Migraine affects more women and requires personalized treatment

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If you don’t suffer from migraines, you probably know at least one person who does. Nearly 40 million Americans have it — 28 million of them are women and girls — making migraine the second most disabling condition in the world after back pain. Several studies have found that migraines have also become more frequent during the pandemic.

I have migraines and headaches, but luckily they’re more bizarre than terrible. Every few weeks, the ocular migraine obscures my vision with strange zigzag lights for half an hour. And once or twice a year I have attacks that cause temporary memory loss.

(One of these occurred when I was shopping and I couldn’t remember what month or year it was, what I had gone shopping for, or how old my kids were.)

Despite migraine being so common, research into the condition has long been underfunded. The US National Institutes of Health spent just $40 million on research into this condition in 2021; by comparison, they invested $218 million in epilepsy research, which afflicts 12 times fewer Americans. Why is this devastating condition so sadly understudied?

“It’s a women’s disease,” explained Robert Cowan, a neurologist and former director of the Stanford Headache Program. In other words, he said, sexism almost certainly plays a role in medicine’s apathy toward this disease.

The good news is that over the last few years the medical community has become more interested in the issue and several new treatments for migraine have been approved by the FDA (Food and Drug Agency of the US government). Some of them are quite promising. Here’s what migraine sufferers should know about the current treatment landscape.

Identify symptoms and get a diagnosis

Many of those who have migraines suffer in silence. “Less than 30% of people with migraine seek medical advice, and only a few of these patients will receive adequate treatment,” said Santiago Mazuera, a neurologist at the Sandra and Malcolm Berman Institute of the Brain and Spine in Baltimore.

Migraine is a neurological disorder and differs from common headaches. People are likely to suffer from migraine if they have had at least five headache attacks in their lifetime, each lasting from four to 72 hours, and if the pain meets two of these four criteria: throbbing or pulsing; occurs only on one side of the head; is moderate to severe; worsens with activity. In addition, these attacks should cause nausea or sensitivity to light and sound.

If you think you might have migraines, see your primary care doctor, suggested Mazuera. “There has been a better understanding of migraine in the primary care community in recent years and more knowledge about the latest treatments,” he said.

But if you’re not getting the help you need, you might want to see a headache specialist or neurologist, said Seniha Ozudogru, a neurologist at Penn Medicine. People with migraines are also at higher risk for other disorders, including heart disease, stroke, epilepsy, anxiety and depression.

Make lifestyle changes

If you have migraines, consider keeping a headache journal or downloading a migraine app to identify potential triggers. Women, for example, often have migraine pain just before menstruation. It can be treated in a number of ways, including with an estrogen patch, Cowan said.

Other common migraine triggers include stress, excess or lack of sleep, caffeine or alcohol intake, weather changes, certain foods, dehydration, light and specific odors, according to the American Migraine Foundation.

Often, the triggers are partial and additive: You may not get a migraine after drinking a glass of red wine, but a glass of red wine and a bad night’s sleep can trigger it, Cowan said.

A headache diary can also help you identify your triggers and find out if you have chronic migraine, which is defined as headaches on 15 or more days a month for more than three months, and when at least eight of those headaches have migraine characteristics.

Based on symptoms and frequency, your doctor may recommend a preventative migraine treatment to stop the headache from starting. These types of medications include antidepressants like amitriptyline, blood pressure medications like propranolol, and epilepsy medications including valproate, Cowan said.

The problem with these drugs is that they often “have unpleasant side effects,” the doctor said, so they’re not always recommended or tolerated. I took propranolol briefly to control my migraines, but every time I exercised I got dizzy and passed out.

If you don’t see improvement, look for new treatments

In the last five years, a handful of new drugs and devices have been approved for the prevention and treatment of acute migraine.

Many of these drugs block the activity of a pain-related protein called CGRP, explained Ozudogru. These include, for the prevention of migraine, monoclonal antibodies that are periodically injected or given intravenously.

There are also pills, called gepantes and ditans (with brands like Nurtec ODT, Ubrelvy, and Reyvow) that can be taken at the onset of a migraine to block CGRP activity. Rimegepant (Nurtec ODT) has been approved by the FDA to prevent and treat migraines, Ozudogru said, which is notable because most drugs do just one thing or another.

These drugs don’t appear to have significant side effects, Cowan said — although they can cause mild nausea — but are usually not prescribed until a person has tried several first-line treatments.

That’s mainly because the new drugs are expensive, he said. According to Ozudogru, some doctors are also cautious when trying the latest treatments because they are so new and no one can say whether they are safe in the long term. Among other things, CGRP helps the body heal from strokes, so drugs that inhibit CGRP activity can make it harder for someone who has a stroke to recover, she said.

Another drug that has been approved to treat chronic migraine is the cosmetic drug Botox. It is injected into areas around the head and neck and is believed to work by blocking chemicals that carry pain signals to the brain.

“I really like Botox,” Cowan said. But, he added, “not everyone can handle being poked 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 control migraines. “They have good data,” Cowan said, and they are ideal for people who cannot tolerate medication or are pregnant.

Gammacore, a handheld device, targets the vagus nerve in the neck. Nerivio, a smartphone-controlled device applied to the arm, uses electrical signals to interrupt pain pathways. Cefaly stimulates the trigeminal nerve in the forehead and Relivion also stimulates the occiput.

Translated by Luiz Roberto M. Gonçalves

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