Tech & Innovation in Healthcare

Monoclonal antibodies can help prevent future episodes.

Migraine headaches can be debilitating for some patients, even resulting in hospitalization. However, researchers have isolated a neurological protein that can be blocked to reduce the effects of a migraine or help prevent them from occurring.

Learn how you can help ease your patients’ pain with oral and injectable medications.

Get to Know the CGRP Protein

Produced by neurons in the central and peripheral nervous systems, the calcitonin gene-related peptide, or CGRP, is a 37-amino acid neuropeptide that is directly connected to the propagation of migraines and how long the patient suffers from the condition. “The physiology of migraine is very broad and we’re still learning more about it, but we definitely know that CGRP is a key component,” says Nasima Diana Shadbehr, DO, director of the Headache Clinic for Cedars-Sinai in Los Angeles, California.

Researchers think the CGRP protein is implicated in vasodilation (making the blood vessel diameter larger), inflammation, and pain signaling. In studies of the brain during a migraine attack as well as cluster headache attacks, researchers found elevated CGRP levels, which is how they determined the protein was involved with migraine episodes.

Patients experience the pain and inflammation when the CGRP protein attaches to its receptor. This pain and inflammation are what result in a migraine. Luckily, by identifying the CGRP protein and the effects it causes during migraine episodes, researchers have developed several treatment options in the past three years that can provide reliable relief to patients suffering from acute or chronic migraines.

Prevent Migraine Pain by Stopping the CGRP Protein

By isolating one of the causes behind the pain and duration of the condition, scientists have developed medications that block the CGRP protein from binding with its receptor. Acute and long-term therapies allow patients to enjoy fewer days with migraines each month. “There’s been a lot of recent advancements in the last three years pharmaceutically and therapies that have been employed to kind of disrupt this process,” Dr. Shadbehr says.

In 2018, the U.S. Food and Drug Administration (FDA) first approved erenumab for the treatment of migraines after three randomized controlled trials showed an overall 50 percent reduction in the frequency of migraine headaches. After that first treatment approval, the FDA approved six more anti-CGRP treatments between 2018 and 2021.

Currently, providers have several treatment modalities available to prescribe to their patients if the patient is eligible. These treatment modalities include:

• Oral medications
• Injections
• Intravenous (IV) infusions

Stop a Migraine at the Onset of Symptoms

While there is no cure for migraines yet, scientists have developed several CGRP-inhibiting oral medications that patients can take at the first onset of their symptoms.

Medications in the -gepants class feature small molecules that target and block the CGRP receptor to disrupt the protein. Medications in this class include ubrogepant, rimegepant, and atogepant. Ubrogepant is formulated for acute migraine treatment, atogepant is made for migraine prevention, and rimegepant is ideal for both treatment and prevention.

“Rimegepant is unique because it’s the only one that has the FDA label for prevention and it’s dosed as an every-other-day pill or as an acute medication at the onset of a migraine,” Dr. Shadbehr says.

Prevent Migraines From Occurring

Providers can also help reduce the frequency of migraines in their patients with preventative medication. A new class of migraine treatment involves monoclonal antibodies (mAB) that target the CGRP pathway. “With the preventative medications, the hope is that as the medications get into your system, they will decrease the frequency of the attacks, when they do occur, but overall, decrease the number of attacks the patient has to manage,” Dr. Shadbehr says.

Erenumab binds to the CGRP receptor, while galcanezumab and fremanezumab attach to the ligand of the CGRP molecule to prevent the molecule from binding to its receptor. Galcanezumab “also has a dosing regimen that’s approved for episodic cluster headaches,” Dr. Shadbehr says.

Each of these three mAB treatments are available in an injectable form that the patient can administer themselves. The fremanezumab is also available as a quarterly injection, so you can administer a three-month dose to a patient with a single injection.

If your patients don’t like the self-administered injections or they’ve failed the self-administered injection treatment option, you can offer eptinezumab. This medication is a quarterly IV infusion, where the patient receives a three-month dose of the medication during one infusion appointment.

Can Patients Receive Injections and Oral Medications?

CGRP-inhibitor medications have shown to be effective in treating acute migraines and in the prevention of migraines from occurring for chronic sufferers. The medications are an ideal treatment option if the patient qualifies since they have minimal side effects, such as injection site pain, and injection site reactions are rare. Physicians can also administer the medications to patients with a wide range of comorbidities.

Dr. Shadbehr stated that patients who receive the injections or IV infusions can also take the oral medications if they experience an acute migraine episode. That seamless interaction has been a meaningful change in the treatment of migraines.

“The management of migraine has really shifted in the last three years; it’s probably been the single most monumental treatment discovery after Botox for patients who are suffering from migraine, so they’ve been excellent treatment options,” Dr. Shadbehr says.