Prevention of chronic migraines is an important issue for many patients around the world. There are several steps that can be taken to reduce the frequency and severity of these attacks. Initially, the treatments that are preferred by many doctors and insurance companies are medications that are used as needed for migraines as they happen. The medications used as needed that are most commonly seen are Imitrex (sumatriptan), Zomig (zolmitriptan), and other similar drugs. These come in many forms including oral tablets, injections, and nasal sprays and are used during the onset of migraine symptoms. If the patient is experiencing frequent migraines while taking the medications as needed, they will prescribe oral medications that are taken on a daily basis. Medications that are taken on a daily basis include medications such as Lopressor (metoprolol) and Inderal (propranolol); as well as drugs typically used to treat epilepsy such as Depakote (divalproex) or Topamax (topiramate) or antidepressants such as Effexor (venlafaxine). If the patient is still experiencing frequent migraines while on a preventative medication, the prescriber may turn to injectable preventative medications.

Injectable preventative medications that are commonly used are associated with a quicker effect and fewer side effects than oral medications. There are also very few pre-existing conditions that would make a patient ineligible to receive an injectable treatment. Three of these medications will be discussed in further detail.

Emgality (galcanezumab) is an injectable medication that is given as a monthly injection. The first dose of this drug will be higher than the following monthly injections in order for the drug to be as effective as possible. The first dose, also known as a loading dose, is 240 mg which is administered in two injections of 120 mg. Every following monthly injection is 120 mg. This medication can be administered by the patient and does not require a visit to the doctor. There are very few side effects associated with this medication; however, there is a possibility of inflammation at the site of injection.

Ajovy (fremanezumab) is another injectable medication that can be used to prevent migraines. Ajovy can also be injected by the patient without a medical professional and can also be given once monthly at one consistent dose of 225 mg. It can also be given once every three months if the patient uses three doses in the same location but not the same injection site. The most common side effect with this medication once again is inflammation at the site of injection with very few other possible side effects.

Aimovig (erenumab) is similar to the other two medications previously discussed in that it has once monthly injections administered by the patient for the treatment of chronic migraines. There are some differences that should be noted. Firstly, if this medication is not effective at the first dose of 70 mg, there is an opportunity for an increased dose of 140 mg that could be more effective. However, there are more side effects associated with this medication. In addition to the possibility of injection site inflammation, there is also a small possibility of constipation and muscle cramps. While these side effects are not likely, they should be considered when taking this medication.

So how do you get a prescription for one of these medications? For most insurance plans, these medications will require a prior authorization. A prior authorization is a form that a doctor would fill out and submit to a patient’s insurance company in order for your insurance to pay for certain medications. In order to obtain approval from the insurance for one of these injectable medications, a patient must either not see relief of symptoms on typical oral prevention measures or they may see a neurologist who would be more likely to prescribe these medications first.

How do I know if this medication is right for me? Talk to your doctor at your next scheduled visit to discuss if this medication is right for you.

This article was written by student pharmacist Michael Waugh from University of the Sciences Philadelphia College of Pharmacy.