What

1
Whats New in Migraine Management
Sponsored Through an Educational Grant from Merck
Co., Inc.
2
Introduction

• Welcome to a patients guide to advances in
• managing migraine
• What are the current treatment options for
  migraine?
• What is the current state of ongoing research?
• What are the newest advances in managing migraine?

3
Dont Suffer in Silence

• More than half of people with migraine suffer
• for at least a year before they are diagnosed
• with migraine
• 38 suffer for 3 or more years before diagnosis

NHF. American Migraine Study II Migraine in the
United States. Burden of Illness and Patterns of
Treatment. www.headaches.org.
4
Treatment Is Available

• Many treatment options are available
• Ask your healthcare provider whats right for you
• Follow your treatment plan
• Lifestyle modification
• Nonpharmacologic and complementary therapies
• Acute medications
• Preventive medications

5
Lifestyle Modification for Migraine

• Eat healthfully and regularly do not skip meals
• Get enough sleep, but do not oversleep
• Keep a regular sleep schedule
• Keep well hydrated
• Exercise regularly
• Rest during a migraine, and do not overexert
  afterward
• Reduce your stress
• Identify your triggers and avoid when possible

6
Nonpharmacologic and Complementary Therapies

• Relaxation training
• Hypnotherapy
• Biofeedback training
• Cognitive/behavioral management
• Acupuncture
• Nutritional supplements (B12 and others)
• Physical therapy and/or massage

7
Acute Medications for Migraine

• Triptans
• Almotriptan (Axert) Rizatriptan (Maxalt)
• Eletriptan (Relpax) Sumatriptan (Imitrex)
• Frovatriptan (Frova) Zolmitriptan (Zomig)
• Naratriptan (Amerge)
• Ergotamine derivatives (eg, DHE)
• Over-the-counter pain killers (acetaminophen,
• ibuprofen, naproxen, and combinations of
• aspirin/acetaminophen/caffeine)
• Prescription pain killers (used infrequently)

8
Preventive Medications for Migraine

• Preventive medications are taken every day
• to reduce the frequency and severity of
• headache attacks
• Approved therapies include
• Beta blockers (propranolol, timolol maleate)
• Anticonvulsants (divalproex sodium, topiramate)
• Serotonin antagonist (methysergide maleate)
• Other (antidepressants, other serotonin
• antagonists, NSAIDs)

9
State of Current Research

• For many years, there was limited research on
  headache, but the approval of the triptan drugs
  for the acute treatment of migraine opened up the
  industry to the realization that there was a
  financial market out there for drugs for the
  long-standing headache sufferer. It is now
  interested in looking for newer and better
  methods.
• Seymour Diamond, MD Executive Chairman of the
  NHF

10
State of Current Research

• More than 20 pharmaceutical and biotech
• companies are researching or developing
• new drugs
• Time to market for new drugs 10-15 years
• 1 in 5 drugs tested on humans is eventually
• approved for use

11
Advances in CareThermal Aerosol Inhalation Device

• How it works
• Uses heat to vaporize a drug into an odorless
  mist
• that is inhaled
• Drug passes from the lungs into the bloodstream
• Potential benefit
• Rapid relief it is hoped that inhalation will
  provide
• symptom relief within 60 seconds
• Current state of development
• Large, ongoing clinical trial using
  prochlorperazine
• (Staccato Alexza Molecular Delivery Corp)

12
Advances in CareSkin Patch

• How it works
• Uses low-level electrical energy to release drugs
• into the skin
• Transdermal patch containing the drug and a small
• battery-powered electronic controller precisely
• controls the rate and amount of drug released
  from
• the patch
• Potential benefit
• Rapid initial delivery of drug to bloodstream,
  followed
• by sustained, low-level, maintenance dose
• Current state of development
• In early clinical trials using zolmitriptan
• (Actyve Vyteris)

13
Advances in CareNasal Powder

• What it is
• Powder form of dihydroergotamine,
• administered nasally
• Potential benefit
• Powder may offer easier and more rapid absorption
  
• Current state of development
• DHE Nasal Powder Britannia Pharmaceuticals in
• collaboration with Novartis Pharmaceuticals

14
Advances in CareDrug Combination

• What it is
• Combination of sumatriptan (a triptan) and
  naproxen
• sodium (an NSAID)
• Potential benefit
• May provide faster pain relief in combination
  than
• individually through multiple mechanisms of
  action
• Current state of development
• Clinical trials completed (Treximet from Pozen
  Inc.
• in conjunction with GlaxoSmithKline)
• FDA approved Treximet in April 2008

15
Advances in CareMedications With New Uses

• Medications used for other conditions are being
• studied in headache and migraine
• Currently in clinical trials
• Tripleptal (anticonvulsant Novartis
  Pharmaceuticals)
• Doxepin (antidepressant Winston Laboratories)
• Aricept (Alzheimers Eisai)
• Diclofenac potassium (NSAID ProEthic
  Pharmaceuticals)

16
Advances in CareCarbon Dioxide Inhaler

• How it works
• Sends pressurized carbon dioxide up one nostril
• and out the other
• Carbon dioxide would not be inhaled, but would
• permeate nasal mucous membranes
• Current state of development
• In clinical trials Capnia

17
Advanced in CareAK Receptor Antagonist

• How it works
• Selectively blocks transmission of pain signals
  from
• receptors without constricting blood vessels
• Current state of development
• Beginning phase III clinical trials
• (Tezampanel TorreyPines Therapeutics)

18
Advances in CareCapsaicin Nasal Spray

• What it is
• The ingredient in cayenne pepper that gives it
  its hot
• and spicy taste
• How it works
• Relieves pain by destroying a chemical that
  carries
• pain messages to the brain
• Current state of development
• Under development by Winston Laboratories

19
Advances in CareMedical Procedures

• Patent foramen ovale (PFO)
• A valve-like opening between the right and left
  atrial
• chambers of the heart
• Usually closes shortly after birth, but remains
  open
• in 25 of people
• Closure of PFOs in patients with intractable
  migraine
• results in decreased migraine and cluster
  headaches
• Current state of development
• Connection between PFO closure and migraine is
• under investigation
• St. Jude Medical and Coherex Medical are working
  on therapeutic options

20
Advances in CareMedical Devices

• Neurostimulation devices
• For patients who have not responded to other
  treatments
• Current state of development
• Precision Advanced Bionics Corporation
• Genesis Neurostimulation System Advanced
• Neuromodulation Systems
• Medtronic Synergy IPG Medtronic, Inc.
• Vagus Nerve Stimulation Therapy Cyberonics

21
Talk to Your Doctor

• There are many treatment options
• Talk to your healthcare practitioner to determine
• what is right for you
• Develop a comprehensive treatment plan
• Follow your practitioners recommendations
• Follow up with your practitioner about your
  progress

22
Summary

• Current treatment options include lifestyle
• modification, nonpharmacologic and
• complementary therapies, and acute and
• preventive medications
• New treatments are currently under investigation
• New formulations and routes of administration
  thermal
• aerosol inhalation device, skin patch, nasal
  powder
• Combination sumatriptan/naproxen
• New uses of drugs approved for other conditions
• New treatments carbon dioxide inhaler, AK
  receptor
• antagonist, capsaicin nasal spray
• New medical procedures and devices

23
The National Headache Foundation

• For more information about headache causes
• and treatments, visit the National Headache
• Foundation (NHF) Web site www.headaches.org
• An online database of NHF physician members is
  available on the NHF Web site