The newer options were designed more specifically around the changes in the brain that lead to migraine.
Research shows that CGRP-targeting therapies, which include both monoclonal antibodies and gepants, are among the most effective preventive options for episodic migraine, and they are generally better tolerated than older drugs like topiramate and propranolol. Frequency determines whether migraine is chronic or episodic. More than 15 headache days per month, with at least eight that include migraine features, for more than three months, is considered chronic. Less frequent, episodic migraine can worsen into chronic migraine.
CGRP Inhibitors (Monoclonal Antibodies) These drugs were developed specifically for migraine prevention. They block the protein CGRP or its receptor, interrupting a pathway strongly linked to migraine attacks. The following are in this class of drugs:
- erenumab-aooe (Aimovig)
- fremanezumab-vfrm (Ajovy)
- galcanezumab-gnlm (Emgality)
- eptinezumab-jjmr (Vyepti)
“CGRP is a substance that is released in large quantities on the surface of the brain at the start of a migraine,” says Tobin. The drugs do not stop CGRP from being released, but they block it from activating the pathway that helps trigger migraine.
Most CGRP Inhibitors are given monthly or every three months by injection or infusion. The most common side effect is a reaction at the injection site, though constipation and fatigue can also occur.
Atogepant (Qulipta) Atogepant is an oral gepant used only for prevention.
“Atogepant attaches to the CGRP receptor, preventing CGRP from activating it,” says Tobin. Data suggests that the drug’s benefit can increase over time.
Potential side effects include nausea, constipation, and fatigue.
Botox Injections of onabotulinumtoxinA (Botox) in the head, neck, and shoulders can lower the frequency and intensity of migraine. Injections last about 12 weeks, which is one drawback: Patients need to see their provider more often than for other medications.
“We definitely feel extraordinarily comfortable with Botox, because it’s been approved by the U.S. Food and Drug Administration [FDA] for migraine for over 15 years,” says Jarrard.
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