Migraine Treatment: Current Acute Medications and Their Potential Mechanisms of Action

Abstract

Migraine is a common and disabling primary headache disorder with a significant socioeconomic burden. The management of migraine is multifaceted and is generally dichotomized into acute and preventive strategies, with several treatment modalities. The aims of acute pharmacological treatment are to rapidly restore function with minimal recurrence, with the avoidance of side effects. The choice of pharmacological treatment is individualized, and is based on the consideration of the characteristics of the migraine attack, the patient's concomitant medical problems, and treatment preferences. Notwithstanding, a good understanding of the pharmacodynamic and pharmacokinetic properties of the various drug options is essential to guide therapy. The current approach and concepts relevant to the acute pharmacological treatment of migraine will be explored in this review.

An Evidence-Based Review of Fremanezumab for the Treatment of Migraine

“…Triptans such as sumatriptan are selective 5-hydroxytryptamine (5HT1B/ 1D) receptor agonists that act as potent vasoconstrictors by opposing the vasodilatory effects in cerebral vasculature and inhibiting neurotransmitter release in trigeminal nociceptive neurons [47]. It is important to note that administration of acute therapy before the onset of migraine attacks is more effective than after migraine symptoms emerge [49]. The use of triptans is limited to acute therapy, since the risk of developing medication overuse headache (MOH) correlates with frequency of triptan use [50].…”

Status Migrainosus in Children and Adults

“…The recommendations are as follows: "Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine (Should offer-Level B). 43,44 DHE and triptans should not be administered within 24 hours of each other. Because of lack of evidence demonstrating efficacy and concern about subacute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy (May avoid-Level C)."…”

“…37 Repeated doses of triptans are unlikely to provide added relief nor will they prevent recurrence of attacks. 43,44 DHE and triptans should not be administered within 24 hours of each other. Concomitant administration of triptans and DHE (or ergotamine) within a 24-hour period is contraindicated due to the risk of elevated blood pressure and coronary artery vasoconstriction.…”

Mitochondrial Migraine: Disentangling the angiopathy paradigm in m.3243A>G patients

“…35 Since then various new treatment modalities have become available for which we refer to recent reviews and guidelines. 16,65,75 Based on the disentangling of the angiopathy paradigm, ROS production sites, ROS-redox metabolism, or ROS-induced inflammation pathways might become new targets for innovative classes of drugs to treat mitochondrial migraine in m.3243A>G patients. Such new drugs might either act alone or might be used as adjuvant to current treatment modalities.…”