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Migraine Matters: A totally new approach to preventing and treating migraine PROFESSOR DEBBIE HAY FBPHS Migraine - a prevalent and debilitating neurological disorder Migraine is one of the most prevalent neurological disorders, affecting 10-20% of adults. Classified as a disability, the World Health Organisation cites migraine as a priority for finding more effective treatments. In New Zealand, migraine places a substantial burden on individuals, families and society. Migraine matters. Some patients are able to manage their migraines by avoiding their triggers, using the “triptan” class of medication to blunt their attacks once they have started, or they can use regular pain treatments, such as paracetamol and ibuprofen. Unfortunately, these drugs do not work for all patients and many patients, especially those who suffer from chronic migraine, typified by 15 migraine days per month, have no effective treatment. New hope has come from research into the underlying mechanisms of migraine. Through decades of research we now understand that naturally occurring substances called “neuropeptides” are released from the nerves that control sensation in the face and head, promoting pain transmission. Calcitonin Gene-Related Peptide (CGRP) is a key player in migraine One of these neuropeptides, CGRP, seems to play a particularly important role in migraine. Migraine sufferers have higher amounts of CGRP than others, and if CGRP is given to them via an intravenous infusion, CGRP triggers migraine-like headache but not those who don’t usually suffer from migraine. This suggests that people with migraine are more sensitive to CGRP, although we don’t yet know why this is. Based on this and other research into migraine, the quest to find ways to block CGRP signals in nerves began. New treatments for migraine stop CGRP in its tracks, relieving migraine symptoms Antibodies that “mop-up” CGRP in the blood or prevent it binding to its matched protein target on nerve cells (called CGRP receptors) are currently the subject of much excitement to neurologists and to patients. Four of these drugs have successfully completed global clinical trials and three of them are now available to patients in other countries. They are erenumab (Aimovig®, Amgen/Novartis), galcanezumab (Emgality®, Lily), fremanezumab (Ajovy®, Teva) and eptinezumab (Alder; awaiting decision). These drugs are given by injection monthly or every three months, and they are used to prevent migraine attacks from occurring. Galcanezumab has also recently received approval by the United States Food and Drug Administration for episodic cluster headache, which is a major advance for cluster headache patients. Mysteries remain – how does the future look? The main question is when will these new treatments be available to patients in New Zealand? Keep looking out for them and talk to your neurologist. Also look out for another new class of treatment that is on the horizon that also stops CGRP from working. If given the green light, these will be available as tablets, rather than injections and they will either be available for prevention or as acute treatments. It looks like these might work for people who can’t take or don’t respond well to triptans, which will mean that there are more options for patients. The future is certainly looking much brighter for migraine patients, but we can still do better. When examining the clinical trial data for all the CGRP blocking drugs it is clear that some patients respond much better than others. Why is this? It seems that we don’t have all the answers yet and we will be busy working with others around the world to find those answers. Headlines 7