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.
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 headache.
I need to go lie down.
It was common to think of migraine as a condition that was
either caused by or heavily influenced by psychological
or psychiatric factors.
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 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.
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.
Migraine is often misdiagnosed.
I think it's because
the characteristic features of migraine are not uniformly present.
So although the name migraine comes from the term
hemicrania meaning one side of the head,
it doesn't have to be.
And so people for whom
headache is on both sides of the head,
or generalized, might be inaccurately
diagnosed as having tension-type headache.
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.
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 too, I think migraine is often
thought of as a disorder that principally affects women.
That's true,
but because it's so common, it affects a lot of men, too.
So I think that men
with the disorder are at risk
of being diagnosed as having something else,
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.
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.
Probably the biggest category
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.
There all you 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.
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.
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.
They're generally very
well tolerated
and they're more effective than placebo for treating an
individual attack of headache.
And then the ditans—these are medications that
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.
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.
They span from different 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.
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. 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.
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 categories
of medication that can work in both ways.
Antiinflammatory medications, for example, aspirin
can be used to treat an individual attack
and there's evidence from randomized controlled trials
that aspirin can be helpful
in cutting down on the number of attacks.
The same is true for the gepants.
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.
Unfortunately,
many of the medications 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.
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.
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.
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
and it needs attention at a congressional level.
I'm excited about where we are in terms of
understanding migraine
and by the momentum that I see.
People who are suffering and are disabled by migraine
deserve to feel better.