Drugs for Migraine Prophylaxis.

Abstract

Frequent or severe migraine attacks are an indication for drug and nondrug prophylaxis. In this narrative review, we summarize the guideline of the International Headache Society concerning the treatment and prophylaxis of migraine with drugs, with additional consideration of meta-analyses on monoclonal antibodies and gepants. In episodic migraine with an average of 8 migraine or headache days/month at baseline, oral prophylactic drugs lowered the number of migraine days per month by 1.27 (beta-blockers), 0.44 (flunarizine), 1.2 (amitriptyline), and 1.4 (topiramate) compared to placebo. Monoclonal antibodies against calcitonin gene-related peptide (CGRP) or the CGRP receptor are effective against both episodic and chronic migraine: Eptinezumab lowered the number of migraine days per month by 0.7-3.2, fremanezumab by 1.3-3.8, galcanezumab by 1.1-3.7, and erenumab by 1.0-2.5. High-level evidence also supports the efficacy of the CGRP receptor antagonist atogepant (0.7-2.4 fewer migraine days per month) in both episodic and chronic migraine. The monoclonal antibodies, atogepant, and onabotulinum toxin A are well-tolerated and have been found effective even in patients for whom previous oral migraine prophylactic drugs were ineffective, as well as in chronic migraine both with and without acute drug overuse. The new prophylactic drugs against migraine are effective, well-tolerated, and especially useful for patients for whom traditional oral migraine prophylactic drugs and onabotulinum toxin A are ineffective, not tolerated, or contraindicated.