Cheap Migraine Drugs More Effective Than New Expensive Ones

By Pat Anson

Migraine treatment drugs known as triptans are more effective in relieving acute migraine pain than new expensive medications and should be used more widely, according to new study published in The BMJ.

A team of researchers at Oxford University analyzed the results from 137 clinical studies to see which migraine drugs were more effective in helping patients become pain-free after two hours and whether that relief was sustained 24 hours later. Nearly 90,000 people participated in the studies, over 85% of them women.

Four triptans - eletriptan, rizatriptan, sumatriptan, and zolmitriptan – were rated the best overall, ahead of rimegepant (Nurtec), ubrogepant (Ubrelvy) and lasmiditan (Reyvow) in efficacy and tolerability.

“Overall, the results of our network meta-analysis suggest that the best performing triptans should be considered the treatment of choice for migraine episodes owing to their capacity for inducing rapid and sustained pain freedom, which is of key importance for people with migraine,” wrote lead author Andrea Cipriani, MD, a professor of psychiatry and director of the Precision Psychiatry Lab at Oxford.

Triptans work by narrowing blood vessels in the brain and preventing the release of chemicals that cause migraine pain; while rimegepant and ubrogepant inhibit calcitonin gene-related peptides (CGRPs), a protein that triggers pain. Lasmiditan reduces pain by binding to serotonin receptors in the brain.

The drugs’ mechanisms of action are different and so is their cost. A packet of 6 tablets of eletriptan costs about $106, while a similar-sized packet of rimegepant (Nurtec) costs $1,061; ubrogepant (Ubrelvy) costs $1,097; and lasmiditan (Reyvow) is priced at $790. The cost of those three drugs is much higher because they are only available as brand name medications, while triptans are widely available in cheaper generic formulations.

Despite their cost and extensive marketing promoting their use, lasmiditan, rimegepant, and ubrogepant were rated no more effective in treating migraine pain than over-the-counter drugs such as acetaminophen (paracetamol) and non-steroidal anti-inflammatory drugs (NSAIDs). Researchers say those OTC pain relievers should be considered second line options, if triptans are ineffective.  

“While the recent introduction of lasmiditan, rimegepant, and ubrogepant has expanded options for the acute treatment of migraine, the high cost of these newer drugs, along with the substantial adverse effects of lasmiditan (dizziness), suggest their use as third line options, after the less expensive, similarly efficacious, second line options,” researchers said.

“Limited access to triptans and their substantial under-utilization represents missed opportunities to offer more effective treatments and deliver better quality of care to people who experience migraine.”

Some people can’t take triptans due to cardiovascular problems or unwanted side effects, but researchers say the best performing triptans should be included in the World Health Organization’s List of Essential Medicines to help expand their use.

Another recent study also rated triptans as superior to other migraine medications, although that research didn’t include the newer CGRP inhibitors.

Migraine affects about 39 million people in the United States and 1.1 billion worldwide. In addition to headache pain, migraine can cause nausea, blurriness, and sensitivity to light or sound. Women are three times more likely to suffer from migraines than men.  

Survey Finds Patients Wary of Trying CGRP Migraine Drugs

By Pat Anson, PNN Editor

Khloe Kardashian and Serena Williams have their work cut out for them. Despite their endorsement of a new type of migraine medication, many patients remain wary of the drugs and few have tried them, according to a large new survey.

The annual survey of nearly 4,700 migraine patients by Health Union found that about one in four (26%) are currently using a preventive CGRP medication, down from 29% in last year’s survey. And only 11 percent of patients said they were using a CGRP to treat migraine pain.

CGRP stands for calcitonin gene-related peptides, a protein that binds to nerve receptors in the brain and triggers migraine pain. Since 2018, the FDA has approved four injectable CGRP inhibitors (Aimovig, Ajovy, Emgality, Vyepti) to prevent migraine and two CGRP tablets for acute migraine (Ubrelvy, Nurtec). The latter two were recently endorsed by reality star Kardashian and tennis star Williams.   

Although Eli Lilly, Teva, Amgen, and other drug companies have aggressively marketed CGRP medications and even given the drugs away for free to get people to try them, sales growth has been slow. Only Aimovig and Emgality are used by at least 10 percent of migraine patients.

PERCENTAGE OF PATIENTS CURRENTLY USING CGRP INHIBITORS

SOURCE: HEALTH UNION 'MIGRAINE IN AMERICA 2020'

Most migraine patients continue to rely on older and cheaper medications such as triptans, anti-depressants, anti-convulsants, over-the-counter drugs, and Botox injections.

The Health Union survey helps explain why. While most patients are aware of CGRP inhibitors and nearly half (43%) had tried a preventive CGRP, most stopped taking them after trying just one brand. That’s not uncommon for migraine sufferers, who often have try multiple treatments before finding one that works.   

“Everybody’s experience with treatment is different. And the fact that there are multiple brands available is actually a really good thing. Because some of them just happen to work better for some people than others,” says Brian Green, Health Union’s vice-president of community business solutions.

CGRP’s do work for some patients. The Health Union survey found that 58% of patients currently using a preventive CGRP reported having less head pain. And nearly half said they didn’t react as strongly to migraine triggers such as loud noises and bright light.  

Those who had heard of preventive CGRP medications but had not tried them cited a number of reasons:

• 44% Doctor has not recommended it

• 27% Concerned about side effects

• 21% Concerned about long-term safety

• 19% Can’t afford them

• 14% Insurance won’t cover

CGRP medications are not cheap. Eight doses of Nurtec, the acute CGRP endorsed by Kardashian, can cost over $1,000 without insurance.

Nearly half the patients surveyed said they were still using triptans or over-the-counter pain medication for migraine relief. Antidepressants and Topamax were the most commonly used medications for migraine prevention. 

Migraine affects more than 37 million people in the United States, according to the American Migraine Foundation. In addition to headache pain, migraine can cause nausea, blurriness or visual disturbances, and sensitivity to light and sound. Women are three times more likely to suffer from migraines than men.

New Migraine Prevention Drugs Making Inroads

By Pat Anson, PNN Editor

Over half the patients taking a new class of medication designed to prevent migraines say the benefits of treatment outweigh the drugs’ side effects, according to a new survey.

The drugs prevent migraines by blocking a protein — calcitonin gene-related peptides (CGRP) -- from binding to nerve receptors in the brain. Since 2018, the FDA has approved three injectable CGRP inhibitors for migraine prevention and recently approved the first oral tablet for migraine treatment.

Although the drugs are still relatively new, a recent survey of over 4,700 migraine patients by Health Union found that about a third (29%) are currently using a CGRP medication, while 12% had used one in the past.

Most said the drugs were effective at migraine prevention and worth the side effects, which include constipation, fatigue and weight gain. Only 9 percent said the drugs were not worth the side effects.

“CGRPs are in many ways a treatment revolution,” says Brian Green, vice-president of community development for Health Union. “There has not been a new class of medication specifically designed for treatment of migraine for decades. So this really is groundbreaking.” 

Green said patients with chronic severe migraine are more likely to be early adopters of CGRP therapy, as opposed to people who have episodic migraines and fewer attacks.   

Patients on CGRP therapy were more likely to say their migraine attacks increased over time and that they experience a wide array of symptoms, including head pain, brain fog, difficulty concentrating, fatigue, loss of words, memory loss and sensitivity to touch. 

“Their symptoms are so severe they want the first available new treatment,” Green told PNN. 

But the early adopters were also more impatient. Health Union’s survey found that patients who were not satisfied with a CGRP inhibitor wasted little time switching to a new brand. About 40% waited less than a month and 43% waited up to 3 months. Most of those who switched said the drugs did not work or stopped working after an initial period of efficacy. 

The three CGRP inhibitors currently on the market are Aimovig, Ajovy, and Emgality, which are taken by injection about once a month. The first oral CGRP for migraine treatment, Ubrelvy, was approved by the FDA last month and is expected to be available in the next few weeks.  

Most patients surveyed by Health Union said they would prefer taking a daily CGRP pill as opposed to a monthly injection.  

Constipation was the leading side effect reported by patients getting CGRP injections. Nearly a third said the drugs made them constipated, while others complained of reaction at the injection site (16%), fatigue (15%), weight gain (12%) and dry mouth (11%). 

About half the patients surveyed said they were still using a triptan or over-the-counter pain medication for migraine relief. Antidepressants and Topamax were the most commonly used medications for migraine prevention. 

Regardless of the drugs used, only 12% of patients said their migraines were well controlled under their current treatment plan.  

New Drug Eliminates Migraine Pain in Some Patients

By Pat Anson, PNN Editor

The U.S. Food and Drug Administration has approved Ubrelvy (ubrogepant) tablets for the immediate treatment of migraine with or without aura. In clinical trials, the drug eliminated migraine pain in about one of every five patients.

Ubrelvy is the first oral medication that blocks a protein released during migraine attacks — calcitonin gene-related peptide (CGRP) — from binding to receptors in the brain. The FDA has previously approved injectable CGRP inhibitors for migraine prevention.

“Ubrelvy represents an important new option for the acute treatment of migraine in adults, as it is the first drug in its class approved for this indication. The FDA is pleased to approve a novel treatment for patients suffering from migraine and will continue to work with stakeholders to promote the development of new safe and effective migraine therapies,” said Billy Dunn, MD, acting director of the Office of Neuroscience in the FDA’s Center for Drug Evaluation and Research.

Migraine affects about a billion people worldwide and 36 million adults in the United States, according to the American Migraine Foundation. It affects three times as many women as men. In addition to headache pain, migraine can also cause nausea, vomiting, blurriness or visual disturbances, and sensitivity to light and sound.

The effectiveness of Ubrelvy was demonstrated in two Phase 3 placebo-controlled trials involving 1,439 adult patients with a history of migraine with or without aura.

In one study, over 19% of patients said they were pain-free within two hours of taking Ubrelvy and nearly 39% were relieved of nausea and hypersensitivity to light and sound. That compares to 12% and 28% of patients, respectively, who were relieved of symptoms while taking a placebo.

Ubrelvy was effective for up to 24 hours. It is not approved as a preventive treatment of migraine.

"As someone living with migraine for 14 years, my life seems to be on pause when I experience a migraine attack," Kristin Molacek, a clinical trial patient, said in a press release from Allergan, which developed Ubrelvy.

"During the clinical trial, my experience with Ubrelvy was positive. It relieved the migraine symptoms that bothered me the most without serious side effects. We have needed this type of on-demand oral relief for a very long time, and I look forward to having the ability to better manage my migraine attacks."

Allergan said Ubrelvy will be available in the first quarter of 2020. Ubrelvy is non-narcotic and does not have addiction potential. It has been approved with two dose strengths, 50 mg and 100 mg. Allergan did not say how much the medication will cost.