Emerging Therapies in Acute Migraine Treatment

In a recent article in Neurology Reviews, several new formulations and delivery systems for acute migraine medications which have been developed and are in clinical trials or awaiting approval were discussed. At the Headache cooperative of New England’s 21^st Annual Headache Symposium Alan Rapoport, MD reviewed several new drug delivery systems as well as emerging therapies and off-label uses for approved medications and devices. For triptans, early administration is key to treating migraine acutely and must be taught to patients. Injection of triptans is the most rapid treatment option, but can result in adverse events. If patients experience nausea or vomiting it is likely due to not absorbing the drug well by mouth, but symptoms may be alleviated by changing to a nasal spray, injection, or other administration route. A novel Dihyrdoergotamine (DHE) delivery system called Levadex was also discussed. This system consists of a breath-actuated inhaler designed to deliver the majority of the drug deep into the lungs while simultaneously minimizing deposition on the mouth and pharynx. This device allows DHE to be used acutely when the patient has already developed central sensitization and allodynia with little risk of nausea and vomiting. Another device called the OptiNose, a bidirectional breath-powered sumatriptan powder delivery system was discussed. This device not only coats the bottom of the nose like nasal sprays did, but coasts the entire nasal cavity bilaterally allowing for better absorption. Another novel device which was discussed was the Zelrix patch which uses low levels of electric current to drive approximately 6 mg of sumatriptan through the skin. This device was called exciting by Rapoport because the adverse events from trials of the patch were limited to localized sensations at the patch site, making Zelrix a good alternative for people having adverse reactions to oral triptans. A new medicine, glial activator AV411, currently in phase II trials has ibudilast as its active ingredient which works by suppressing the production of proinflammatory cytokines, enhancing the production of anti-inflammatory cytokine interleukin-10, and up-regulating the release of neurotrophic factors. The final development which was discussed was COL-144 a 5-HT_1F agonist in IV form that contains lasmiditan and was shown to significantly reduce pain without any significant adverse effects. Rapoport concluded his talk by saying “We’ve got a lot of good medications coming, so we’ve got so much to look forward to,” a sign of hope for many migraine suffers.