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Content Update

November 15, 2019

Newly Approved Medications for Migraines: The U.S. FDA approved three new medications with novel mechanism of action for migraine prophylaxis. The calcitonin gene-related peptide (CGRP) antagonists, erenumab (Aimovig®), fremanezumab (Ajovy®), and galcanezumab (Emgality®) were approved in 2018 for migraine prophylaxis.

The CGRP antagonist therapies were approved for migraine prophylaxis in adults because of its hypothesized role in mediating trigeminovascular pain transmission and vasodilation activity for neurogenic inflammation. Although these medications appear effective, more data are needed regarding their long-term safety as well as use in special populations. All three therapies are available in the United States.

LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Differentiate types of headache syndromes based on clinical features.

  2. Recommend nonpharmacologic measures for headache treatment and prevention.

  3. Determine when the pharmacologic treatment of headache is indicated.

  4. Construct individualized treatment regimens for the acute and chronic management of headache syndromes.

  5. Monitor headache treatment to ensure its safety, tolerability, and efficacy.

INTRODUCTION

Headache is a common medical complaint with approximately 50% of the adult population experiencing at least one headache per year.1 image Even when persistent or recurrent, headaches are usually a benign primary condition; secondary headaches are caused by an underlying medical disorder and may be medical emergencies. Primary headache syndromes are the focus of this chapter. Patients may seek headache care from multiple providers. All clinicians should be familiar with the various types of headache, clinical indicators suggesting the need for urgent medical attention or specialist referral, and nonpharmacologic and pharmacologic options for treatment. image The International Headache Society (IHS) classifies primary headaches as migraine, tension-type, or cluster and other trigeminal autonomic cephalalgias.2

EPIDEMIOLOGY OF HEADACHE DISORDERS

Migraine Headache

Migraine is a primary headache disorder with an estimated 3-month prevalence rate in the United States of 14.2% in adults over 18. Prevalence is higher in females at 19.1% compared to 9%. Highest prevalence was in females 18 to 44 years of age at 23.5%.3 In pediatric patients, there is also a higher incidence in females after the age of 10.4 The difference in gender distribution is thought to be due to hormonal differences.

Tension-Type Headache

image Tension-Type Headache (TTH) is the most common primary headache disorder and can be further divided into episodic or chronic.2 The term TTH is used to describe all headache syndromes in which sensitization to pericranial nociception, noxious stimuli, is the most significant factor in the pathogenesis of pain.5 Overall reported prevalence of TTH is approximately 86%, and incidence is more common in women than men. Episodic ...

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