A Bright Horizon for Migraine Treatments

Thomas Berk, MD, Clinical Assistant Professor, Department of Neurology, NYU Langone

Thomas Berk, MD

In May, the FDA granted approval of erenumab (Aimovig, Amgen/Novartis) for the treatment of migraine and it was a landmark moment, with erenumab becoming the first approval in a class of calcitonin gene-related peptide (CGRP) inhibitors. With 3 CGRP monoclonal antibodies competing for FDA approval as potential treatment options for migraine, the future looks bright. Hope surrounding additional players in the pipeline like fremanezumab and galcanezumab has significantly increased.

To provide more insight into the therapeutic landscape, Thomas Berk, MD, Clinical Assistant Professor, Department of Neurology, Division of Headache Medicine, NYU Langone, told NeurologyLive that if fremanezumab and galcanezumab are approved, these medications will broaden the class of medications, allowing for better patient access. The current therapeutic landscape, according to Berk, is a very good place to be right now.

NeurologyLive: What is the current therapeutic landscape of migraine?

Thomas Berk, MD: The current therapeutic landscape of migraine I think is evolving and is basically a very, very, very good place to be right now. There’s a very bright future ahead for us. When you talk about the therapeutic landscape for migraine, a lot rests on the shoulders of all of the treatments that we’ve had for decades past, and you can couple that with the latest and the greatest, the newest treatments, the things that are targeted to what we know really provokes migraine, things like CGRP. Other things that are new and coming out, many of them are non-medical treatments, things like the neuromodulators, all these new devices are very well-tolerated, and many times can be very effective in treating a migraine. My take on the therapeutic landscape of migraine is that it’s broad and it’s wide and it’s just getting broader—the horizon is very bright.

Is there an area that has not been met by medication?

TB: Absolutely, there are many patients that even despite all of these great treatments, still are struggling and still are not necessarily improving. There are a lot of patients that have medical contraindications to taking either newer treatments or certainly many of the older drugs. Thinking about older patients or people who have vascular risk factors, taking triptans, you know there’s definitely a great need for better acute medicines for when migraines come. There are new treatments, which are terrific, some of the newer neuromodulators are used acutely in the treatment of migraine but there still is a major need to find effective medication that can help just about everyone, that are both safe and effective.

How do you determine the best treatment for each patient?

TB: The way that I determine it is very much through a conversation that I have with each and every patient. A majority of it is based on what their profile is with regards to their headaches. In other words, somebody who has very severe nausea right away, you know that you can’t give them something by mouth as needed, somebody who’s having very frequent migraines would need a preventive medicine and you know it’s explaining to them, what treatments based on research and based on our own clinical practice would benefit them the best and would be associated with the least amount of side effects.

It’s a conversation that I have with each and every patient, and every patient I have basically gets a different treatment, very few patients get the exact same thing. Even if at some point there are many patients that will take one medicine or another, the way they get the result is very different. It’s always listening to the patients, listening to their concerns, listening to their unique stories and trying to figure out an individualized approach.

If fremanezumab and galcanezumab are approved, what does this mean for the patient population?

TB: I think they’ll help provide access to CGRP antagonists medicines for more patients and I think that’s absolutely essential. You know we’ve had so far just over the past few months only 1 CGRP antagonist, broadening the class of medications I think is a very, very positive thing. More than anything, I think it will allow for better patient access.

Transcript edited for clarity.