Abstract
The road ahead for migraine treatment depends on targeting pharmacological therapies to known pathophysiological mechananisms. Acute medications of the future may include calcitonin gene-related peptide antagonists, various glutamate antagonists, and serotonin 1F receptor agonists. New formulations of older medications include effervescent diclofenac, an orally inhaled dihydroergotamine, and sumatriptan iontophoretic patch and needless injection, all either approved in the US or in phase III trials. Preventive future treatments may include the use of botulinum neurotoxin type A for chronic daily headache and gabapentin enacarbil for episodic migraine, in addition to hormonal treatments and a potential for neuromodulators, but the preventive pipeline is far less developed. In the US, the United Council for Neurologic Subspecialty Board certification for headache medicine should raise quality of care and research in the future.

Keywords
Migraine, acute treatment, preventive treatment, future treatment, calcitonin gene-related peptide (CGRP), dihydroergotamine (DHE), sumatriptan, botulinum neurotoxin type A, gabapentin enacarbil

Disclosure: Susan L Hutchison, MD, has served as a consultant or been an advisory board member for Endo Pharmaceutical, Forest Pharmaceutical, GSK, Merck, NuPathe, Ortho- McNeil, and Pfizer, is on the speakers’ bureau for Endo Pharmaceutical, Forest Pharmaceutical, GSK, Merck, and Pfizer, and has participated in research studies for GSK. Stewart J Tepper, MD, has received grants and research support from ATI, GSK, MAP, Merck, and St Jude, has served as a consultant and advisory board member for GSK, MAP, and Merck, and is on the speakers’ bureau for GSK, Merck, and Valeant.
Received: December 15, 2008 Accepted: August 17, 2009
Correspondence: Susan L Hutchinson, MD, Director, Orange County Migraine & Headache Center, PO Box 54726, Irvine, CA 92619-4726. E: drhutchinson@ocmigraine.org