What Pharmacists Need to Know About Migraine

Migraine is a very common neurological disease-as the third most prevalent illness worldwide, it affects 39 million women and children in the US, according to the Migraine Research Foundation. Despite its prevalence, migraine often goes undiagnosed and undertreated.  

Every year in the US, $36 billion is spent on migraine-associated healthcare and lost productivity costs, and 157 million days of work are missed due to migraine. More than 4 million adults suffer from 15 or more migraine days monthly, known as chronic daily migraine. Medication overuse often contributes to chronic migraine. Chronic migraine is also associated with depression, anxiety, and sleep disturbance.

According to The American Headache Society, preventive treatment for migraine is an important part of the treatment plan. Drugs with established efficacy include anti-epileptic drugs (divalproex sodium, topiramate), beta blockers (metoprolol, propranolol), and BOTOX. 

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Drugs categorized as probably effective include the antidepressants venlafaxine and amitriptyline, and beta blockers atenolol or nadolol. Several other drugs are categorized as possibly effective, including carbamazepine, lisinopril, and clonidine, among others.

Currently, four injectable drugs are available for prevention, including BOTOX and monoclonal antibodies. BOTOX (onabotulinumtoxinA) is approved for chronic migraine with a recommended total dose of 155 units.

Another migraine drug, lasmiditan (Reyvow, Eli Lilly), was approved last month. Lasmiditan tablets were approved for acute (active/short-term) treatment of migraine with or without aura in adults. The most common side effects are dizziness, fatigue, paresthesia, and sedation. The drug may cause driving impairment; patients are advised not to drive within eight hours of taking the medication. 

Monoclonal antibodies are approved for episodic and chronic migraine and may be promising in patients who have failed prior preventive treatments; three are currently available with another, eptinezumab, in the pipeline. All three are administered subcutaneously. 

Emgality 

• (galcanezumab-gnlm) 

• 240 mg loading dose, followed by monthly doses of 120 mg.

Aimovig 

• (erenumab-aooe) 

• available in 2 doses (70 mg and 140 mg, either can be used as a starting dose), given once monthly. 

Ajovy 

• (fremanezumab-vfrm)  

• dosed as 225 mg monthly or 675 mg every 3 months.

An acute migraine should be treated immediately. For a mild/moderate attack, NSAIDs, acetaminophen, or combination drugs with caffeine (aspirin/acetaminophen/caffeine) can be used.

For a moderate/severe attack, or if the above treatment does not provide relief, triptans or dihydroergotamine are recommended.

The American Academy of Neurology does not recommend opioids or butalbital in the treatment of migraine, except as a last resort, as routine use of these medications often causes more frequent and severe headaches.

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Patients regularly using medications for acute headache should be evaluated to ensure they are receiving preventive treatment to help avoid development of medication overuse (rebound) headaches.

Patients who prefer nondrug therapies or have failed to respond to or cannot tolerate medications may be candidates for neuromodulation. Neuromodulation, which can be used as an acute or preventive treatment, uses an electric current or magnetic field to stimulate the nervous system. FDA-approved devices include Cefaly, Spring TMS, and gammaCore.

As accessible healthcare professionals, pharmacists can be a valuable resource to patients who suffer from migraine. In addition to counseling patients on medications, pharmacists can help patients with nonpharmacologic advice.