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First drug to prevent chronic migraines approved by EU (theguardian.com)
113 points by al_ramich 7 months ago | hide | past | web | favorite | 61 comments

The title is misleading, as other medications have been used for migraine prophylaxis. This is the first drug, per the article, that has been specifically approved for migraine prophylaxis. Medications such as beta blockers and valproic acid are other medications used for migraine prophylaxis but were originally approved for other conditions.

Additionally, please note that this drug has already been approved in the US, since May.

Now, onto the meat of this. If I'm not mistaken, erenumab is a cgrp inhibitor that made much fanfare a few months ago in New England Journal of Medicine when two studies found a clinical benefit in cgrp.

Basically healthcare providers are prescribing this if you failed the aforementioned therapies for migraine prophylaxis (since those are way cheaper).

On a funnier note, medical students such as myself have started referring to all of these new biologic drugs as "what-the-f*-umabs" since they all have weird names and we can't keep up with the rapid development of them.

As someone suffering from multiple auto-immune diseases, I love the "biologic era".

I'm currently taking Cosentyx and it's been life-changing.

More and more the treatment goal of my condition is becoming sustained drug-induced remission.

I totally agree. A drug development timeline of 6-7 years from start to regulatory approval is a pretty dramatic shift from previous eras and can better target your specific problem.

On the other hand, however, you then run into rapidly increasing costs for medication, which isn't going to be sustainable in the long run. Maybe the economies of scale will bring that cost down, but I'm no expert on that.

Would Cosentyx also help bring Hashimoto thyroid disease into remission ?

Potentially, as there is some evidence that Hashimoto's has some increased interleukin 17a (what cosentyx targets). However, it was my understanding that Hashimoto's is something that could be treated long term with thyroid hormone supplementation (synthroid, etc).


They have similar name endings because of naming conventions. umab indicates a human monoclonal antibody. See https://en.wikipedia.org/wiki/Nomenclature_of_monoclonal_ant..., https://en.wikipedia.org/wiki/Drug_nomenclature#List_of_drug...

We know the naming conventions and can consult the nomenclature as needed, this is more tongue-in-cheek.

Valproate is far from ideal, because it's massively teratogenic. Migraine is far more prevalent in women, so erenumab could become very useful when it goes off patent.

Some people have been able to successfully treat migraines, as well as cluster headaches, with hallucinogens such as psilocybin and LSD:

"These patients are in a desperate and vulnerable situation, and illicit psychoactive substances are often considered a last resort. There appeared to be little or no interest in psychoactive effects per se as these were rather tolerated or avoided by using sub-psychoactive doses. Primarily, psilocybin, lysergic acid diethylamide, and related psychedelic tryptamines were reportedly effective for both prophylactic and acute treatment of cluster headache and migraines. Treatment results with cannabis were more unpredictable. No severe adverse events were reported, but it was observed how desperation sometimes spurred risky behavior when obtaining and testing various treatment alternatives." [1]

"The authors interviewed 53 cluster headache patients who had used psilocybin or lysergic acid diethylamide (LSD) to treat their condition. Twenty-two of 26 psilocybin users reported that psilocybin aborted attacks; 25 of 48 psilocybin users and 7 of 8 LSD users reported cluster period termination; 18 of 19 psilocybin users and 4 of 5 LSD users reported remission period extension. Research on the effects of psilocybin and LSD on cluster headache may be warranted."[2]

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584001/

[2] https://www.ncbi.nlm.nih.gov/pubmed/16801660


I know someone who uses MDMA every few months to prevent migraines. Reportedly it works at least for a month or two after a 100mg dose.

Really wish it was legal to research around this compounds - the case of 2-Bromo-LSD suggests a successful anti-migraine drug does not have to have psychedelic effects.

I have a friend who gets regular migraines. He takes triptans to abort them, but if the frequency becomes too much he takes a low dose of psilocin and it banishes them for a couple months.

Yes, it's been found to work well on certain types of "cluster" type migranes. However, it hasn't been found to work for chronic migranes, which is what this new drug is focused on. Prevention of chronic migranes is horribly elusive, and while there's a number of "preventatives," for many people they don't work well or for very long.

I have chronic migraines, the frequency isn't too bad (2-3 times a month). Personally I've spent 2 years migraine free doing LSD and psilocybe mushrooms (and other related drugs) every couple of months during a year and a half. Sometimes in the range of microdosing: ~25µg LSD monthly for the last 3 months). I know, n=1, but still.

Chronic migranes is defined as 15 days or more per month. Many people have it 24 hours a day.

Frequency is what chronic migranes are about.

The study states the psylocybin was found to be effective for acute treatment of migraines. Obviously it's only one study, but unless you have sources I disagree that psychedelics have not been found to work for migraines. Also you say "'cluster' type migraines", but cluster headaches are not a sub-type of migraines.

I know someone who does this and the discovery has been a godsend. Doesn't even take a strong dose either!

I've been taking Feverfew extract daily (the brand is Mygrafew, I think) and it has reduced my migraines by about 80%. For the rest of the time there's sumatriptan, which works about 70% of the time. Between the two, I've got my migraines under control (maybe one a month).

I used to get at least one a week, and I know there are people who get them much more often. I'm glad there are advances being made in this area because I feel like for all the pain migraines have caused me, I'm mostly a dabbler and others have it much worse.

It's really one of the worst pains I've ever experienced. They are kind of evil. With some pain, you know "at least it's for a reason" (like your body self-healing something). With migraines, it's devoid of any purpose. The pain only exists to torture you. Nasty things.

I know two people who suffer from chronic, debilitating migraines. As someone who gets episodic clusters, I am sympathetic / empathetic to their plight. My attacks (which only happen every two years or so) can be treated pretty effectively with oxygen and/or sumatriptan injections, so it's tempting to think that sumatriptan (primarily a migraine drug in the first place) should just work.

Everyone is different, and there is so much we don't understand about migraines (and clusters, which often benefit from migraine research). If you think that ginger, cannabis, or just avoiding your triggers is all it takes, that's not always (nor probably often) the case.

I hesitate to subject a friend's personal blog to the HN effect, but if you want to learn about chronic migraine from one firsthand account, read through some of the archives at thedailyheadache.com. She has been trying desperately and relentlessly to find peace for a long time.

Interesting you mention oxygen -- this means you breath from an oxygen tank? I notice I yawn a lot when a migraine is about to occur -- I always thought this had something do with lack of oxygen.

I always have a supply of MaxAlt (rizatriptan benzoate) with me which short circuits my migraines if I take it in the correct window of time. 1 MaxAlt usually works, 2 or 3 in the worse case.

For cluster headaches, a high rate of oxygen (like 10-12 liters per minute) acts as a vasoconstrictor, which can relieve pressure on the nerve.

Botox and muscle relaxers have helped me immensely - and yet I still get headaches frequently. There’s also the crocodile yoga position.

I've found a quarter teaspoon of powdered ginger surprisingly effective for migraines. Don't take my word for it: https://www.ncbi.nlm.nih.gov/pubmed/23657930

I've been taking high dose riboflavin (vitamin B2) at the recommendation of my neurologist for the last 4-5 months and it's been shockingly effective.


Almost the same with me. The neurologist did a blood test which showed a huge lack of vitamin B12 and Q10. High doses of both made a huge difference -> I feel way more fit and awake. The last time I had migraine was about 2 months ago. I'd get it up to 3 times a week previously. Plus while trying to find out the cause for my migraines I encountered coffee to be a trigger. I stopped consuming caffeine in general as well.

Thanks for this, I'll try this next time I feel one coming on (assuming I'm at home and can get to some powdered ginger)!

I can't imagine how it is to eat powdered ginger given how a piece of solid ginger tastes like

You can make (rather strong) tea from it, i saw it even being sold in supermarkets straight in tea bags. Add some lemon and honey and it is delicious and great for those long winter evenings

I've packed it inside empty capsules before to make it more palatable.

I've heard often that sea salt mixed with lemon juice helps, wonders of home medicine

I wonder if natural ginger ale could have a prophylactic effect when drank at lunch each day. That would be a super thing if it did — and safe for pretty much anyone.

If you can, add 1/4 tsp tumeric powder and black pepper as well. I’m basically declaring war on all inflammatory foods/factors.

Exactly! The black pepper has a bioavaibility enhancer called piperine which ensure that you absorb more of the curcumin as well. https://www.ncbi.nlm.nih.gov/pubmed/9619120

There is growing evidence that hyperinsulemia is related to migraines. Insulin-resistant individuals and/or people with metabolic syndrome who suffer migraines could try lowering their insulin levels by removing fast-digesting carbohydrates (refined sugars, starches, junk food in general) and seeing if that helps.

Along the same lines: chronic migraine sufferers can sometimes have good results at reducing frequency by lowering the blood pressure.

A low carb diet, or ketogenic diet, can cause lowered blood pressure. The only downside with diet instead of medication is that eating carbohydrates will reverse the effect.

A couple of naive (and admittedly political) questions I didn't see addressed in the article...

Is there any way to find out how much of the R&D money for the medicine came from public funding? I can understand if the information is simply not available because it comes from a larger pool of R&D monies.

> Erenumab is now expected to be considered by English and Scottish health agencies to assess whether it is appropriate for NHS use.

Curious whether it has to be approved by the EU first before its use by NHS is allowed (or if its assessment is even worth it until EU approval occurs). Also curious whether "appropriate for NHS use" means at no cost to migraine sufferers.

Side effects include chronic migraines and death.

you could also just avoid your migraine trigger, I have and get around 3 migraines a year max rather than having one every month or 2 or 3 a week as a teen.

Jerry Weinberg, who died yesterday, used to say that every time you hear the j-word ("just") you should replace it with "have trouble", i.e. "you could also have trouble avoiding your migraine trigger". He was talking about software projects, but the rule is surprisingly general. The j-word usually indicates that difficulty is being glossed over.

Anecdotally, over the years I've tried identifying my triggers by keeping logs of food, drink, sleep, stress, travel, etc, and correlating the data. After all that, I've identified a few specific foods, but even those were unreliable triggers, and avoiding them didn't cause a significant decrease overall. Medication gave me my life back.

I was under the impression that identifying the trigger can be quite difficult, to the point where some folks who suffer from Chronic migraines can spend years trying to figure out the combination of factors that act as the trigger?

You state that as if it's simple and anyone can do it.

What if something common like changes in atmospheric pressure trigger it? What if you have multiple common triggers? What if you don't know all your triggers?

Just keep a food log, mood log, sleep log, stress log, barometric pressure log, air quality log, oxygen level log, altitude log, brightness log, screen-time log, eye strain log, face-shoulder-neck tension log, spine pain log, head trauma log, and a blood pressure log.

Then you can hook up all the data into a recurrent neural network that finds the patterns in the data and lets you know what combination of conditions will give you migraines.

It's really easy to find all your migraine triggers if you follow these very basic steps.

Should also probably log stool weight/color, mineral/vitamin intake across all foods, etc etc - just to make it even more clear that a person has no time to “just log everything” that could possibly play a role. And at the end, it would probably not explain a majority of the headaches - at least in my experience.

> it would probably not explain a majority of the headaches - at least in my experience

This is my experience too. I know a good number of my migraine triggers, but some days I do everything right: I eat good food (regularly), plenty of sleep, no over-exertion, lots of water, breaks from screen time, no eye strain, etc etc...still get a fucking migraine!

Sometimes there's just not a reason for it.

Yep and that list of things you did correct could go on for pages. It’s similar for how I treat my headaches. I don’t just take a triptan. I do the yoga stretch, maybe a cup of tea (full cup of coffee if I’m in 9/10 zone), some Gatorade, ginger powder, tumeric powder, heat on the traps, TENS unit on the traps/neck/temples, ice, etc and nothing. I’ve even fallen asleep while doing half of those in the crocodile position before. It worked that time, too.

You should also do weekly MRI's just to see if there's anything neurologically you might be able to notice/track.

Also, might be helpful to just download your consciousness into a synthetic brain

With the variety of triggers that are possible and the possibility of there being multiple triggers with complex interactions, that is much easier said than done for many. After keeping meticulous logs of anything that might be a trigger, I've managed to reduce my migraines to 1 a month from 3-4 per weeks over a period of about 4 years, eventually identifying 7 or 8 causes. Even then, when I do get one, which combination of pain drugs to take is a huge gamble. CBD oil seems to be the only thing that always works, but that's unfeasible for me. So I'm not going to complain about a new drug for it.

Well, most migraine triggers are basically oxidative stress (https://onlinelibrary.wiley.com/doi/abs/10.1111/head.12725), and it is impossible to avoid oxidative stress since even simply burning glucose contributes to it.

Interesting. Perhaps this explains why people on ketosis with very low sugar report fewer migraines.

There may be two effects going in parallel, but: for chronic migraine sufferers reducing blood pressure can be effective in reducing attack frequency, and ketogenic (and other very low carb diets), can reduce blood pressure frequently. Blood pressure being a big factor in the effects of vasodilation.

Honestly, I've long dismissed the claimed benefits of ketogenic diets like 'reduced inflamation' as... minor and uninteresting. A few weeks into a low-carb diet for my migraines and my sedentary butt is suddenly running and with my untrained knees never having felt better. I would not be shocked if there were other beneficial effects of ketosis on migraines.

I found high-sugar foods to be one of my many triggers. Never really understood why...

Not all migraines have triggers. This drug in particular is for chronic migraines, and while the definition of chronic is 15 days or more, the people who will qualify for this drug (and who it was really designed for) are the people who have them 24 hours a day, 7 days a week non-stop. So living is their trigger. Nice advice.

Hard to do when sometimes migraine triggers can be changes in the weather.

For a lot of people cannabis works great for their migraines, but I guess it is difficult for pharma to make money off of it so it is still a gray area in the EU. I am only pointing this out because the hype coming from the article makes the situation grotesque.

Using painkillers (including CBD) chronically puts you at risk of developing medication overuse headache.

Preventive migraine treatments are not painkillers (beta blockers, anti-epileptics, and more, among which the CGRP blocker described in the article).


1. It isn't so difficult. "Pharma" makes drugs from plants all the time. It isn't hard to imagine having strains specifically for treatment, packaged in prepackaged dosages with the right strains with different strengths. Or inhalers and things. "Pharma" also makes things like aspirin, after all. Besides, "Pharma" isn't the only one with an interest here - alcohol and tobacco companies would surely jump in to fill the niche. Not to mention that many countries have taxpayer-funded health care and have a vested interest to provide lower-cost treatments that work.

2. It depends on what is causing your migraines. I have a family member that will smoke occasionally if the migraines get bad enough. But they also have allergies, and sometimes smoking irritates them. That means that she has a small chance of the headache changing forms. One type of pain traded for another.

3. The situation is pretty horrible. I don't have them, but they run in my family. I've had to pick a person up because they got an aura while driving. I've known another that goes literally months with headaches. The pain gets bad enough that folks near "If I overdose, at least the pain stops". It can literally disable folks for hours. Cannabis doesn't always work well enough and doesn't prevent them. Most things that help with the pain still disable folks enough that they can't drive nor do their work.

1. That's the thing - it is cheap, safe and easy. If there is no monopoly established (like in the UK) there is little money to be made. You cannot do aspirin at home easily, but you could make your migraine (or other) medication from cannabis easily.

2. You don't have to smoke it.

3. It doesn't work for all, but that is not an argument to deny it to those that they find it works for them.

1. See, but there is money to be made, just not by the folks you are referring to. Monopoly or not. If anything, saving money in the healthcare system is in the government's interest. Taxes and things as well. And "easy" is ... kinda. Depends on what sorts of things you need it for.

2. Of course not. But that takes away from the ease of above: The person in question gets some irritant effects from the smoke, but also tends to get allergic reactions from random stuff... like corn pollen. The same person will try about anything legal.

3. I'm not argueing that at all. I'm actually very pro-legalisation, both for recreational use and for pharma use (not only with pot, but including drugs I wouldn't personally ingest). I generally push there to be separate categories for the uses, in part so we can specialize (I think this will happen). But I also try to push back at cure-all sorts of language, and this was more to demonstrate that even with it legal, migraines are still horrible and it doesn't prevent them. In a best-case scenario with this new medicine, a person would have the prevention available plus a variety of treatments to treat the ones they still get, including cannibus if it happens to be right for them.

Does cannabis actually prevent migraines or help after they started? I would be interested in reading the peer reviewed studies on the effectiveness of cannabis in preventing migraines.

I am skeptical of anecdote because half of my family is Mexican and the grandmothers on that side of the family are convinced that being cold causes colds or that homeopathy actually works. But in reality it’s just quite literally old wives tales not backed by any reputable, reproducible studies.

To be clear, I am not disputing that cannabis could have some beneficial effects, but the science should be there before we start suggesting that government is up to some conspiracy to boost pharma profits.

Am marijuana is still illegal in most EU countries — so don’t blame pharma for not manufacturing and testing cannabis medications, blame the democratically elected EU governments for trying to “protect” people from making their own decisions about what to ingest.

My sister in law lived in the netherlands, and they actually prescribed her mushrooms (the magical kind) for her migraines.

It is known to work for specific types of cluster migraines. But unfortunately only those kinds.

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