Managing your migraine

Several new treatments have come along to help reduce the frequency of migraine attacks and to minimize their often-debilitating pain.

migraine
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By Ejaz Shamim, MD

If you’ve ever experienced the throbbing pain of a migraine headache, you’re not alone. Some 35 million Americans suffer from migraines—about 4 million of those experience them on a chronic basis, meaning 15 days or more per month.

A migraine is a very difficult condition to live with, as I can attest to firsthand: I have suffered from migraines since I was 15 years old. The exact cause of migraines remains a bit of a mystery, but scientists now believe these headaches are probably the result of fundamental abnormalities caused by genetic mutations at work in the brain. It’s not surprising, then, that migraines often run in the family. If you have a parent who has suffered from these crushing headaches, you have a very high likelihood of developing them at some time during your life.

Here’s the good news: In recent years, several new treatments have come along to help reduce the frequency of migraine attacks and to minimize their often-debilitating pain. Moreover, research focus has shifted from simply treating symptoms to actually preventing episodes.

While I’m excited by the potential for these new treatments—and I will describe several below—it’s important to take a holistic approach to migraine treatment. My preferred strategy at the start is to work with patients to understand their unique triggers and patterns. Often, by making some relatively simple lifestyle adjustments over the course of three to six months, patients can greatly diminish the frequency of migraines in their lives and significantly mitigate the need for medication or further treatment.

Knowing your triggers

Migraine triggers vary widely by patient. For some, it’s perfume. For others, it’s drastic weather changes, allergies such as hay fever or certain foods like chocolate, red wine and caffeinated drinks. The most common migraine triggers involve stress and poor sleep. Some patients grind their teeth or snore during sleep, which can trigger migraines.

Patients can find it difficult to understand and accept their triggers. Complicating the picture, sometimes multiple variables are involved: Your migraines might come on, for example, when you are experiencing a period of stress, not getting enough sleep and have indulged in a trigger food such as chocolate.

There are ways to help alleviate headaches without the need for medication. Eliminating triggers is important: Stress management and getting a good night’s sleep are very helpful, as are daily exercise and relaxation techniques, such as meditation, yoga and tai chi. In addition, some over-the-counter supplements like magnesium and vitamin B2 have been found helpful in preventing migraines.

Because there can be several lifestyle variables to address and fine-tuning a treatment regimen can be a complicated process, some people seek what they imagine to be quick relief through medication. But many currently available medications—most of which were not developed specifically for migraines but happen to be helpful in deterring them—have significant downsides with bad side effects like hair loss and weight gain. Frequent use of pain medications can also lead to addiction.

That’s why I believe the best approach for migraine sufferers is to understand and manage their triggers to keep episodes to a minimum and to rely less on medications in managing migraines when they do occur

However, when medication is required, physicians have a variety from which to choose. Over-the-counter analgesics (taken no more than two to three times per week) can help. Beyond analgesics, we prescribe a drug to be taken at the onset of a migraine to lessen its severity. Such medications include a particular class called triptans, which make blood vessels constrict and block pain pathways in the brain. Triptans can be taken by pill, nasal spray or injection.

For chronic migraine sufferers who experience at least 15 episodes a month, we prescribe medication with the goal of preventing migraines from starting. Some of these medications are antidepressants, mood stabilizers or blood-pressure medicines, and some are used for seizure prevention. Needless to say, these medicines carry the risk of significant side effects.

For some chronic migraine sufferers, Botox (botulinum toxin type A) has proven to be a successful treatment. Head and neck injections are given every 12 weeks or so to dull future headache symptoms. Positive results may last up to three months.

Exciting advances

Given the challenges associated with some current medications, I’m encouraged to report that there are exciting new options coming on the scene. At a recent meeting of the American Academy of Neurology, we learned about the effectiveness of a noninvasive new treatment called STMS, or single-pulse transcranial magnet stimulation. Patients hold a small device against the head twice a day and receive magnetic stimulation to prevent migraines. This device can also be used to treat a migraine in progress.

Other relatively new treatments use electrical stimulation that targets nerves in the brain. The Cephaly device is a battery-powered band of plastic that patients wear across the forehead. The band delivers precise micropulses to the upper branch of the brain’s trigeminal nerve to prevent future migraine attacks. The device can be worn for about 20 minutes a day with the only side effect being a slight tingling sensation.

On the medication front, there is a new wave of therapies now in clinical trials. These drugs target an amino acid peptide called CGRP, or calcitonin gene-related peptide, which is believed to play an important role in migraines.

During a migraine, CGRP is released in the brain. When the migraine is over, CGRP also subsides. These new drugs contain antibodies that attack the CGRP itself, keeping it from binding to brain receptors that could cause migraines. In clinical trials, these drugs—which must be injected on a regular basis—prevented migraines before they started. This is the first type of drug to do so.

All of this is good news for patients who have been struggling to manage their condition. Living with migraines is never easy, but with careful trigger management and the availability of new treatment approaches, life will get a whole lot better for migraine patients.

For more information about migraine treatment and research currently underway, visit the National Institute of Neurological Disorders and Stroke’s Migraine Information page.


Ejaz A. Shamim, MD, MBA, MS, is a neurologist with the Mid-Atlantic Permanente Medical Group.

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