Expert: Everyone Has a Unique Headache

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Providers can consider the patient’s medication history, comorbidities, or migraine type to help choose a first line treatment or refer the patient to specialized care.

Pharmacy Times welcomes Fred Cohen, MD, a headache specialist and assistant professor of medicine and neurology at Mount Sinai in New York, who gives a deep dive into the types of medications that are used to treat migraines and headaches. The specialist discusses what type of patients qualify for what type of medications, highlighting the need for personalization to best treat patients. Cohen— who also discusses his approach to educating primary care providers— ultimately encourages providers and pharmacists to not dismiss patients with migraines because it is not the most life-threatening condition.

PT Staff: So over-the-counter prescriptions are [often] not going to work [for migraines]. What other pharmacologic agents are there and how do you approach figuring out a medication or a treatment that will work for someone?

Fred Cohen, MD: There's a lot of stuff. For some people, acetaminophen-aspirin-caffeine (Excedrin; GlaxoSmithKline) or acetaminophen (Tylenol; Johnson & Johnson) or ibuprofen (Advil; GlaxoSmithKline) works and that's great. I envy those people.

Headache area on brain X-ray | Image credit: Iaremenko - stock.adobe.com

Headache area on brain X-ray | Image credit: Iaremenko - stock.adobe.com

But unfortunately, for a good degree people, that doesn't cut it. So first migraine treatment falls into preventative and abortive therapy, 1 to reduce frequency, 1 to stop when it happens. So the treatments we tend to do the stop when it happens are classes such as what's called triptans; you might have heard of sumatriptans and rizatriptans, or the newer class called gepants; those are ubrogepant (Ubrelvy; AbbVie), rimegepant (Nurtec; Pfizer), and zavegepant (Zavzpret; Pfizer), which I know they’re having commercials for. Those are designed for you to take when the attack comes.

But if you're having a good amount [of migraines], like usually more than 5 to 6 attacks a month or higher, that's when a preventative treatment is given to reduce that frequency because you want to be taking those abortive medications all the time.

So there's a wide class wide classes of treatments to give from anti-seizure drugs like topiramate (Topamax; Janssen Pharmaceuticals), beta blockers like propranolol (Inderal LA; ani Pharmaceuticals, Inc), antidepressants from amitriptyline (Elavil; Zydus) or the last thing is duloxetine (Cymbalta; Eli Lilly and Company) are effective to reduce your headache frequency.

Then you have what came out 5 years ago, similar to drugs like ubrogepant and Rimegepant— they target something called calcitonin gene-related peptide (CGMP). What's that? It's a neurotransmitter we know that is in the whole cycle of migraine. So they make a once-a-month injectable pen, you take once a month for that.

And even believe it or not, botox is actually an effective treatment for those who suffer from chronic migraine, meaning more than 8 or more migraine attacks a month with 7 or more other headache days a month, for those patients it's FDA approved that they get 31 or more injections all over their head and up the shoulders. Botox, it's very effective.

So you can see there's a lot of different options available. And I tell them my patients, “Everyone’s headache is unique.” People come to my office, and they'll say, “Oh, my friend got fremanezumab-vfrm (Ajovy; Teva) or Botox, or atogepant (Qulipta; AbbVie). I want to try that.”

And “Oh, it doesn't work. Why doesn't work?” Everyone's headache is different, but there's a lot of these options. And when patients come to me, what dictates what do I choose is based on what's going on.

For example, let's say you haven't tried anything, and you're having 6 or 8 headache attacks a month and you're also having issues with sleep, I would give amitriptyline (Elavil) which is an antidepressant class because it can also help with sleep. Kill 2 birds [with] 1 stone. Let's say this blood pressure issue; then it might do propranolol. Let's say you're on tons of medications and unfortunately you're sick with other conditions. I might do Botox because that's injected up here [and] I don't have to worry about it interacting with another drug. So there's a lot that goes in hand, involved, with determining what [may work] for you. And again, based on other things going on or the medications you're on, etc... that is what dictates what I try first.

PT Staff: Do you see people who have other comorbidities that tend to have many other medications?

Fred Cohen, MD: It’s again, based on their history is what determines what I prescribe. For instance, if you have asthma, I wouldn't give a beta-blocker. That can make the asthma worse. If you have, or maybe if you're on an antidepressant already (or maybe you have another maybe behavioral or mental condition diagnosed) I won't do an antidepressant. If you're receiving a monoclonal antibody already, which is how those once-a-month injector pens work, maybe I won't do that. If you tell me that you have a sensitive stomach, for instance, atogepant or erenumab (Aimovig; Amgen) are known to cause constipation. We don't want to make that worse.

In the same breath, let's say someone has come to me and they are obese— weight is an issue. Well, topiramate, which is firstline migraine preventative, also has a side effect of weight loss. So all right, we're sort of 2 things there but hold on, what if you have history of kidney stone? Then I won't give topiramate. There's a lot that goes involved and this is why the first visits important, asking these questions on their history, because it goes in hand of what I will give.

PT Staff: I can tell you're so knowledgeable about these medications and what works for what person. With that, a lot of times we hear about that individuality not being recognized. You'll just get 1 of 3 of the most common medications and call it a day…

Fred Cohen, MD: I used to be a primary care doctor and I understand the restraints and burdens placed on the primary care where they must do a lot of little amounts of time. While 70% of migraine management is in the primary care hands, the rest is with a head specialist or in the neurologist and other providers. But there's a lot of restraints and circumstances that are under primary care as well.

What I preach— because I teach primary care doctors and residents here at Mount Sinai about headache medicine— is [for primary care] to start the ball rolling, because you're right; for some patients, those first line treatments might do it.

So I say [to them to] start a treatment and then send them to me because, unfortunately, headache specialists are rare— I have a long waiting list. And trust me, I would love to invent the 25th hour in a day and cloned me but the goal and what I strive to educate and give talks on is for the providers to see the patient [and] get the ball sort of rolling and not just a patient wait.

I have an hour for a new visit [and] that's a lot of time because my specialty allows that; primary care doctors would love to [but] unfortunately, the reality of the healthcare system (and when you when I run for president you guys want to vote for me, because that will be my platform) [rather], the woes of the American healthcare system is that, unfortunately, we're under a lot of time constraints and there's a lot more we want to do. So, because of that a lot of patients feel stigmatized and minimized. And this is why I always say [that] you are your own best advocate. If you're having these headaches, bring it up to your provider. At the very least get referred to a neurologist or a headache specialist.

PT Staff: Any last closing thoughts for what we've talked about today? What would you like pharmacists, patients, or providers to know about headaches migraines?

Fred Cohen, MD: A headache diary is the most important thing when you come to your visit, because then you can recall accurately what's going on. So I always ask that my patients keep a headache diary. If you get a headache, “What's it like? How long? What is the last [medication] that you took, etc…” and then you have an accurate log to bring to your doctor or bring up to your primary care. [That’s] what you start with and maybe it ends with them sending you to someone like me.


For pharmacists or other providers, really just know how much migraines can affect somebody. Don't minimize this [or] shrug it to the side like “Oh, I have to take care of patients who will have heart attacks or whatever.”

This is a very burdening, disabling painful condition that, unfortunately, doesn't get taken as seriously as other ones. So just have that sort of thought. As a last closing thing, for more information I do have a blog and website called headache123.com. I talked about topics from diet to sleep and a bunch of things because there's so many factors that go in headache and migraine, so many. [It can be] endless and everything relates to it.

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