Headache Medicine: Navigating the Highs and Lows of 2020

In this video, Neurology Learning Network’s Migraine Section Editor Stephanie Nahas, MD, reviews key developments in the field of headache and migraine this year, including new therapeutics, virtual conferences, and more. A full transcript is provided below.

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Stephanie J. Nahas, MD, MSEd, is an Associate Professor of Neurology, and Director of the Headache Medicine Fellowship Program at Thomas Jefferson University in Philadelphia, Pennsylvania.


Stephanie J. Nahas, MD, MSEd: Hi, I'm Dr Stephanie J. Nahas. I'm an associate professor of neurology and board‑certified neurologist and headache medicine specialist. I work at Thomas Jefferson University, where I direct the Headache Medicine Fellowship Program at the Jefferson Headache Center. We're located in Philadelphia, Pennsylvania, USA. Today, we're going to be reviewing some of the highlights in headache medicine for the year 2020.

I guess it makes sense to start a conversation about 2020 with the pandemic. I know we're all tired of hearing about it, thinking about it, and dealing with it, but we would be remiss if we didn't review at a little bit about how the pandemic has reshaped headache medicine.

First of all, on the clinical side, we've all had to adopt to a more virtual environment for both caring for patients and keeping up with our academic pursuits. Many of us have been doing telemedicine for the first time, getting more comfortable with things like Zoom, Teams, and other virtual platforms for our meetings, and attending meetings virtually to continue to further our knowledge.

On the patient side, there's been a lot of anxiety and fear with what the pandemic may mean for them and their access to health care and moreover, what happens if they catch coronavirus and get COVID‑19? How might that affect their headache disease?

In fact, we've seen many patients who have unfortunately contracted coronavirus, had COVID‑19, and either started with a headache problem anew as a result, or had their headache problem destabilized as a result.

There's still lots to be learned about how we might manage this problem differently from how we ordinarily manage migraine. There's a lot more to come in the scientific realm in that respect. On the other hand, there have been some silver linings, as I touched on in the last series.

Many patients have found it terrific to be able to pursue telehealth and have their visits from the comfort of their own home, and not have to worry so much about making their way to an office for care, where it's distant. They have to deal with parking, tolls, traffic, and everything else that can trigger more headaches. Let's always remember to look on the bright side of things, too.

In addition, this year, on the therapeutics side, we've had a number of new products come to the market for both the acute and preventive treatment of migraine, or as I'm liking to say, for attack therapy and migraine reduction therapy. We're always talking about changing the lexicon and keeping up‑to‑date with our language, right?

First and foremost, we've got the gepants. The first 2 gepant medications have come out for the treatment of migraine attacks. These are ubrogepant and rimegepant.

Many patients have been filling prescriptions for these medications. Like any other drug, it doesn't work for everybody, but I can tell you, for a number of my patients, they've been game‑changers.

What's most exciting about these drugs, besides the fact that we finally have something brand new for the treatment of migraine attacks for the first time in decades, is these medications tend to be safer and better‑tolerated with comparable efficacy options, both FDA‑approved and non‑FDA‑approved.

Furthermore, we are gaining data on gepants, notably rimegepant and atogepant, which is not yet available, for migraine reduction treatment. In other words, migraine prevention. Now, there are no gepants currently approved for this purpose, but the data are accumulating.

In the next couple of years, we'll have that as a treatment option for our patients as well. These, of course, target the calcitonin gene‑related peptide receptor, the CGRP receptor, and antagonize it. This is the system that is the darling target of this current era, this platinum era of headache medicine.

We're familiar with the monoclonal antibodies erenumab, fremanezumab, and galcanezumab, which have been out for a couple of years now, as subcutaneous monoclonal antibody monthly injections, or in one case quarterly, to reduce migraine over time.

This year, in February, we finally had the FDA approval for eptinezumab, the only intravenously administered monoclonal antibody, which targets CGRP, the ligand, like fremanezumab and galcanezumab do.

The difference being that it's intravenously administered, therefore, its bioavailability is nearly instantaneous. The safety, tolerability, and efficacy data for eptinezumab are comparable to the other monoclonal antibodies, which is great news.

In addition, some sophisticated statistical analyses have suggested that the onset of efficacy for this treatment can be as soon as the very first day. Doing a closed‑loop analysis, looking backwards from day 84 all the way back to day 0, there is a consistent difference between the treatment arms and the placebo arms with respect to the probability that a migraine attack would occur that day.

That difference remained significant all the way to the very first day after treatment. The long and short of it is that, if you get eptinezumab vs placebo, you are less likely to have a migraine attack in all of the days following, compared to whether you got placebo.

That's great news for patients who are hoping for fast relief from their migraine reduction therapy or their migraine prevention therapy, because most of the time, we have to wait a while. There's a trial and error process with migraine prevention, and especially with oral medications.

It can weeks, if not months, to see some results. Now, having an intravenous option that targets a brand‑new system—well, it's not really brand new, but a brand‑new target that's specific for migraine pathophysiology.

Also, cluster headache physiology, but we're talking about migraine here. That's what's very, very exciting, to have a clean, precision tool that works quickly, safely, and effectively, for a broad population of patients with both episodic migraine and chronic migraine.

Related to the release of these new products, there's a lot more awareness about migraine disease and headache in general. We have some celebrity spokespeople for the first time. You may have noticed that there are advertisement for both rimegepant and ubrogepant by the companies who make them, and they've been able to engage celebrity spokespeople to help raise awareness.

Serena Williams and Khloe Kardashian have come out as having migraine and letting the world know that this is a common disease, can be very disabling, but it's one that can be managed with the right tools and the proper education.

Besides new and emerging medications, which have been utilized more and more this year, we have an array of devices for headache and migraine treatment. These devices are really nothing brand new. In fact, one of them has been out for several years now, a supraorbital, transcutaneous neurostimulator device that attaches to the forehead.

What's new with that device this year is that you can now get it without a prescription. It is FDA‑cleared for both acute and preventive treatment of migraine—in other words, attack treatment and migraine reduction therapy.

In the end of 2019, another device was cleared by the FDA for the acute treatment of migraine attacks, that is a remote electrical neurostimulator device that attaches to the arm and delivers a subnoxious stimulus—in fact, it's just under the pain threshold—to engage the brain's natural mechanisms for reducing nociception.

That, you do need a prescription for, but its use has been increasing throughout this year. Many patients are finding it tremendously useful, either on its own or to augment the effect of the medication that they're taking to treat their acute attack. We can look forward to more devices coming down the pike, and we'll talk more about that next month.

Related to this pandemic, and all of us having to adapt to more virtual environments, all of our meetings have been converted to virtual, if not canceled. Some of them had to be very restricted with the virtual presence.

For example, the American Academy of Neurology's annual meeting was scheduled to happen right as the pandemic was hitting. It got canceled at the very last moment, but still, online content was made available, and there was lots of valuable information to be disseminated.

The European societies and the American Headache Society also made a rapid turnaround to convert as much of their scientific and educational content as possible to the virtual space. In most cases, this information is still online and available, and was available for free. Registration had zero cost for the first time ever.

In addition, the American Headache Society does have a separate website dedicated to highlights from our 2020 scientific meeting, which occurred in June of this year. I would encourage you to go and check that out to learn and read about the latest findings in epidemiology, pathophysiology, acute, and preventive treatment.

There's a special section on COVID‑19 and how it's affected headache medicine and our understanding of headache. There's aspects of medication overuse headache, cluster headache, post‑traumatic headache, updates in pediatric headache and migraine—a whole array of topics to be had.

The American Headache Society also has an annual meeting in Scottsdale every fall. That's our major educational offering. That, in total, was 100% online. We didn't cut anything out, but we cut everything down.

All of the lectures are in bite‑size chunks, easy to digest, 15 minutes, but every single topic that you expect to see at the American Headache Society's Scottsdale symposium is still covered in our online space. That is still available, and it will be until this spring.

Finally, on this dissemination of education front and virtual learning and virtual spaces, the American Headache Society also has an initiative for primary care education. We've developed virtual grand rounds presentations, as well as an entire educational website, targeted at primary care and first contact providers.

Not just internal medicine and family medicine, but OB/GYN, emergency medicine, pediatrics, school nurses, anybody who might be those first contacts. We're still expanding our reach and expanding our content for our audiences, but I encourage you to check it out at www.americanheadachesociety.org/primarycare.

Thanks again for joining us on the Neurology Learning Network to talk a bit about some of the highlights of 2020—a unique year, to say the least, for all of us. I want you to look forward to what 2021 may bring. Next month, we're going to talk about some of the scientific advancements that we're hoping to see fleshed out further and what else might be coming down the pike for headache therapeutics.

Thanks again for joining us.