NAPLEX Question of the Week: Migraine Therapy

This week's question focuses on a common issue that can cause significant debilitation and loss of productivity for many patients.

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A 47 year old female presents to her primary care physician for migraine management. Her past medical history is significant for migraines, hyperlipidemia and GERD for which she takes Lipitor 40mg HS and Prilosec 20mg daily. She takes Imitrex 50mg PRN typically 3-4 times monthly for acute therapy of her migraine headaches. She has attempted propranolol previously with no effect and wishes not to take Depakote due to concerns over weight gain. She has read about "CGRP therapies" and wishes to know if one of these would be appropriate for her. Which of the following is true regarding use of these agents for migraine prophylaxis?

A. Galcanezumab-gnlm (Emgality) may be given once monthly as SQ injection or intravenous infusion.

B. Fremanezumab-vfrm (Ajovy) once removed from the refrigerator and stored at room temperature must me given within 7 days.

C. Rimegepant (Nurtec ODT) is an oral CGRP agonist indicated for migraine prophylaxis.

D. Erenumab-aooe (Aimovig) is the least likely among the CGRP antagonists to induce hypertension.

Answer with rationale:

The correct answer is B. Calcitonin gene-related peptide (CGRP) is a potent endogenous vasodilator that has been recently targeted for pharmacologic therapy in both migraine treatment and prophylaxis. Small molecule CGRP antagonists, like rimegepant and ubrogepant, are used to abort active migraines therefore making answer C incorrect. The other answers listed are all CGRP antagonists given subcutaneously for migraine prophylaxis, making answer A incorrect as the only IV CGRP antagonist is eptinezumab (Vyepti). Answer D is incorrect as this agent recently had hypertension added as a warning/precaution within the labeling due to cases of severe hypertension noted while on therapy, typically within 7 days of last dose. Studying the warnings/precautions within a package insert is a great way to understand some of the most important adverse reactions within a particular agent. 

Have a great week everyone!

Dr. B

Christopher M. Bland

Clinical Professor, University of Georgia College of Pharmacy

Dr. Christopher M. Bland is a Clinical Professor at the University of Georgia College of Pharmacy at the Southeast GA campus in Savannah, GA. Dr. Bland has over 20 years of academic and clinical experience in a number of clinical areas. He is a Fellow of both the Infectious Diseases Society of America as well as the American College of Clinical Pharmacy. He is co-founder of the Southeastern Research Group Endeavor, SERGE-45, with over 80 practitioners across 14 states involved. Dr. Bland serves as Associate Editor for the NAPLEX Review Guide 4th edition as well as Editor-In-Chief for the Question of the Week. He has provided live, interactive reviews for more than 10 Colleges/Schools of Pharmacy over the course of his career.