March 28, 2023

Dr. Christopher Boes, a neurologist and Division Chair of Neurology Education at Mayo Clinic, discusses new drugs to help prevent migraine headaches. Dr. Boes is also a content editor for the Mayo Clinic Health Letter.

Welcome back to mayo clinic radio i’m dr. tom shives and i’m traci mccray well hopefully traci you’ve never had a migraine headache i think maybe yes recently no i got divorced one thing about it is you are not alone the national headache foundation estimates that nearly 12% of the population have migraine headaches that’s nearly 40 million people and women like

You are about three times more likely to have migraines than are men migraine headaches can cause significant pain for hours even days and they can be so severe that they’re there disabling there’s a long list of drugs that may help to treat a migraine once it occurs or reduce the chances of having one but most of these drugs were designed to treat other problems

Like depression seizures or heart disease with a side benefit sometimes of also helping migraines all that is about to change we’re finally seeing treatments devised specifically to prevent migraines let’s talk with the mayo clinic experts with us today is neurologist and division chair of neurology education at mayo clinic dr. chris bass welcome to the program

Dr. basis nice to meet you thank you nice to meet you too dr. base thanks for being here i would bet that there are a lot of people in this country that are glad to hear that finally there are some drugs that are designed to actually prevent migraine headaches specifically prevent migraine headaches yeah so this is an exciting development there was a preventive

Many many years ago called method surge i’d that was developed based on the pathophysiology of migraine unfortunately it had severe side effects and so it’s no longer available so this development is really nice like you said all the prior preventives they kind of were chosen in this fashion they a patient with migraine and let’s say high blood pressure would be

On a medicine like a beta blocker the patient would report to their doctor you know my blood pressure is better but boy my migraines are better hmm so then the drug company that would make the beta blocker would say well let’s study that and migraine patients who don’t have high blood pressure and they would study them versus like a sugar pill a placebo and if

It showed a response then it would become part of a practice so it’s really an exciting time because i think finally patients have a feeling that we were investigating the underlying pathophysiology or a cause of their migraine and that this treatment is specific you know for their underlying etiology or cause of their migraines what took so long to get here well

It’s interesting this you know this class of drugs was based on research done where they find elevated levels of in the blood of a molecule called calcitonin gene related peptides see grp and that’s been known since the 80s so when i did my headache fellowship i did it in england with one of the folks who first did research on this topic so they knew about this

But it just took a long time first they attacked that molecule with a pill pardon me and they’re still doing that but unfortunately the first round of drugs had liver toxicity as a side effect so you know that didn’t go very far so then what’s happened over time as they try to create medications that basically work against seay grp they found the current class

Which is basically a special antibody they’ve created against either cg rp which is a molecule so it’s kind of like the key or there’s antibodies against the c grp receptor where the molecule works and that’s kind of like the lock so you can have antibodies against either cg rp itself so antibodies against the key or animal one antibody commercially available

Against the lock so these what you’ve figured out is that this cg rp which is did you say as a protein or a peptide yeah and that’s what triggers our migraine it’s interesting you know it’s easy rp is involved in numerous systems and the brain peripheral nervous system heart skin pancreas cut all over the body but what they you know the basic research started off

By saying we’re gonna measure in the blood what happens to see grp when you have a migraine it goes up when the migraine is treated let’s say with a medicine like sumatriptan or imitrex it goes down so then they said well you know maybe we should try to manipulate that system since it’s a marker of the migraine itself so that’s kind of where they decided to try

To find different medicines that would affect that specific mechanism is it cg rp that makes a difference if it’s a migraine or just a regular headache yeah that’s interesting so not necessarily so the cr p is elevated and other kinds of headache like cluster headache it seems to be a marker of to feel pain your try geminal nerve which you know controls sensation

From your face and kind of your forehead needs to be activated in some way so cg rp is released into the blood when that trigeminal nerve is activated so i see lots of patients with cluster headache and migraine it is not a clinically useful test right now but it is when they measure it they find that so yeah it’s a very exciting time so these drugs how many are

Available and are some more effective than others and are they fda approved so it’s interesting so there are 3 fda approved cg rpe monoclonal antibodies now so one of them is against the receptor that one’s called a rhenium ab or a mav egg two of them are against the key or the molecule itself so that’s a fremen azim ab which is a jovi and gal key nezam ab which

Is m gala t so there are three of them commercially available one was approved in may 2000 18 or so and the other was later in september there’s another one that will be coming online i suspect i mean i i don’t work for the fda but it’ll probably be coming out and this year most likely that one’s given intravenously so that will have its own set of problems and the

Other ones given orally the others are given by its shots under the skin injections and they’re either given monthly which is the most common treatment or quarterly so they have a very long they last a long time in your body so that’s one of the benefits as compared to typical preventive medicine so in migraine they’re sort of everybody has to have something to

Take when you get a migraine that’s called acute treatment but you also need a preventive treatment if your headaches are quite frequent let’s say a couple times a week then the preventive you know the benefits are start outweigh the risks so and so it’s really nice you know to take one injection a month versus a pill and some of my preventives you have to take 2-3

Times a day are there any side effects yeah so you know every every every treatment is a little bit of poison in it right so the it’s remarkable though with this class of drugs that they work about as well as the quote/unquote old preventives you know but half of the people have a 50% reduction in how frequent they have migraines but they have pretty markedly fewer

Side-effects and you know some of them like with a rhenium ab some people get a little constipation people can get because these are injections they can get some injection site reactions like in your thigh or your arm or you inject them but you know i sometimes i drug i i sort of evaluated medicine by how many phone calls i get from the patients and i just don’t

Get a lot of phone calls on these medicines then the main phone calls had to do with giving getting it covered by insurance it’s expensive so these are out of pocket about sixty nine hundred dollars a year which you know is a pricey number how can insurance not cover this well life is complicated so most of the insurance companies have sort of fallen into this

Sort of practice where you have to fail a couple of the older oral ones which is not unreasonable since again these new ones work just about as well as they did those are in some cases super cheap propranolol which is an old migrant preventive is very inexpensive so and you know it depends so private payer insurance versus if you’re on medicare medicaid versus if

You’re self paid there are different ways though i will say that i’ve been able to get in all those different sort of situations i’ve been able to get the medication coverage covered by different either safety net programs or programs through the pharmaceutical industry or others oh that that all sounds good so finally some really good news for migraine sufferers

New drugs designed specifically to prevent migraine headaches we’ve been talking with neurologists in the division chair of neurology education at mayo clinic headache expert dr. chris bae’s doctor base thanks so much for being with us thank you

Transcribed from video
New migraine prevention drugs: Mayo Clinic Radio By Mayo Clinic