If you do not suffer from migraine headaches, you
probably know at least one person who does. Nearly 40 million Americans get
them — 28 million of them women and girls — making migraine the second most
disabling condition in the world after low back pain.
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Several studies have found that migraine became more
frequent during the pandemic, too.
I get migraine headaches, but thankfully they are
more bizarre than excruciating. Every few weeks, ocular migraine clouds my
vision with strange zigzagging lights for a half-hour; and once or twice a year
I get attacks that cause temporary memory loss. (One came on while I was
grocery shopping, and I could not remember what month or year it was, what I
was there to buy, or how old my kids were.)
Despite its ubiquity, research on migraine has long
been underfunded. The National Institutes of Health spent only $40 million on
migraine research in 2021; by comparison, it spent $218 million researching
epilepsy, which afflicts one-twelfth as many Americans. Why is this devastating
condition so woefully understudied?
“It’s a woman’s disease,” explained Dr Robert Cowan,
a neurologist, and a former director of the Stanford Headache Program. In other
words, he said, sexism almost certainly plays a role in medicine’s apathy
toward the condition.
The good news is that over the past several years,
the medical establishment has become more interested in the issue, and a
handful of new treatments for migraine have been approved by the US Food and
Drug Administration. Some of them are quite promising.
Here is what migraine sufferers should know about
today’s treatment landscape.
Recognize the
symptoms of migraine and get a diagnosis
Far too many people with
migraine suffer in silence. “Fewer than 30 percent of people suffering with
migraine seek medical advice, and only some of those patients will receive an
appropriate migraine treatment,” said Dr Santiago Mazuera, a neurologist at the
Sandra and Malcolm Berman Brain & Spine Institute in Baltimore.
Migraine is a neurological disorder and it differs
from garden-variety headaches. People are likely to suffer from migraine if
they have had at least five headache attacks in their lives, each lasting
between four and 72 hours, and if the pain fulfills two out of these four
criteria: It throbs or pulsates; it is on one side of the head; it is moderate
to severe; it worsens with activity. Also, these attacks must cause either
nausea or sensitivity to light and sound.
If you think you might have migraine, see your
primary care practitioner, Mazuera suggested. “There is better understanding of
migraine within the primary care community in recent years and more knowledge
about the newer treatments,” he said.
But if you are not getting the help you need, you
might want to see a headache specialist or neurologist, said Dr Seniha
Ozudogru, a neurologist at Penn Medicine. People with migraine are also at
increased risk for other disorders, including heart disease, stroke, epilepsy,
anxiety, and depression.
Try lifestyle
changes and first-line treatments to start
If you have migraine,
consider keeping a headache diary, or downloading a migraine app, to identify
possible triggers. Women, for instance, often have migraine pain right before
their period; it can be treated in a variety of ways, including with an
estrogen patch, Cowan said. Other common migraine triggers include stress, too
much or too little sleep, caffeine, alcohol, weather changes, certain foods,
dehydration, light, and particular smells, according to the American Migraine
Foundation.
Often, triggers are partial and additive: You might
not get a migraine attack after drinking one glass of red wine, but a glass of
red wine and a bad night’s sleep might do it, Cowan said. A headache diary can
also help you identify your triggers and figure out if you have chronic
migraine, which is defined as having headaches on 15 or more days per month for
more than three months, and when at least eight of those headaches have
migraine-like features.
Based on your symptoms and their frequency, your
doctor may recommend a preventive migraine treatment to stop the headaches from
starting. These types of medicines include antidepressants like amitriptyline,
blood pressure medications such as propranolol, and epilepsy drugs including
valproate, Cowan said.
The problem with these drugs is that often “they
have nasty side effects,” Cowan said, so they are not always recommended or
tolerated. I briefly took propranolol to control my migraines, but every time I
exercised, I felt lightheaded and faint.
If you cannot get
relief, discuss new treatments with your doctor
Over the past five years, a handful of new drugs and devices have been
approved for prevention and acute treatment of migraine.
Many of these drugs block the activity of a
pain-related protein called CGRP, Ozudogru explained. These include, for
migraine prevention, monoclonal antibodies that are periodically injected or
administered intravenously. There are also pills, called gepants and ditans
(with brand names like Nurtec ODT, Ubrelvy and Reyvow) that can be taken at the
onset of migraine to block the activity of CGRP.
Rimegepant (Nurtec ODT) has been approved by the FDA
to both prevent and treat migraine, Ozudogru said, which is notable because
most drugs do only one or the other.
These drugs do not seem to have significant side
effects, Cowan said — though they can cause mild nausea — yet they are not
usually prescribed until after a person has tried several first-line
treatments. That’s in large part because the new drugs are expensive, he said.
Ozudogru said some doctors are also cautious about trying the latest treatments
because they are so new, and nobody can say how safe they are over the long
term. Among other things, CGRP helps the body heal from strokes, so drugs that
inhibit CGRP activity might hinder recovery in someone who has a stroke, she
said.
Another medication that has been approved to treat
chronic migraine in particular is the cosmetic drug Botox. It is injected into
areas around the head and neck and is thought to work by blocking chemicals
that carry pain signals to the brain. “I like Botox a lot,” Cowan said. But, he
added, “not everybody can tolerate being stabbed in the head 31 times, even
with a tiny needle.” Usually, too, Botox treatment is repeated every 12 weeks.
Several medical devices have also been approved in
recent years to manage migraine. “These have good data,” Cowan said, and they
are ideal for people who cannot tolerate medicines or are pregnant. Gammacore,
a hand-held device, targets the vagus nerve in the neck. Nerivio, a
smartphone-controlled device worn on the arm, uses electrical signals to
disrupt pain pathways. Cefaly stimulates the trigeminal nerve on the forehead,
and Relivion stimulates the trigeminal and occipital nerves.
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