CGRP is a neurotransmitter, elevated during attacks of migraine. Injecting CGRP in a migraine patient between attacks reliably triggers an attack. Several monoclonal antibodies targeting CGRP itself or its receptor are in clinical trials. They are given either by subcutaneous injection or intravenous infusion. Results of the trials have been promising. A medication may be available within the next year or two.
DHE has been used for many years as an acute treatment. It is available by injection or with a nasal spray, but these delivery routes have issues and are infrequently used. A new device uses an oral inhaler. Phase III trials are completed. Approval by the FDA is on hold because of problems with the delivery device.
Ketorolac (Toradol) is an NSAID that is often given by injection in urgent care for a prolonged migraine. It is available in a nasal spray to treat pain short-term, and clinical trials for acute treatment of migraine are ongoing.
Rizatriptan (Maxalt) utilizing a thin film strip that dissolves rapidly in the mouth, is being tested. The drug is not absorbed in the mouth but rather through the GI tract.
Botox is approved by the FDA for use in adults but not in adolescents. Our center is a site in a phase III trial testing this medication in adolescents.
Sumatriptan and zolmitriptan are available as nasal sprays. There are technical difficulties, as much of the medication is swallowed and not absorbed by the nasal mucosa. A new breath-powered bidirectional intranasal system delivers sumatriptan powder more efficiently at a lower dose and appears more effective and better tolerated. It should be available in the next 1 to 2 years.
A new transdermal formulation of sumatriptan has received FDA approval and is likely to be widely used starting in the next several months.