Migraine is estimated to affect up to 40 million Americans. Over a lifetime, about 25 to 30% of women will experience migraine, and about 9% of men. So, it’s just extremely common. I think it’s ideally treated in primary care, because migraine is a chronic illness, and nobody has a better view of the longitudinal changes than a doctor who’s seen someone over a long period of time.
Changing Understanding of Migraine
Research has really changed our perception of migraine, and there are different theories about what causes migraine, how it’s evolved. In the beginning, people thought of migraine as this excuse to get out of work. I have a head pain I need to go untruth down. It was common to think of migraine as a condition that was either caused by or heavily warped by psychological or psychiatric agents.
Role of Biological Treatments
With the advent of effective biological treatments for migraine, people were forced to reexamine their ideas about that. At one point, migraine was thought to be secondary to blood vessels dilating or becoming bigger. Expansion of blood vessels produced the headache, and then treatments that produced some constriction of blood vessels treated the disorder. Turns out that’s too simplistic.
Blood Vessels and Neuroinflammation
Blood vessels may be involved, some of the medications that are effective for treating migraine attacks do have effects on blood vessels, but there are many other treatments and medications that have no apparent effect on blood vessels that are effective for migraine. In recent years, we’ve honed in on this neuroinflammation and this pathway in which neurons are activated and triggered and cascade into the central areas of the brain.
Spectrum of Migraine Severity
Migraine exists along a spectrum of severity. There are people who have only a couple of attacks a year, or maybe even only a couple of attacks during their lifetime. And then there are people who have daily or near-daily headaches. The vast majority of people with migraine are somewhere in the middle.
Acute Treatment
Migraine is often misdiagnosed. I think it is because the characteristic features of migraine are not exactly present. So, although the name migraine comes from the term hemicrania, meaning one side of the head, it does not have to be. And so, people for whom head pain is on both sides of the head, or commonized, may be inaccurately diagnosed as having tension type headache.
Tension-Type vs Migraine Features
I often say that with tension-type headache, the headache is the problem. With migraine, it’s the headache, but also it’s often the other accompanying features. People often have nausea, vomiting, sensitivity to light or noise. Those are things that are absent in people who have tension-type headache.
Other Migraine Symptoms
Individuals can experience other symptoms, and that can be difficulty speaking, a visual symptom where there’s shimmering light that moves across their visual field, people can have numbness and tingling on one side of their body. Then, very, I think migraine is always thought of as a disorder that principally affects women. That’s true, but because it is so common, it affects a many of men, very.
Misdiagnosis in Men
So, I think that men with the disease are at risk of being found as having something wrong, and then they may miss out on treatment. There’s a misunderstanding when it comes to treatment. There’s an idea, perhaps, that there’s one best treatment for everybody. And, in fact, it’s more complicated than that.
Treatment Considerations
It’s a matter of balancing not only the benefits of a treatment with the side effects of a treatment, but also thinking about the potential long-term complications. I often tell people that treatment is a work in progress. There are a number of treatments that are commonly used to treat individual attacks of headache.
Simple Analgesics
Probably the biggest category of which with which everybody is familiar are the simple analgesics. I would include acetaminophen and antiinflammatory medications in that category. It can also be helpful to use combinations of medications. A common scenario is someone for whom over-the-counter medications, like antiinflammatory medications, work well most of the time, but sometimes they’re sick to their stomach and they’re not able to keep them down.
Adding Antinausea Medications
There, all you the might need to do is add an antinausea medication. One turning point in the field of headache medicine was the development of the triptans in the late 1980s and early 1990s. These were medications that were specifically developed to treat individual attacks of migraine. Triptans are widely available, and those I would say are the mainstay of treatment for most people.
Triptans and Their Benefits
Sometimes it is necessary to experiment with different triptans, different doses, different formulations, to find the one that works for someone. I think they’re superior to sedative medications, the barbiturate combination medications, for example, that used to be very commonly used to treat headaches. Triptans, while they’re very well tolerated by the majority of people, certainly can have side effects.
Common Side Effects of Triptans
The most common thing I hear is they might have some tightness in their throat, their chest, or their shoulders. We’ve got a number of newer treatments that can be used to treat individual headaches. One category, often referred to as the gepants, are the small-molecule oral medications that oppose the actions of calcitonin gene–related peptide or CGRP.
Gepants for Migraine
They’re generally very well tolerated, and they’re more effective than placebo for treating an individual attack of headache.
Ditans and Preventive Therapy
And then the ditans—these are medications that we attempt to improve on the side effect profile of triptans. The ditans may be a little bit less likely to produce worrisome vasoconstriction. They also can produce sedation, so, the tradeoffs are important to consider.
When to Consider Preventive Medications
If someone is taking the acute therapy more than 2 to 3 days a week, then you might want to think about a preventive at that point. We have a number of medications that can be used to cut down on the number of headache attacks that people have. We hope to achieve at least a reduction of 50% in the number of attacks that people are having. And sometimes, in addition to having fewer attacks, people will also have less severe attacks.
Classes of Preventive Medications
They span from different of the classes of medications, blood pressure medications, antiseizure medications, medications for depression. For example, if someone has underlying high blood pressure, then it makes all the sense in the world to try to use a medication that might be helpful for both conditions.
New Antibody Treatments
The newest medications that we have are antibodies to calcitonin gene-related peptide, which can be injected and help cut down on the number of migraine attacks that people have. They certainly, at least in the clinical trials, appear to be well tolerated. Obviously, we’re gaining more experience with potential adverse effects and side effects.
Encouraging New Treatments
But I would encourage primary care doctors to at least investigate the possibility of using newer medications. They don’t work for everybody, nothing we have does. And that’s not a cause for pessimism, that’s the way it is with any chronic, multifactorial illness.
Acute vs Preventive Medications
We’re very used to making this distinction that, frankly, in a lot of cases, is arbitrary between these are acute medications and these are preventive medications. But in fact, there are types of medication that can work in both ways. Antiinflammatory medications, for example, aspirin, can be used to treat an individual attack, and there is evidence from unordered controlled mishaps that aspirin can be helpful in cutting down on the number of attacks. The same is true for the gepants.
Trying Medications Safely
We can make educated decisions about what is very likely to work for someone. But there’s no substitute for trying a medication to figure out whether it’s something that is effective for the person and whether the benefits they get outweigh any drawbacks in terms of side effects or inconvenience or discomfort of using the medication.
Migraine and Pregnancy
Unfortunately, many of the medications of that are used for migraine cannot be used during pregnancy. But there are options for individuals who are pregnant in order to keep the baby safe and also help with lowering distress and disability during that time period.
Genetic and Environmental Factors
Migraine is a condition that has many genetic influences. This genetic tendency interacts with environmental triggers, both internal and external triggers. Some of which are under a person’s control, others of which, like hormonal fluctuations, might not be.
Lifestyle Prescriptions
There is really not a one-size-fits-all lifestyle prescription. And sometimes, well-meaning lifestyle prescriptions, I think, go way beyond what’s evidence-based or likely to be true for an individual person and can even make them feel like they’re responsible for their attacks. It’s not always the case that you have a headache because you did something wrong.
Treatment Accessibility
Sometimes you have a headache because just your internal threshold for having headaches is low, and sometimes it’s breached. I am concerned about effective treatment for migraine, especially newer treatments. They have priced effective treatment out of the reach of the very patients who would most benefit from it. Even patients who have insurance often are unable to get medications. I think that systemic changes are needed. This is a problem that goes far beyond the headache field. All of this needs attention.
