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Determining the most appropriate acute treatment for migraine


Peter McAllister, MD, FAAN*

TITLE: How do we determine the most appropriate acute treatment for our patients with migraine?

Peter McAllister, MD, FAAN: We often hear from patients that they try to take their medication as soon as they feel a migraine attack coming, but we know that’s not always possible.

Many of our patients experience nausea, vomiting or other gastrointestinal issues with migraine. Then we have patients who say they don’t always get relief from their oral medications, or the relief doesn’t last. Additionally, patients taking anti-CGRP preventive therapy still experience breakthrough attacks and many times these acute attacks are treated with oral anti-CGRP treatments.

With all the limitations of oral treatments—dosing window, GI complications, relief that doesn’t last, similar mechanisms of action as preventive—here is why I would consider treating with Trudhesa.

First of all, the long-term proven efficacy of the molecule dihydroergotamine mesylate (DHE): If you recall, across 4 different clinical trials of traditional DHE nasal spray, patients experienced relief rates ranging from 47% to 70% at 4 hours.

Then, there’s the results of the Trudhesa phase 3 safety study. Trudhesa exhibited a well-tolerated safety profile with no cardiac TEAEs, and no clinically significant ECG interpretations, no treatment emergent adverse events associated with abnormal ECG and only 0.6% of doses resulting in nausea (with more than 6000 doses administered during the 52-week trial).

Patients with a history of cardiovascular events or presenting with significant risk factors for cardiovascular disease were excluded from the study.

The most common local irritative symptoms were the typical treatment emergent adverse events reported with nasally administered products, including nasopharyngitis (at 21%) and rhinitis (at 19%).

Exploratory efficacy endpoints demonstrated rapid, consistent, sustained relief with Trudhesa, with no dosing window. 38% of patients reported pain freedom at 2 hours and of those patients, 93% remained pain free after 24 hours and 85% at 48 hours.

Patients also reported experiencing pain freedom despite taking Trudhesa late into the migraine attack. The percentage of patients who were pain free at 2 hours post dose was similar whether patients took Trudhesa within 2 hours of migraine attack onset or from 2 to 4 hours after attack onset (at 39.3% and 39.4%, respectively). Even among those who took Trudhesa more than 4 hours after attack onset, 30.9% were pain free at 2 hours post dose.

Additionally, of the 4257 migraine attacks treated during the 24-week trial, 85% treated with Trudhesa did not require rescue medication.

If you have patients who struggle with dosing windows, GI complications, relief that doesn’t last, or have breakthroughs on preventive medications, what are you offering them? It’s time to consider Trudhesa.

Could your patients benefit from Trudhesa?

DHE=dihydroergotamine.

*Paid consultant of Impel Pharmaceuticals Inc.