In this episode, TRC Healthcare editor, Rachel Cole, PharmD, evaluates 3 new migraine treatments: Atzumi, Brekiya, and Symbravo. She’ll explain their dosing techniques and how they compare to existing therapies, while providing practical guidance on clinical considerations and cost-effective alternatives for acute migraine management.
This is an excerpt from our August 2025 Pharmacy Essential Updates continuing education webinar series.
CE Information:
TRC Healthcare offers CE credit for this podcast for pharmacist subscribers at our platinum level or higher and pharmacy technician subscribers. Log in to your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose.
The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights:
- Article: Stay Up to Date on “New” Migraine Meds
- Chart: Drugs for Acute Migraine
- Chart: Migraine Prophylaxis
- FAQ: Medication Overuse Headache
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Transcript:
This transcript is automatically generated.
00:00:04 Narrator
Welcome to Clinical Capsules from TRC Healthcare, your go-to podcast for fast, evidence-based insights.
00:00:11 Narrator
On this episode, Assistant Editor and Clinical Pharmacist Rachel Cole dives into the evolving landscape of acute migraine treatment, spotlighting three newly approved medications, Atzumi, Brekiya, and Symbravo, and how they compare to tried-and-true therapies… in an excerpt from our popular Pharmacy Essential Updates webinar series.
00:00:31 Narrator
TRC has been a trusted resource for healthcare professionals for over 40 years—and now we’re bringing that expertise straight to your ears every 2nd and 4th Tuesday, in bite-sized, actionable episodes…right here on Clinical Capsules.
00:00:45 Narrator
And new starting this month… this podcast offers Continuing Education credit for pharmacist subscribers at our platinum level or higher and pharmacy technician subscribers.
00:00:55 Narrator
Please log in to your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses.
00:01:03 Narrator
None of the speakers have anything to disclose. With that, let’s get started…
00:01:14 Rachel Cole
Our article says that three new meds for acute migraine have recently been approved. We’re going to put the hype about these meds in perspective, since they’re just new versions of old meds and also outline their role in therapy.
00:01:28 Rachel Cole
So migraine is a complex neurological dysfunction, leading to a headache with moderate to severe throbbing or pulsating pain. We usually see migraine more often in females, and genetics also plays a role. Since we see these types of headaches run in families and there’s still a lot we don’t know about this condition.
00:01:48 Rachel Cole
A migraine is usually felt on one side of the head, and patients often also experience additional symptoms with the headache like nausea, vomiting, sensitivity to light and sound, and some patients also experience what’s known as aura, which can look like flashing lights, blurred vision or facial tingling
00:02:07 Rachel Cole
And migraine affects up to 15% of the general population.
00:02:12 Rachel Cole
So let’s meet Mary and keep her case in the back of our minds as we walk through the content today and we’ll swing back around to her as we conclude. So Mary is a 23 year old female college student with a family history on her moms side of migraine. Mary started to have migraines when college was especially stressful, and she’s presently had four so far, about 1 migraine per month.
00:02:35 Rachel Cole
She’s only tried acetaminophen so far, with little relief. She has no cardiovascular history or drug allergies, and we can think on some treatment options for Mary as we walk through the treatments.
00:02:48 Rachel Cole
So there’s two approaches when treating migraine headaches, preventing migraines from occurring before they start, which is recommended for those having weekly migraines or too severe migraines per month. These meds are usually taken regularly to reduce their frequency and severity of migraine attacks, and they include CGRP.
00:03:08 Rachel Cole
Targeting agents, ACE inhibitors, angiotensin receptor blockers and several more that you can review on our updated resource, Migraine Prophylaxis, on our website.
00:03:19 Rachel Cole
Abortive therapy is to treat migraines as needed, preferably as soon as possible. When the migraine begins, and will typically see OTC non opioid analgesics, triptans and dihydroergotamines as an example.
00:03:36 Rachel Cole
So in treating acute migraine, it’s important to individualize therapy choices, and the choice should be based on what the onset of the migraine looks like.
00:03:46 Rachel Cole
Is it rapid or slow? Are there other symptoms like Aura preceding the pain? How frequent are they? How severe? Is the patient still able to work? Or are they completely debilitated? Do they need to also manage nausea and vomiting?
00:04:01 Rachel Cole
Do they have comorbid conditions like cardiovascular issues since some of our treatment options have contraindications with these types of conditions?
00:04:11 Rachel Cole
Recommend patients start their meds ASAP with the right drug and avoid medication overuse headaches, and consider combination therapy like possibly an NSAID plus a triptan.
00:04:24 Rachel Cole
Medication overuse headache, also known as rebound headache, is a chronic headache condition that develops from the frequent and excessive use of acute headache medications. It’s characterized by headaches occurring on 15 or more days per month for at least three months following the overuse of pain relievers for other headache conditions.
00:04:44 Rachel Cole
So in essence, the medications you use to treat headaches end up causing more headaches.
00:04:52 Rachel Cole
And some of the big culprits for this are the use of opioids or butalbital. These pose the highest risk for rebound headaches. Triptans are also a frequent cause, mostly due to their widespread use. Also, ergot derivatives, or dihydroergotamines, also known as DHE.
00:05:11 Rachel Cole
Then some combo analgesics, especially those with caffeine and possibly lasmitidan , but has a much lower risk.
00:05:21 Rachel Cole
Now let’s move into our treatment options for acute migraine. These include NSAIDs like ibuprofen or naproxen, our triptans, acute CGRP, or our gepants , lasmiditan or Reyvow, and our dihydroergotamines or DHE.
00:05:39 Rachel Cole
So remember, we’re always going to ask what the patient has tried before and the result and that will give us a place to.
00:05:45 Rachel Cole
Start if adequate pain relief isn’t achieved within two hours after a dose of a non opioid analgesic like an NSAID or acetaminophen or a combo agent. Recommend moving up to a migraine specific agent based on the patients response in prior migraine. How well they tolerate certain meds.
00:06:06 Rachel Cole
And their risk factors. So before moving up in treatment, the dose should be optimized or you can possibly try a different NSAID.
00:06:16 Rachel Cole
If the patient is not getting adequate relief from OTC analgesics in general, recommend a quicker acting oral triptan such as rizatriptan or Sumatriptan and think of naratriptan or frovatriptan for longer lasting or recurrent migraines. But these take longer to kick in and think about it in injection.
00:06:36 Rachel Cole
Or nasal spray for patients who have severe nausea or vomiting and don’t rely on oral disintegrating tabs for quick onset since they still need to be absorbed in the gut.
00:06:47 Rachel Cole
Recommend starting at the Max single dose such as oral rizatriptan, 10 milligrams or Sumatriptan 100 milligrams and taking the triptan as soon as possible at migraine onset and tell patients to take the same triptan for at least 2 migraines with redosing if needed before calling it a failure.
00:07:07 Rachel Cole
And explain that it may take a few tries to find one that works best, and don’t be surprised if you see some experts mix or alternate triptans, such as using an oral triptan for mild migraine or a nasal formulation if the patient is vomiting.
00:07:22 Rachel Cole
But it is contraindicated to use two different triptans within 24 hours, or to use a triptan within 24 hours of an ergot derivative, and if a patient uses any triptan more than two days per week, we want to consider a preventative.
00:07:38 Rachel Cole
Approach to limit medication overuse headache. It’s also important to remember that several cardiovascular conditions, such as heart disease, a history of stroke or TIA, uncontrolled hypertension or peripheral vascular disease, are contraindications for using triptans.
00:07:58 Rachel Cole
So this is one of our new meds. Symbravo is the new oral meloxicam, 20 milligrams rizatriptan 10 milligram combo tablet for acute migraine with or without Aura joining the only other NSAID triptan combo tablet Treximet or Naproxen 500 milligrams, Sumatriptan 85 milligrams.
00:08:19 Rachel Cole
You’ll hear reps tout that its delivery system enhances meloxicam’s absorption and solubility to provide pain relief within two hours and up to 24 hours for some patients, even if taken later in the migraine attack.
00:08:32 Rachel Cole
Symbravo has led to pain freedom in two hours in 2.5%, 8.3%, and 13% more patients than rizatriptan meloxicam or placebo, but there was no comparison to a triptan and NSAID taken simultaneously, and it cost about.
00:08:52 Rachel Cole
$1100 for 9 tablets and may not be covered by insurance, so instead recommend lower cost options such as taking these two meds individually or whatever NSAID and triptan combo works for your patient.
00:09:07 Rachel Cole
So our CGRP antagonist may be harder to access than triptans due to cost or payer requirements. So consider these for adults who can’t use triptans or who have failed 2 triptans. They’re generally well tolerated. The current cardiovascular safety data is reassuring and they don’t appear to cause medication overuse headaches.
00:09:30 Rachel Cole
This next medication works similarly to triptans, but on a different receptor subtype, so it has a different effect on blood vessels, lasmiditan or Reyvow can be used in patients with contraindications to triptans or those who have failed two triptans. And this is a controlled substance. So keep this in mind.
00:09:50 Rachel Cole
And the side effects include feeling tired and drowsy, so the patient should not drive or operate machinery within 8 hours after taking the medication.
00:10:00 Rachel Cole
The other two new medications are different formulations of dihydroergotamine Atzumi nasal powder and Brekiya subcutaneous autoinjector. So these two medications will join the nasal spray and IV forms that have been available for years, but all are options for acute migraine with or without aura.
00:10:21 Rachel Cole
But don’t expect these new forms of DHE to change its role for acute migraine. We want to continue to save DHE for patients not responding to first line treatment such as triptans.
00:10:31 Rachel Cole
And ask patients about any cardiovascular medical history. Since DHE is contraindicated in uncontrolled hypertension, ischemic heart disease, and several other cardiovascular conditions, and carries risk for serious adverse effects such as stroke and patients with factors predictive of coronary artery disease like smoking.
00:10:52 Rachel Cole
High cholesterol should receive their first dose in a healthcare facility, plus is contraindicated in pregnancy and we can anticipate that these new DHE formulations will be expensive and require prior authorization.
00:11:06 Rachel Cole
So Atzumi nasal spray is indicated for acute migraine with or without aura, and the patient will pump the Atzumi device three times into the same nostril while inhaling to get the 5.2 milligram dose and will not prime it before use or the dose will be wasted, the dose can be repeated once after at least one hour.
00:11:28 Rachel Cole
Brekiya or the new Autoinjector formulation, is also indicated for cluster headaches. In addition to migraine, with or without aura, and patients will inject into the mid thigh to deliver the 1 milligram dose and may repeat at one hour intervals with a maximum of 3 milligrams in 24 hours.
00:11:49 Rachel Cole
For those patients suffering with nausea and vomiting, metoclopramide or Prochlorperazine can be effective if needed, as these may improve the efficacy of the migraine medications by helping to manage the GI symptoms. Other options are ondansetron and promethazine.
00:12:07 Rachel Cole
Some drugs we want to avoid as options when treating migraine are opioids and butalbital containing products. Since these have a high risk of causing medication overuse headaches, they have limited evidence of efficacy and migraine and can lead to rapid tolerance and have the potential of abuse and dependence.
00:12:28 Rachel Cole
So swinging back around to our patient, Mary, what are the best options for initial treatment of Mary’s migraines? Well, since she hasn’t tried anything besides acetaminophen at this point with little effect, adding an NSAID would be a logical next step, like naproxen, ibuprofen, dosed optimally and with some food to protect the stomach.
00:12:48 Rachel Cole
After trialing an NSAID/acetaminophen combo, the NSAID can be switched. For example, switching to a naproxen if ibuprofen isn’t getting results to see if she gets better results.
00:13:00 Rachel Cole
Then we can move to trying a triptan, possibly Sumatriptan, that has several formulation options, and again the Med should be chosen based on our individual headache profile and then we can possibly move up to a triptan/NSAID combo if needed.
00:13:17 Rachel Cole
We’d want to counsel Mary about avoiding possible migraine triggers and see if she’s already pinpointed anything. Some examples are waiting too long to eat. Hormones can be a trigger for those experiencing menstrual migraines. Emotional stress can be a trigger for Mary, since her migraine started during stressful times in college and we could help her.
00:13:36 Rachel Cole
Strategize how to control her stress levels.
00:13:41 Rachel Cole
And for those experiencing severe nausea and vomiting, migraines that intensify quickly or are occurring upon awakening, consider an injection or a nasal spray formulation to bypass the GI issues and hopefully have a quicker onset.
00:13:58 Rachel Cole
So to wrap up, we want to help patients identify and avoid migraine.
00:14:02 Rachel Cole
Triggers, recommend they take their migraine medication as soon as possible at onset and also to be cognizant of medication overuse headaches and know when to suggest preventive migraine medications. Counsel patients on side effects of their chosen medication and consider the other medications they take and comorbidities.
00:14:23 Rachel Cole
Especially cardiovascular conditions.
00:14:27 Rachel Cole
After choosing the best medication, it’s important to monitor for side effects and adjust treatment as needed and encourage patients to keep a headache diary to track triggers and treatment efficacy.
00:14:39 Rachel Cole
And finally, remember our patients with frequent migraine and using acute migraine treatments are at risk of developing medication overuse headaches. So limit use of acute meds to less than 10 days per month and consider preventative therapy in patients with frequent migraines.
00:14:57 Rachel Cole
Check out our resources online, Drugs For Acute Migraine and our frequently asked questions on medication overuse headache.
00:15:08 Narrator
We hope you enjoyed and gained practical insights from listening to this episode!
00:15:13 Narrator
Now that you’ve listened, pharmacist subscribers at our platinum level or higher and pharmacy technician subscribers can receive CE credit.
00:15:21 Narrator
Just log into your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses.
00:15:30 Narrator
We’ve linked the resources we mentioned—and more on today’s topic—right in the show notes. Those links will take you straight to our websites, where you’ll find even more concise, evidence-based charts, articles, and tools.
00:15:43 Narrator
If you’re not yet a subscriber, now’s the time—sign up today to stay ahead with trusted, unbiased insights, and continuing education. And as a listener, you can save 10% off on a new subscription with code cc1025 at checkout.
00:16:00 Narrator
Also, be sure to explore our other TRC content—podcasts like Medication Talk and Rumor vs Truth, plus our full Pharmacy Essential Updates webinar series for deeper dives.
00:16:12 Narrator
Thanks for listening… stay sharp, stay current—and we’ll catch you next time on Clinical Capsules!
Clinical Capsules
