Looking Forward at Migraine Meds and 'Backwards' at Lumbar Punctures

Interviewer: Bret S. Stetka, MD; Interviewee: Deborah Friedman, MD, FAHS, MPH

Disclosures

June 06, 2018

Editorial Collaboration

Medscape &

Editor’s Note: Since the publication of this article, the FDA has approved erenumab, the first anti-CGRP monoclonal antibody for the treatment of migraine.

Last month in Los Angeles, California, Medscape attended the American Academy of Neurology's 2018 Annual Meeting. While onsite in the exhibit hall, we spoke with neurologist and headache expert Deborah Friedman, MD, FAHS, about exciting migraine advances presented at this year's conference. Dr Friedman is chief of the Division of Headache Medicine and the founding director of UT Southwestern's Headache and Facial Pain Program. She is the past-chair of the headache and facial pain section of the American Academy of Neurology, serves on the board of directors of the American Headache Society, and is a past-president of the North American Neuro-Ophthalmology Society. Dr Friedman also serves on the steering committee for Medscape's Migraine Center of Excellence.

Medscape: What migraine developments presented at this meeting have impressed you most so far?

Friedman: Certainly CGRP [calcitonin gene-related peptide] drugs are the hot topic. This has been a hot topic in the headache world for a few years, but now that the clinical trials have been done, we have results and companies are moving forward with the US Food and Drug Administration (FDA), so it looks like this is going to become a reality within the next year. It really is very exciting, and I think it will be a game changer in headache medicine.

Medscape: This is the first new class in decades, right?

Friedman: Yes, since 25 years ago when sumatriptan came out.

Medscape: Presumably we will see one, maybe two, of these compounds approved this year. How do you see them fitting into migraine treatment sequencing?

Freidman: It's a hard question to answer because a lot of this has to do with what the payers will accept and what limits they'll put forward, and they are already starting to work on that, as you can imagine.

In my own practice, I'm talking to my patients about the monoclonal antibodies, especially people who have had fairly refractory headaches regardless of the frequency of the headaches, because the antibodies were studied from 4 headache days a month through chronic migraine. So I'm actually keeping a list of my patients who have been through a lot of medications but haven't tolerated them. I'm telling them to go look up information on these drugs. I have a lot of patients who I think will be really good candidates for this treatment.

And the good news is that they're incredibly well tolerated. Not only is the effectiveness rate really good, but people seem to tolerate them really well. With many of our oral preventives, we can't really say that.

Medscape: Is there any chance they'd be considered a first-line treatment right off the bat?

Friedman: I doubt that we will be having that luxury, due to costs and coverage restrictions. That would be a shame, but I think that's the way it will work out.

Medscape: Besides the CGRP inhibitors, what else at the meeting has impressed you?

Friedman: Lasmiditan is an investigational acute migraine medication, a 5-HT1F receptor agent that will hopefully be helpful in patients who can't take triptans because of contraindications with coronary artery disease. That should hopefully be surfacing soon on the market.

Also, the CGRP small molecules are quite exciting, and so are the oral medications that are being tested for acute as well as chronic migraine.

There have also been a lot of discussions about devices. There's nothing that I'm aware of that's earth-shattering about them, but the various noninvasive stimulation devices are showing promise. There's the vagus nerve stimulator that was FDA approved for cluster headache as well as migraine. The supraorbital stimulator got approval for acute treatment of migraine. The transcutaneous magnetic stimulator got FDA approval for prevention as well as acute treatment.

Medscape: It seems like these stimulators are being studied in every condition under the sun. Do you feel like they're promising?

Friedman: I do. I really do. Having noninvasive options is very attractive.

Medscape: Shifting gears, what are you presenting at the meeting this week?

Friedman: (Laughs) Where do I start? I did a session with colleagues called "Ask Us Anything About Headache," and there were 250 people there in a very casual environment out in the middle of the hallway. The really fun thing for me is that there is so much interest in headache right now.

I just did a program with Larry Newman [New York University Langone Health] about primary headache disorders, which was also full, so I'm really appreciative of all the interest.

I'm also participating in a challenging-cases session, a course on high and low spinal fluid pressure disorders, and a course about the history of the lumbar puncture. Something new and different!

Medscape: The history of the lumbar puncture sounds really interesting. When did doctors start performing this procedure?

Friedman: They first started doing this in Germany in the late 1800s, and it became a part of clinical practice in the United States in the early 1900s. It really hasn't changed that much since it was originally used. There have been some modifications to the needle, but overall the technique has not changed much. The initial reason people used it was for tubercular meningitis; patients developed hydrocephalus and were in agony because of the pain, so it was being used therapeutically to drain the spinal fluid off and ease the pain.

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