Pharmacological strategies to treat attacks of episodic migraine in adults

ABSTRACT

Introduction

Migraine patients prioritize early complete relief of headache and associated symptoms, sustained freedom of pain, and good tolerability. One major obstacle for the successful use of drug treatment of migraine attack is that the speed of action of triptans, 5-HT_1B/1D receptor agonists, is delayed.

Areas covered

In this review, the author discusses the following features of acute migraine drugs: pharmacology; pharmacokinetics, and absorption of drugs during migraine attacks. Next, dose–response curves for effect; and the delayed onset of action is reviewed. In the more clinical part of the review, the following items are discussed: overall clinical judgments; comparison of triptans; comparison of triptans with NSAIDs; early intervention with triptans; medication-overuse headache; comments on the effect of gepants; and the general principle of acute migraine therapy.

Expert opinion

The delay in the onset of effect of acute migraine drugs is likely due to a complex antimigraine system involving more than one site of action. Investigations into the mechanisms of the delay should have a high priority, both in studies with animals, migraine models, and in migraine patients during attacks. Non-oral administration of antimigraine drugs resulting in early absorption of drugs should be developed as they possibly also can increase E_max.

KEYWORDS:

• Acute migraine therapy
• delayed onset
• tolerability
• triptans
• NSAIDs
• lasmiditan
• gepants

Article highlights

• The NSAIDs are the most frequently used drugs for migraine attacks, and triptans are used by a minority of migraine patients (18% in the US).

• The therapeutic gain (TG) for 2 h pain freedom varies among oral triptans from 13% to 32%.

• The TGs for pain freedom for the gepants, rimegepant and ubrogepant, are considerably lower: 6-11%.

• Migraine patients want a quick resolution of symptoms, but the onset of action of all anti-migraine drugs is delayed considerably.

• Possible mechanisms for this delay should be investigated in animal models and in spontaneous and/or provoked migraine attacks.

This box summarizes the key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript is not funded.