For migraine sufferers in the Triad, relief has arrived.

It comes in the form of Dr. Antonia “Toni” Ahern, a double board-certified neurologist and expert in headache medicine. Ahern joined Novant Health earlier this year with advanced training in migraine and headache disorders and more than 14 years of outpatient neurology experience.

She’s Novant Health’s first dedicated headache specialist in the Triad, and she sees patients in Greensboro and High Point. The High Point clinic is new and co-located with Novant Health Spine Specialists and Novant Health Brain & Spine.

Ahern had a successful career in IT before becoming a physician. She returned to school in her 30s — while raising two young children. And she knows about migraines from first-hand experience; she began having them in college.

Her arrival isn’t the only good news for migraineurs, a term used for people who have migraines. We talked to her about a class of medication that’s highly effective at preventing migraines called CGRP inhibitors.

There’s a medication that prevents migraines?

Yes. A group of drugs, the CGRP inhibitor class — that stands for calcitonin gene receptor peptide — blocks the excess CGRP protein, which triggers severe pain. It’s the first migraine preventive we’ve ever had. And that’s crazy because about 40 million Americans suffer from migraines.

How do these CGRP inhibitor drugs work?

The same way that taking an antihistamine helps with your allergies.

We've known for a long time that inflammation causes migraines. Specific neuropeptides can trigger neurogenic inflammation. (Neuropeptides are small, protein-like chemical messengers that act as neurotransmitters to modulate brain activity.) Finally, somebody figured out how to block this particular peptide, which then blocks the migraine.

There are different forms of CGRPs — the preventive kind for chronic migraineurs and another kind we prescribe for occasional, or episodic, migraine sufferers.

How new is this class of migraine prevention drugs?

They’re not new, although I’m never surprised when patients tell me they haven’t heard of them. They’ve been around since about 2018. (Botox, which is not in this class of drugs, was FDA approved for migraine prevention in 2010.)

When they first came out, I saw TV commercials for them all the time. But I don’t see those anymore. And that’s the challenge. People who’ve had migraines for years may have given up on finding anything effective. I want them to know: There’s help.

How are CGRP inhibitors administered?

In several ways.

The first one, Aimovig, came out in 2018 in injectable form. Then, two more injectables were introduced — Ajovy, followed by Emgality. The injections are self-administered like the GLP-1s we often hear about. So, it’s a medication you administer just once a month.

They also come in pill form and as an intravenous (IV) infusion called Vyepti. For that, patients go to an infusion center every three months.

How do you determine which form — injection, pill or infusion — is right?

It depends on the patient and their lifestyle. A lot of patients are tired of pills and would much rather take a monthly injection.

You might forget to take a pill. I’m a doctor, and I sometimes forget. You’re much likelier to remember an injection you give yourself once a month. And compliance leads to a better effective rate.

Of course, some people don't like needles. So, they can choose the pill or the quarterly IV infusion. That takes just 30 minutes, and I have many patients who say it’s easy for them to fit that into their schedule.

So, it’s all based on personal preference. All forms of these medicines are extremely effective. One might work better for you than the other, just as Tylenol may work better for someone than ibuprofen.

What are the side effects of CGRP inhibitors?

They have an incredibly good side effect profile — in other words, there aren’t many. The most common is injection site reaction. Constipation is also fairly common. In the years I’ve been prescribing them, I’ve never had a patient say they couldn’t take it because the side effects were too extreme.

And it’s not like patients need to come in every three to six months for me to check their white blood cells. Unless there’s an issue they need to discuss with me, I see patients just once a year.

Are the side effects similar, no matter what form you take?

Yes, very similar.

Are CGRP inhibitors as expensive as the GLP-1s?

They are expensive, but in my experience, manufacturers are very willing to work with patients to make them affordable. There are a lot of coupons out there, and I have a good track record of helping patients get that kind of assistance.

Does insurance cover CGRP inhibitors?

There are still some insurance plans that insist people try — and fail — traditional medications before they’ll approve a CGRP. But we’re starting to see more insurance companies recognize that these are the most effective medications for migraine. So, it’s becoming easier to get people approved.

Will people need to be on CGRP inhibitors for the rest of their lives?

You don't have to be on them forever; it depends on your migraine frequency and severity. Some people are lifelong migraineurs, and they may need to be on it indefinitely. But others have only occasional migraines.

Migraines can wax and wane throughout your life. You could be on these medications for six months to a year, and then come off. As an example, some women begin having more migraines during perimenopause. They might need to take these until they’re past menopause.

Is there anybody who shouldn’t take CGRP inhibitors?

We don’t know about birth defects because we don’t do clinical trials on women who are pregnant or lactating, but I wouldn’t prescribe them for women who are pregnant or breastfeeding.

The once-a-month injection has a very long half-life. If a patient told me she wanted to get pregnant in the next six months, I wouldn't put her on an injection. But I might prescribe a pill, which is much shorter-acting.

Although there are no specific safety concerns, I’d think twice about prescribing them for people with certain heart diseases or issues affecting blood flow to the brain.

How effective are CGRP inhibitors at preventing migraines?

When we talk about effectiveness, we’re not only talking about decreasing how many migraines you have, but also improving the ones you do have. In general, at least half the people in clinical trials achieved at least 50% improvement — some even more.

But some people have improvement much greater than that. We can’t cure migraines; the best we can do is to manage them.

Do you have patients who’ve had a dramatic change as a result of being on one of these CGRP inhibitors?

So many. Many people have tried absolutely everything, and nothing has worked. And then I put them on a CGRP, and everything changes. Some of those changes can’t be measured. You can’t measure lost time with your family, right?

Whenever I put anybody on one, I get very excited. I’ll tell them I’ll see them in three months unless things are going so well that they want to push that follow-up appointment out. And I’ll add that I expect things will go really well.

What’s the difference between a migraine and a really bad headache?

A migraine is a headache severe enough to disrupt life — a headache that’s pulsating, pounding, throbbing. You’re sensitive to light. You’re nauseated and may be vomiting. You may have to go into a room with blackout curtains.

A lot of times, they occur on one side of the head, but they could be anywhere. Some people don't even recognize they’re having migraines; they think it’s just a really bad headache.

Do you suffer from migraines?

I do. They started in college. But I was one of those people who didn’t know they were migraines. It wasn’t until I was in med school and in a neurology lecture that I thought: Wow. I have migraines.

Are you on a CGRP inhibitor?

No, because I started Botox before the other CGRPs came out, and it works very well for me. I will use the kind of CGRP you take occasionally if I'm having a breakthrough migraine. And by the way, CGRPs work spectacularly when you layer one on top of another treatment.

If somebody is on Botox and it’s working, should they switch to a CGRP inhibitor?

It’s worth exploring with your doctor. Say somebody has 30 migraine days a month — and there are people who have migraines every single day. If I put them on a CGRP and they get a migraine 12 fewer days a month, they’ll be happy.

Now, someone who’s never experienced a migraine might say, “But you still have 18 migraine days.” And the person who’s gotten some relief says, “But there are 12 days that I’m not in bed in a darkened room and able to leave my house.”

They feel like it’s awesome. But I might say, “We might be able to make it a little more awesome. Let’s layer something else on top.” It may even be one of the older medications we use as an adjunct. The combination can be truly amazing.

So, even if you're on a migraine medication that’s working, but still experiencing some migraine days, it's worth talking to your doctor about CGRPs?

Absolutely. We may even be able to titrate them off the older medication which has more side effects.

These medications are far superior. They also work a lot quicker than the older ones. We usually tell people to give a medication at least 12 weeks, but I've seen these work in the first month. These medicines are truly revolutionary. It’s so much fun being a headache doctor now.