Migraine prophylaxis: Newer options for migraine management

Newer prophylactics being explored for their potential role in migraine management include monoclonal antibodies, botulinum toxin, nonsteroidal anti-inflammatory drugs (NSAIDs), serotonin antagonists, trigger point therapy, nerve blocks, and others.

Research on the biochemistry of migraines has focused on a protein in the brain, calcitonin gene-related peptide (CGRP). When CGRP is given to people who are susceptible to migraines, an attack is triggered, and CGRP is elevated during an attack in patients with migraines. It has also been shown that blocking this peptide from exerting its effect will prevent migraine.

These findings have led to the development of monoclonal antibodies against CGRP which affect the peptide or block its action.

Currently, three monoclonal antibodies (Erenumab, Galcanezumab, and Fremanezumab) have been approved for use: one binds and inactivates the CGRP molecule and two block its receptor.

Use of any of these antibodies significantly reduces the amount of headache days, the severity, and duration of headache. These agents are generally safe and do not have widespread immune effects.

Onabotulinum toxin type A (otherwise known as Botox) is approved by the FDA for chronic migraine in which there are > 15 days of headache a month. Injections of a small amount of toxin are placed in the frontalis, temporalis, nasalis, and corrugator muscles as well as into the posterior strap muscles. The dose is typically 155 mouse units every 12 weeks.

Potential side effects are facial muscle weakness and asymmetry, generalized weakness, swallowing dysfunction, and local pain.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen and ketoprofen have also been used for prophylaxis. In some headache centers, NSAIDs are used along with riboflavin and magnesium.

Methysergide and methylergometrine are anti-serotonin drugs, or serotonin antagonists, from the ergot family. They cannot be used long term due to the potential development of pulmonary fibrosis.

Although cyproheptadine is an antihistamine, it has actions as a serotonin antagonist. Cyproheptadine is often used in children, but in adults it tends to be too sedating.

When the physical exam indicates a musculoskeletal contribution to the headaches, trigger point injections or dry needling might be considered.

Occipital nerve blocks with steroids and lidocaine, or a longer acting agent, might prove helpful in some cases.

Other treatments have been tried with varying success:

• Acupuncture
• Behavioral training for relaxation
• Biofeedback
• Cervical facet blocks
• Cognitive behavioral therapy (CBT)
• Physical therapy
• Craniosacral manipulation
• Neurostimulation using noninvasive transcranial magnetic stimulation
• Trigeminal nerve stimulation using the CEFALY device (used for both prevention and acute treatment)

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