Zainab Alsamarae, Pharm.D.
St Joseph Mercy Hospital
Over 13 percent of Americans suffer from migraines and of these individuals, more than 90 percent miss work during a migraine attack. To date, there are a number of preventative treatment options for patients with migraines. Many preventative treatment options aid to reduce migraine attack frequency, quantity of migraines, or severity of each migraine. In order for patients to meet criteria for prophylactic pharmacotherapy, they must demonstrate at least two migraines a month with effects lasting at least three days or endorse uncommon migraine conditions such as a prolonged aura.1,2
There are several types of migraines including with aura, without aura, without headache, with brainstem aura, hemiplegic, retinal or chronic. The two most common of these are patients who present with or without aura. Those who suffer from migraines with aura experience visual disturbances that preface the headache by an hour. However, aura isn't always associated with a visual disturbance; patients may also experience neurological disturbances such as numbness, tingling in the extremities or confusion. In patients who experience a migraine without aura, symptoms can be variable and may include blurred vision, nausea, mood changes or increased sensitivity to sound or light.2
First-line agents in patients who meet criteria for pharmacologic therapy would receive beta-blockers, anticonvulsants, antidepressants, or NSAIDs. Ideally, patients would initially trial one of these agents for 2-3 months and then the prescriber may adjust the dose until relief is achieved. In patients who do not find the prescribed agent effective, these patients would be prescribed an alternative first-line agent. At this point, if a patient still does not find relief, a combination of two first-line agents may be warranted to be effective. Though many patients are on these agents, there are many adverse drug reactions associated that may be a barrier to adherence.
Aimovig, approved in May 2018 is the only pharmacologic that holds a FDA-labeled indication for the preventative treatment of migraine in adults. Aimovig is a human monoclonal antibody that is a calcitonin gene-related peptide receptor antagonist that has been studied in patients with episodic and chronic migraines. Patients who experience 4-14 migraine days per month have what is known as an episodic migraine. A chronic migraine is seen in patients who experience more than 14 headache days a month with more than seven migraine days per month. The calcitonin gene-related peptide works as a vasodilator which increases during a migraine attack. By blocking the calcitonin gene-related peptide receptor, vasoconstriction occurs to resolve the headache.3
There were three pivotal studies that were published that got aimovig approved. All three studies compared aimovig to placebo and assessed the change from baseline in mean monthly migraine days, a reduction from baseline in mean monthly migraine days, and a change from baseline in monthly acute migraine-specific medication days. Both aimovig 70 mg and 140 mg consistently demonstrated statistically significant results in all measured outcomes among all three studies.4
New guidelines have yet to be published to suggest aimovig's place in therapy among the current approved prophylactic agents. This is a well-tolerated medication that is administered via a subcutaneous injection monthly. Aimovig's desirable differences including the route of delivery and frequency of administration make this agent unique and more favorable in comparison to the current available prophylactic agents.
However, at this time, a head-to-head study of aimovig compared to other agents currently used for prophylaxis is needed to gain a better understanding of aimovig's benefit against current recommended agents for migraine. Overall, this is marketed as a well-tolerated agent that has reports of injection site reactions. At this point, aimovig is a promising agent that offers benefits in reducing monthly migraine days, reduction from baseline in mean monthly migraine days and a change from baseline in monthly acute migraine-specific medication days in patients with episodic and chronic migraines.5
Migraine Research. https://migraine.com/migraine-statistics/. Migraine Research Foundation. 2019.
Modi S. MD, Lowder D. PharmD. Medications for Migraine Prophylaxis. American Family Physician. https://www.aafp.org/afp/2006/0101/p72.html. 2006 Jan 1;73(1):72-78.
Moawad H MD. Therapies for Migraine Prophylaxis. Neurology Times. https://www.neurologytimes.com/headache-and-migraine/therapies-migraine-prophylaxis. 2018.
Aimovig Package Insert. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/761077s000lbl.pdf. 2018.
Silberstein S.D., Holland S, et al. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults. http://n.neurology.org/content/78/17/1337.full. 2012; 78 (17).