A narrative review of the importance of pharmacokinetics and drug–drug interactions of preventive therapies in migraine management

• Published in: Headache 2021-06, Vol.61 (6), p.838-853
• Main Authors: Joshi, Shivang, Tepper, Stewart J., Lucas, Sylvia, Rasmussen, Soeren, Nelson, Rob
• Format: Article
• Language: English
• Subjects: Adrenergic beta-Antagonists - pharmacokinetics; Adverse events; Antibodies, Monoclonal - pharmacokinetics; Anticonvulsants - pharmacokinetics; Antidepressants; Antidepressive Agents - pharmacokinetics; Antiepileptic agents; Calcitonin; Calcitonin Gene-Related Peptide; Calcitonin Gene-Related Peptide Receptor Antagonists - pharmacokinetics; Calcium; Calcium channel blockers; Calcium Channel Blockers - pharmacokinetics; Calcium channels; Comorbidity; Cytochrome; Cytochrome P450; Cytochromes P450; Drug Interactions; Drug metabolism; drug–drug interactions; Gene polymorphism; Grapefruit; Headache; Humans; Immunotherapy; Ingestion; Migraine; Migraine Disorders - drug therapy; Migraine Disorders - epidemiology; Monoclonal antibodies; Patients; pharmacodynamics; Pharmacokinetics; Pharmacology; Polymorphism; polytherapy; Review; Risk; Risk management
• ISSN: 0017-8748; 1526-4610
• DOI: 10.1111/head.14135

Objective To review the pharmacokinetics of major classes of migraine preventives and the clinical implications of drug–drug interactions (DDIs) with the use of these therapies in migraine management. Background Preventive treatments for migraine are recommended for a large proportion of patients with frequent migraine attacks. These patients often exhibit a number of comorbidities, which may lead to the introduction of multiple concomitant therapies. Potential DDIs must be considered when using polytherapy to avoid increased risk of adverse events (AEs) or inadequate treatment of comorbid conditions. Methods A literature search was performed to identify pharmacokinetic properties and potential DDIs of beta‐blockers, antiepileptic drugs, antidepressants, calcium channel blockers, gepants, and monoclonal antibody therapies targeting the calcitonin gene‐related peptide pathway with medications that may be used for comorbid conditions. Results Most DDIs occur through alterations in cytochrome P450 isoenzyme activity and may be complicated by genetic polymorphism for metabolic enzymes. Additionally, drug metabolism may be altered by grapefruit juice ingestion and smoking. The use of migraine preventive therapies may exacerbate symptoms of comorbid conditions or increase the risk of AEs associated with comorbid conditions as a result of DDIs. Conclusions DDIs are important to consider in patients with migraine who use multiple medications. The development of migraine‐specific evidence‐based preventive treatments allows for tailored clinical management that reduces the risk of DDIs and associated AEs in patients with comorbidities.