Update on Migraine Management

Lisa Larkin, MD, FACP, NCMP, IF


Menopause. 2022;29(5):606-608. 

In This Article

Migraine Prevention

Preventive options should be considered in persons with more than one migraine per week or more than four per month. Preventive therapies reduce the frequency, severity, and duration of migraine attacks; improve the efficacy of acute treatments; and decrease the progression to chronic migraine. All first-line FDA-approved preventive therapies, including beta blockers, antiepileptic medications (divalproex and topiramate), tricyclics, selective serotonin reup-take inhibitors/serotonin-norepinephrine reuptake inhibitors, angiotensin-converting enzyme inhibitors, and botulinum toxin were originally approved for other indications. These options are not migraine-specific, lack efficacy, and are associated with poor adherence because of adverse events (AEs).

Four injectable CGRP monoclonal antibodies (mAbs) have been approved for migraine prevention. Eptinezumab, fremanezumab, and galcanezumab bind the CGRP ligand, and erenumab binds the CGRP receptor.[7] All have been shown to be effective for migraine prevention, although there are no direct comparison data. The current American Headache Society guidelines recommend anti-CGRP mAbs to be used as third-line agents for prevention of migraine, after inadequate response or AEs with two other standard migraine-prevention treatments.

Recently, two small-molecule oral gepants (rimegepant and atogenpant) have been approved for migraine prevention. The efficacy and safety of these agents compared with the CGRP mAbs have not been studied.[8]