Check Your Work: Understanding Migraine Therapies
Dive in and learn more about the answers to yesterday’s quiz.
Before you read further, take the quiz: Quiz: Understanding Migraine Therapies.
Each week during Migraine and Headache Awareness Month, Drug Topics will be publishing a weekly quiz focused on a different aspect of migraine and headache management. Our third weekly quiz, published on Thursday, June 27, focused on migraine therapies. Below, we break down the answers.
Question 1
Which class of medication is recommended for a mild to moderate, non-disabling migraine attack?
Answer: Nonsteroidal anti-inflammatory drugs
Although triptan medications are the first treatment typically recommended for those with moderate to severe migraine attacks, nonsteroidal anti-inflammatory drugs (NSAIDs) may be recommended for patients who experience mild, non-disabling migraine, or for patients who are unable to take triptans. In research conducted comparing NSAIDs with triptans, an NSAID medication has performed “at least nearly as well,” according to the American Migraine Foundation, and coadministration of an NSAID and an oral triptan may be more effective for migraine relief than either drug administered alone.1
Question 2
A patient with chronic migraines is considering taking a daily medication to prevent future attacks. Which class of medication is most likely to be recommended?
Answer: Beta-blockers
Beta-blockers are typically used to treat cardiovascular conditions such as tachycardia, hypertension, coronary artery disease, and cardiac arrhythmias. But since the 1970s, this medication class has also been used as a tool for migraine prevention. Common beta-blockers for migraine prevention include atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL), nadolol (Corgard), propranolol (Inderal), and timolol (Blocadren)2; because these medications are established as first-line treatments, patients with migraine may need to try—and fail—a beta-blocker before their insurance will cover a newer class of medication, such as a calcitonin gene-related peptide (CGRP).
Question 3
Which of the following statements about calcitonin gene-related peptides (CGRP) is the most accurate?
Answer: All of the above
CGRPs are involved in multiple body processes, including blood pressure regulation, tissue repair, and wound healing. These peptides also contribute to inflammation: when released in the brain, CGRP impacts the trigeminal nerve, which is responsible for communicating pain and touch and temperature sensitivities; it is also the cause of migraine pain and inflammation. CGRP inhibitors—including small-molecule gepant medications and large-molecule monoclonal antibodies—are considered the biggest breakthrough for migraine treatment and prevention in the last several decades.3
Question 4
A patient with chronic migraine is starting a CGRP monoclonal antibody therapy. Which of the following is not typically a route of administration for these medications?
Answer: Oral tablet
Evidence in supporting the efficacy, tolerability, and safety of CGRP-targeting preventive therapies is significant. Unlike the gepant class of CGRP inhibitors, which includes rimegepant (Nurtec ODT), ubrogepant (Ubrelvy), and atogepant (Qulipta), CGRP monoclonal antibodies including erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti) are large-molecule drugs, requiring administration through subcutaneous or intramuscular injection or intravenous infusion.4
Question 5
Which of the following medications is not typically used as first-line treatment for a migraine attack?
Answer: Opioids
Although opioids may reduce pain associated with episodic migraine, current guidelines recommend triptans and NSAIDs as first-line acute treatments. Evidence supporting the effectiveness—and the harms—of opioids for migraine remain unclear, and both opioids and butalbital-containing medications are associated with a 2-fold higher risk of medication overuse headache compared to simple analgesics and triptans. Opioid use as an acute migraine treatment “has also been identified as a risk factor for disease chronification.”5
READ MORE: Headache and Migraine Resource Center
References
Non-steroidal anti-inflammatory drugs (NSADs) for acute migraine treatment. American Migraine Foundation. November 18, 2021. Accessed June 26, 2024. https://americanmigrainefoundation.org/resource-library/nsaids-migraine/
Llamas C. Beta-blockers: An old-school tool for migraine prevention. Migraine Again. August 25, 2023. Accessed June 26, 2024. https://www.migraineagain.com/beta-blockers-migraine-prevention/
Helmer J. CGRP inhibitors for migraine. WebMD. February 9, 2023. Accessed June 26, 2024. https://www.webmd.com/migraines-headaches/cgrp-inhibitors-for-migraine
Charles AC, Digre KB, Goadsby PJ; the American Headache Society. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update. Headache. 2024;64(4):333-341. doi:10.1111/head.14692
Acute treatments for episodic migraine. AHRQ Pub. No. 21-EHC009. December 2020. Accessed June 26, 2024. https://effectivehealthcare.ahrq.gov/sites/default/files/cer-239-acute-migraine-evidence-summary.pdf
