Updated December 13, 2023.

When it comes to migraines, there is no one-size-fits-all treatment plan. Severe, one-sided throbbing headache, nausea, vomiting, and sensitivity to light and sound are all hallmarks of migraines. Migraines may be preceded by what is known as aura, which includes visual disturbances and dizziness, symptoms which may be confused with other more serious conditions. Migraine headaches are notoriously resistant to treatment. Their root cause is still unknown but can be associated with heredity, stress, sleeping patterns, lifestyle and dietary habits. Unfortunately, there is no universal cure for migraines. Instead, migraine treatment focuses on alleviating symptoms and preventing future attacks. Treatment options depend on the frequency and severity of symptoms as well as other medical conditions that may be contributing to them. Genetic factors also play a role in which medications will be effective for you. Pharmacogenetic analysis can help find the right mix of drugs to reduce symptoms, alleviate your pain, and potentially prevent the onset of a migraine.

Are migraines caused by other health conditions?

While researchers have not identified a definitive cause for migraines, they have identified associations with other health problems. People who suffer from migraine headaches are over three times more likely to experience additional conditions, including:

• Insomnia
• Depression
• Anxiety
• Gastric ulcer and GI bleeding

People with migraines have more than double the risk of:

• Heart disease, stroke and angina
• Allergies/hay fever
• Epilepsy
• Arthritis

Identification of coexisting medical conditions is critical to accurate diagnosis and treatment selection. Migraine treatment should be multi-dimensional, addressing all conditions holistically to minimize headache occurrences and optimize symptom relief and reduce the frequency of headaches.

What medications are used to treat migraines?

The most commonly prescribed migraine medications are:

• Painkillers (Advil, Celecoxib)
• Triptans (Imitrex, Maxalt)
• Dihydroergotamines (D.H.E. 45, Migranal), Lasmiditan (Reyvow), Ubrogepant (Ubrelvy)
• Blood pressure-lowering medications (beta-blockers)
• Antidepressants
• Anti-seizure drugs
• Anti-nausea drugs

Apart from the drugs above, some new approaches show promising results for migraine sufferers:

1. Botox injections were approved for chronic migraine treatment in 2010. Injections are administered by a doctor every 12 weeks to the head and neck to dull or prevent chronic migraine headaches.
2. Calcitonin gene-related peptide (CGRP) monoclonal antibodies (Aimovig, Ajovy, Emgality, Vyepti) are injectable drugs approved by the Food and Drug Administration to treat migraine. CGRP migraine treatment blocks proteins that may cause inflammation and pain in the nervous system, but its cost is over $530 per monthly injection.
3. Oral Gepants (Ubrelvy, Nurtec ODT) are similar to CGRP migraine treatment, but unlike injectable antibodies, they are taken orally and are metabolized by liver enzymes.

The arrival of Botox and CGRP activators is a relief for those who are susceptible to the side effects of commonly used migraine medication. However, there are a few drawbacks, including the cost, which is very high for someone without insurance that covers them. These branded drugs often need prior authorization from your health benefits plan. The prior authorization process usually requires you first to try (and fail) all other medications that would normally be given for migraines.

Which medications are most effective for migraine treatment?

A recent survey of over 278,000 migraine patients asked to indicate the perceived effectiveness of various treatments. Based on patient feedback, the medications’ effectiveness was ranked compared to ibuprofen.  Triptans, dihydroergotamines and antiemetics worked best for alleviating symptoms. The highest patient-reported effectiveness were eletriptan (Relpax), zolmitriptan (Zomig) and sumatriptan (Zecuity) which are five to six times more likely to block migraine episodes compared to ibuprofen. Opioids, NSAIDs, and combination painkillers containing NSAIDs and caffeine also worked better than ibuprofen. Acetaminophen was less effective than ibuprofen for migraine. Medications’ effectiveness and tolerability are affected by many factors, including your DNA.

What are the side effects of migraine medications?

Side effects are a significant concern when it comes to migraine treatment options. Before starting any medication, it is helpful to understand your risk of potential side effects. Pillcheck pharmacogenetic testing shows how your body metabolizes different medications and highlights those that you are at high risk of adverse effects based on your DNA. Genetic variations in liver enzymes determine how quickly certain drugs are cleared out of your system. Slower than normal clearance significantly increases the risk of side effects.

A pharmacogenetic (PGX) test like Pillcheck, covering the genes responsible for these liver enzymes, can help you tailor your medicine for each health condition according to your DNA. Although not all migraine drugs have PGx guidelines, when you take multiple prescriptions to manage your condition, Pillcheck helps to personalize overall treatment by identifying the medication options that are most suitable for you. The service includes a comprehensive review of your health concerns and medications by an expert pharmacist. The pharmacist can help guide medication selection and dosage to improve treatment efficacy and reduce the chance of adverse side effects, helping you feel better sooner.

Pharmacogenetics for migraine treatment

*No pharmacogenetic guideline established yet. Can be assessed by the pharmacist based on the genetic profile
**Not metabolized by liver enzymes

Other factors affecting migraine medications

Additional factors, including biological sex, hormonal treatments, and stress, can impact the effectiveness of migraine medications. It was noted that males have a lower response to the CGRP-blocking drugs. Additionally, stress and personality disorders are strong predictors of poor response to erenumab, fremanezumab, galcanezumab, and other CGRP inhibitors. Non-responders had a higher rate of anxiety disorders and personality disorders, stressful life events and childhood trauma. Non-responders were five times more likely to have a diagnosis of cluster C personality disorder (anxious and fearful behaviours) and six times more likely to have had stressful life events compared to people who had a good response to these medications.

Summary

• Migraine is a complex, chronic condition with several treatment procedures.
• The efficacy of drugs to treat migraines varies from person to person, depending on their genetic makeup.
• Pharmacogenetic testing can help you know the best possible combination of migraine-related medications with greater efficacy and fewer side-effects.
• Pillcheck pharmacist can review your medications and provide recommendations to your doctor to assure better recovery.

References

1. Buse DC, Reed ML, Fanning KM, et al. Comorbid and co-occurring conditions in migraine and associated risk of increasing headache pain intensity and headache frequency: results of the migraine in America symptoms and treatment (MAST) study. J Headache Pain. 2020;21(23). doi:10.1186/s10194-020-1084-y.
2. The diagnosis and treatment of chronic migraine, Mark W. Weatherall, PMCID: PMC4416971, PMID: 25954496, Therapeutic Advances in Chronic Disease. 2015 May; 6(3): 115–123, doi: 10.1177/2040622315579627
3. https://www.webmd.com/migraines-headaches/default.htm
4. https://www.health.harvard.edu/diseases-and-conditions/are-the-new-migraine-medications-working
5. https://www.medscape.com/viewarticle/psychiatric-disorders-may-reduce-response-cgrps-migraine-2023a1000uq7?ecd=WNL_trdalrt_pos1_ous_231211_etid6144788&uac=188189AX&impID=6144788