lack of effectiveness of DHE nasal spray.

This talk discusses a new innovation that improves upon previous nasal DHE spray called Migranal. It is called Trudhesa and Dr. Tepper discusses how patient-friendly it is for DHE at home, with high reliability and absorption of the drug. It is now a better option for patients who have hard to treat migraine.

This new spray is using an innovative delivery device called POD (Precision Olfactory Delivery) to deliver the drug to the ideal place in the nose for rapid absorption. Thus, making the delivery of the drug into the nose more reliable and consistent.

Devices as drug-free migraine treatments

Medical devices are showing great promise for people who are looking for a drug-free option. Some specific devices were mentioned for migraine relief such as Cefali, GammaCore, and Relivion. However, Dr. Tepper mentioned that there are still significant barriers to accessing those devices because insurance companies push back on paying for them.

Here are some of the other points he emphasized:

If you do get access to one of these devices, you might find it to be effective if used at the onset of the attack to produce pain relief and less helpful if you are already in pain.

In addition, if you are someone who has had many drugs fail, the devices might help to work on your unique neuro target in the brain. Sometimes it is hard to identify our unique trigger for migraine and a medication that targets that trigger. These non-invasive neuromodulation devices are modulating many targets in the brain and might modulate a target that is particularly problematic for you.

Digital therapeutics for migraine

Smart care solutions that are based on your smartphone are another wave of innovation in the world of migraine treatments. These are drug-free options that can help you develop a more holistic way of dealing with migraine.

One such digital solution recently introduced is called Juva for Migraine. It is a digital app that offers biofeedback. It takes the biofeedback techniques that are usually thought in the clinic environment and makes them available on your smartphone.

If you are in a rural area that usually offers little behavioral management services, it may be an excellent opportunity for you to get access to behavioral therapy for migraine.

While Juva for Migraine is available, other apps are making strides in development. For example, Click Therapeutics service recently received a breakthrough device designation by the FDA. This is the first digital therapeutic for headaches to get such a designation. It is not yet on the market, but I look forward to learning more about it when it becomes available.

Another behavioral health and lifestyle app is in development by the Jefferson Headache Center and is called Ctrl-M Health for Migraine. Lifestyle changes are proven to help migraine. Dr. Tepper discussed how these digital therapeutics help by providing an “ongoing manner of improving lifestyle to reduce severity, duration, and frequency of migraines.”

Digital coaching apps and Telehealth  

Coaching works! I have experienced it firsthand as a patient and as a life coach myself now. Since I started my life coaching journey, I see amazing client transformations that lead to better habits, reduced stress and a much-improved quality of life. So, I was glad to hear digital coaching mentioned in Dr. Tepper’s talk as one of the key innovations in this space.

If you are interested in finding out more, Migraine Buddy app was mentioned among digital coaching apps. I have no first-hand experience with it.

Telehealth is another area of innovation particularly important for migraine patients because it offers something that our taxed healthcare system is not always able to accommodate which is faster time to treatment.

Cove, Neurahealth, and Amazon are just a few services mentioned in this talk that started offering neurology telehealth for anyone who needs access to a specialist.

How do they improve the life of a person with migraine?

Dr. Tepper shared that these services offer headache or neurology specialists. He mentioned many benefits of telemedicine for migraine patients:

1. There is no 4-6 months wait time that is now the norm to get access to any specialist.
2. You can obtain a proper diagnosis which is very important. I wrote a post on the importance of diagnosis here.
3. They can help you figure out the appropriate treatment
4. They don’t do a physical exam, but they can provide online telehealth consultations, prescribe medications, provide supportive supplements, and prescribe non-invasive devices.

The talk emphasized that it is not yet clear which of these apps and services are most effective and further studies are needed for that. But everyone agreed it is such a great step in the right direction of making more migraine treatments available to patients worldwide.

My major AHA moments from the talk and final words:

1. Preventative and acute lines are merging with the invention of CGRP therapies. Now you have access to migraine-specific medications that are safe and effective in treating acutely and preventing. The side effect profile is very promising compared to so many other drug groups that are tough to handle.
2. There are new migraine-specific options for chronic migraine sufferers! There is one gepants already approved for chronic migraine prevention and I will be discussing it with my doctor during the next visit. There is also a plan for Zavzpret to seek FDA approval for the prevention of chronic migraine which is the most debilitating migraine with more than 15 migraine days per month.
3. CGRP does not cause medication overuse headaches like other options such as triptans, DHE, and most OTC meds for migraine.
4. Some of the new digital therapeutics offer free access. Since Dr. Tepper mentioned it in his talk, I researched Juva for Migraine and was pleased to find out that they offer 1-year of access to this app for free. I downloaded it and will be evaluating it myself. More on that in future posts!

In short, some serious cosmic shifts have been happening in the world of migraine treatments including CGRP therapies development and digital therapeutics, giving you a full spectrum of options including behavioral and drug-free therapies. This brings much hope and opportunity to discuss some of these options with our doctors.

At the end of the day, we need to be our own best advocates when it comes to proper diagnosis and treatment pathways! This was such a worthy session and I learned much from it as a patient and as a migraine advocate.