Lasmiditan

21 October 2024

Oxford Report on the “Best” Medications – Takeaways…

James Discoveries & Stats, Medications, News, Tips 0

Led by researchers at the University of Oxford, and published in the British Medical Journal, a new study compares migraine medications to find out which is “best”.

Well, they would not phrase it that way. Really, they were trying to judge which medications had the best results in good clinical trials. This is important, because information like this can tell doctors which medication they might want to try with “person X”.

But, of course, there is no “person x”. When a specialist recommends a medication, they should be aware of your medical history, symptoms, and even family history. Study co-author Elena Ruiz de la Torre said it well – “Migraine is a very personal disease”. As also quoted at NewScientist, migraine expert Dr. Peter Goadsby adds that these studies “tell you about a population, but they’re very blunt instruments for trying to understand what’s going on at an individual level.”

With that warning in mind, it is still helpful to have these studies, and here’s what they found.

The now “older” migraine medications, the triptans, are still great tools. In fact, in these studies they are beating out the newer CGRP related medications such as lasmiditan, rimegepant, and ubrogepant.

So the report gave great marks especially to eletriptan, and after that rizatriptan, sumatriptan, and zolmitriptan. Interestingly enough, the humble ibuprofen also got high marks in this report.

In other words, these were the medications that had the best evidence for getting rid of pain and having few side effects.

Again, remember that the newer drugs are helping people that did not respond well to the triptans. And there may be medications and treatments that are better for treating certain people with certain symptoms.

The authors summarize their conclusion based on the studies they reviewed:

Results on both benefits and harms should inform shared clinical decision making, considering the preferences of patients, caregivers, and healthcare professionals. Our findings should help inform future guidelines and updates to recommendations to ensure that patients receive optimal care. Overall, the results of our network meta-analysis suggest that the best performing triptans should be considered the treatment of choice for migraine episodes owing to their capacity for inducing rapid and sustained pain freedom, which is of key importance for people with migraine. While the recent introduction of lasmiditan, rimegepant, and ubrogepant has expanded options for the acute treatment of migraine, the high cost of these newer drugs, along with the substantial adverse effects of lasmiditan, suggest their use as third line options, after the less expensive, similarly efficacious, second line options such as ibuprofen, acetylsalicylic acid, diclofenac potassium, almotriptan, and frovatriptan have been considered.
Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis

So the moral of the story? The general guidelines out there don’t seem to be far off, and this is no time to throw out the old just because we have the new. All things equal, if you’re thinking of trying a medication for migraine, talk to your doctor about the triptans. But be sure your doctor knows your situation. You are not “person x”.

Also see: Major study suggests best treatments for migraines

And from earlier this year: “Older” Migraine Meds on Trial: What Works?

And back to ibuprofen – NSAIDs – Which One Should I Take For Headache?

14 July 2023

Migraine when you’re 60+ >> A few important observations

James Discoveries & Stats, Information, Treatments 0

A useful review was published last year in the medical journal Current Pain and Headache Reports, regarding migraine in patients over the age of 60. It was brought to my attention by an article in Everyday Health last month.

It might be useful to get a quick overview of some of the report’s findings.

Many people with migraine are told that their symptoms will likely diminish or go away as they get older. And that is often the case, especially from a strictly statistical standpoint.

But you are not a statistic, you’re an individual. And the fact is that many people continue to have regular attacks into their 80s, or even start having attacks in their older years. The report found that 10% of older adults had migraine, now spread out more evenly between men and women.

If you started having attacks before the age of 18, you’re more likely to continue having attacks in later years.

How is 60+ Migraine different?

Attacks may not be different, but they can change throughout life. For example, many older adults find that:

Their headache pain is now more often two-sided
They may be less sensitive to light and noise
They may experience fewer “cranial autonomic symptoms”, such as congestion or watery eyes during an attack
Sometimes the attacks are less severe
They may experience “stroke-like” symptoms for the first time, including visual aura, trouble speaking, or difficulty with movement

How is 60+ Migraine diagnosis different?

Your headache specialist will want to make sure that you’re not suffering from other problems that become more serious with age. For example, since migraine attacks can mimic stroke, the most urgent thing with any new symptoms is to quickly rule out stroke.

Cardiovascular issues in general are important to check as well.

The report gives some helpful information about the timing of the headache. For example, if you have headaches that get worse at night, brain imaging might help with diagnosis. Headaches worse in the morning may indicate sleep problems, such as obstructive sleep apnoea.

It’s also all the more important for your doctor to know your medical history, and to watch for any current infections or other problems that may be related. It’s also very important that they pay attention to medications and supplements you may be taking, which could affect or even cause headaches.

How is 60+ Migraine treatment different?

Aside from ruling out other conditions, migraine treatment in older adults can be tricky because of concerns about medication interactions, and other contraindications (e.g. medical reasons why a medication may make another condition or risk factor worse).

CGRP related medications, although they don’t have the long-term history of other medications, are looking like a positive treatment for older adults. The study specifically mentioned lasmiditan, ubrogepant, and rimegepant. Candesartan, also used for high blood pressure, may help.

However, many older medications used for migraine may be used. Some, with newer evidence, are not as much of a concern as they used to be. So there are many other options that your doctor may suggest. The report simply gives the good advice that it’s especially helpful if you’re 60+ to start at a low dose and go up gradually. It requires patients, but it’s worth it.

Although the report briefly talks about lifestyle (diet and exercise), it doesn’t spend time talking about many non-drug treatments. These should be discussed with your doctor, but it widens the options significantly with good evidence-based treatments.

If you or someone you love is 60+ with migraine, it’s worth taking a look at this article, and the report – which is more technical, but has a lot of information.

Article: Migraine After 60: What You Need to Know
Report: Episodic Migraine and Older Adults

5 December 2019

New Drug Coming Early 2020: Reyvow

James Medications, News 0

After many years of waiting, a completely new type of migraine drug is projected to hit local pharmacies in the USA in only a few weeks.

Feel like you’ve heard that before? Of course you have. New medications and even new devices have been hitting the market at an unusual rate over the past couple of years. But yes – as the first paragraph stated – this is once again a new class of migraine medication, something that may help some people who haven’t found a good option in the past.

The new type of drug from Eli Lilly and Company is known as a 5-HT1F receptor agonist, and the drugs in this class are referred to as “ditans”. And there is something else that sets this drug apart from the crowd of the recent new drug approvals. It’s an abortive drug – something to be taken when a migraine attack hits. So this is not another preventative, which has been all the rage lately.

Reyvow, or lasmiditan (or LY573144), is a drug we started talking about in 2012, so it’s been quite the wait. Way back then, when there were more concerns about migraine drugs affecting the cardiovascular system, lasmiditan was considered unique because it didn’t seem to carry the same dangers. In fact, people with risk of cardiovascular disease were eventually included in clinical trials.

Clinical trials have shown effectiveness for some patients within 30 minutes, with the common 100mg or 200mg doses. Reyvow seems to alleviate not only pain, but also sensitivity to light and noise, and nausea.

Long term testing over a year also showed that there were no serious side effects (in particular cardiovascular issues). The most common side effect was some dizziness, and rarely some sleepiness. But remember, these are drugs you take when you are already having a migraine attack. And although a minority of patients did experience some dizziness, over the course of the year the side effects seemed to diminish.

However, as with many abortive migraine drugs, it is recommended that patients avoid driving for a few hours after taking Reyvow.

Preventative drugs may be taken at the same time as Reyvow.

The FDA is currently deciding how to classify Reyvow, and their decision is expected in January 2020. After that, Reyvow will be made available in the United States.

As with the other medications we’ve seen hitting the market recently, Reyvow is not a miracle drug. However, every new approach brings with it the potential that the drug will help patients who have never been helped before, patients who have been unable to take other drugs because of side effects or other health concerns, or patients who are simply not satisfied with their current meds.

So yes, the release of Reyvow is big news – and we wait to see how it will help many of our readers.

For more on Reyvow, visit Lilly’s website here.

17 February 2015

Whatever Happened to Lasmiditan?

James Medications, News 0

We last talked about Lasmiditan in 2012, with hopes that it would be on the market by now. But although a lot of money is being invested, and trials are still ongoing, it’s not likely we’ll see Lasmiditan for migraine until 2018 or later.
CoLucid
Lasmiditan is a migraine abortive and a serotonin receptor agonist, like triptans. But unlike triptans, it doesn’t seem to cause vasoconstriction – very important for those at risk of stroke and heart disease.

Lasmiditan is going to undergo phase III trials, further investigating the drugs ability to fight headache, nausea, photophobia and phonophobia. The company, CoLucid Pharmaceuticals, also has permission from the FDA to include some patients who have some cardiovascular risk factors.

Another future trial will be a pediatric study.

Lasmiditan remains a very promising migraine drug, which may be a major alternative to the familiar triptan medications. But we’ll probably be waiting until 2018 before most of us will have a chance to use it.

For more, see Emerging therapeutic options for acute migraine: focus on the potential of lasmiditan

29 September 2012

Vasoconstrictor: Migraine Headaches

James Information, Medications 1

For many years, a vasoconstrictor migraine headaches connection was at the heart of migraine research. But recently we’ve learned a lot more. It’s now much more common knowledge that migraine is much more than migraine headache (and sometimes there’s no headache at all). We’ve also learned that migraine attacks are a web of reactions that do not just involve changes in the blood vessels.

As a matter of fact, we now know that both vasoconstriction and vasodilation may be a part of a migraine attack – or perhaps may not be involved at all.

Vasoconstriction and vasodilation of course refer to blood vessels. They constrict (get smaller) and dilate (get larger) to control blood flow – you can think of them as pipes in your home, but “smart” pipes.

Back in the day we believed that migraine happened when blood vessels dilated – therefore we looked for medications that would constrict them.

Although some of these medications and treatments worked (somewhat), we now believe that many of them work for different reasons. Triptans are a classic example – though they do have a vasoconstriction effect, researchers now believe that this is not why they relieve migraine symptoms.

In fact, today researchers are looking for drugs that are not vasoconstrictors. Why? Because of concerns that constricting the blood vessels will lead to more heart attacks and strokes.

Some heart problems have been reported by people taking drugs such as triptans. On the other hand, some studies have suggested that there’s generally no connection.

Many doctors are reluctant to prescribe triptans or other vasoconstrictors to patients who are at a high risk of heart disease. And there is evidence that migraineurs in general are at a higher risk than the general population.

On of the drugs being researched is Lasmiditan, which is not a triptan but a ditan. Like triptans, it would be taken for a specific migraine attack, but without the potential dangers of vasoconstrictors.

We can hope that more and more treatments will be available that can stop a migraine attack without unnecessary side effects and dangers. Meanwhile, specialists are increasingly cautious about prescribing too many vasoconstrictors for migraine when there are other options.