Ryan Chandanais, MS, CPhT
Ryan Chandanais is currently employed as an Emerging Therapeutics Analyst at a specialty pharmacy. His job is to gather, analyze, and present pipeline intelligence involving specialty drug products. He has additional drug development-related experience at a contract research organization for pre-clinical studies, where he served as a Research Associate and Report Coordinator. He holds a Master of Science in Integrative Pharmacology from Michigan State University and a Bachelor of Science in Education from Central Michigan University. He has acquired certifications as a Pharmacy Technician from the Pharmacy Technician Certification Board and a Laboratory Animal Technologist (LATG) from the American Association for Laboratory Animal Science.
Due to the symptoms, over 90% of migraine sufferers made at least one visit to a doctor’s office or clinic and 50% went to the emergency room for treatment of migraine in the previous year. Additionally, 89% of employed responders to the survey said that their job performance was adversely affected by migraines and more than half missed at least 2 days of work per month.2
The American Academy of Neurology and the American Headache Society has established guidelines for the use of drugs to treat migraines:
Level A: Medications that are established as effective and should be offered for migraine prevention
- Antiepileptic drugs (AEDs): divalproex sodium, sodium valproate, topiramate
- β-blockers: metoprolol, propranol, timolol
- Triptans: frovatriptan (for short term prevention)
- Antidepressants: amitriptyline, venlafaxine
- β-blockers: atenolol, nadolol
- Triptans: naratriptan, zolmitriptan (for short term prevention)
- ACE inhibitor: Lisinopril
- Angiotensin receptor blockers: candesartan
- α-agonists: clonidine, guanfacine
- AEDs: carbamazepine
- β-blockers: nebivolol, pindolol3
Although the summarized guidelines listed previously use the term “effective” to describe certain drugs that can be taken to treat migraines, many patients don’t get adequate relief from these therapies. It’s estimated that less than half of patients taking currently available prophylactic migraine drugs demonstrate a 50% reduction in monthly migraine occurrences. In fact, these drugs were all developed for other diseases besides migraine.4
Calcitonin gene-related peptide (CGRP) blockers have shown promise as a mechanism of action for treating migraines in studies. Evidence has been found that CGRP is released during a migraine attack and it is theorized that it plays a part in causing migraines. CGRP drugs are given prophylactically and administered by subcutaneous or IV injection, depending on the individual product. Although they are not yet FDA approved, CGRP drugs have shown good efficacy in clinical trials and been well tolerated in terms of adverse events.4
Three CGRP agents have filed with the FDA for review with decisions regarding approval expected in 2018. These drugs are erenumab, fremanezumab, and galcanezumab. In late stage clinical trials, each of these products met the endpoint goal of a statistically significant reduction in mean monthly migraine headache days compared to placebo. Additionally, several other migraine headache drugs are in various stages of clinical trials but have not yet filed with the FDA.4,5
Migraine Headache Expected Upcoming FDA Decisions in 2018 4,5
|Drug name||Manufacturer||Route of Administration||Dose Level in Late Stage Trials (mg)||PDUFA Date*|
|Erenumab||Amgen, Novartis||SubQ||70 and 140||5/17/18|
|Fremanezumab||Teva||SubQ||225 and 675||Regulatory action is anticipated by mid-2018.|
|Galcanezumab||Eli Lilly||SubQ||150||10/11/18 (estimated)|
Migraine headache is a painful condition that has a negative impact on a patient’s well-being and can reduce their ability to do their job or participate in other activities. Currently available treatments often do not provide adequate relief. CGRP blockers may reach the U.S. market in 2018, creating welcome new treatment options for the millions of people who suffer from migraine headaches.
Even more resources pertaining to headaches and migraines can be found on Pharmacy Times' new sister site, NeurologyLive.
- Cutrer FM, Bajwa ZH. Pathophysiology, clinical manifestations, and diagnosis of migraine in adults. UpToDate Website. www.uptodate.com/contents/pathophysiology-clinical-manifestations-and-diagnosis-of-migraine-in-adults?source=see_link. Accessed January 22, 2018.
- Osterhaus, JT, Gutterman DL, and Plachetka JR. Healthcare resource and lost labour costs of migraine headache in the US. Pharmacoeconomics (1992) 2: 67.
- Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults. Neurology. 2012 Apr 24; 78(17): 1337–1345.
- Deen M, Correnti E, Kamm K, et al. Blocking CGRP in migraine patients – a review of pros and cons. The Journal of Headache and Pain (2017) 18:96.
- BioPharm Insight. Infinata; www.biopharminsight.com/. Accessed January 2018.