Dr. Kevin Most: Migraines
How many times have you heard someone say “I have a migraine”, Unfortunately we have people use the term migraine very generically for a simple headache. Although any headache is not comfortable, those suffering from true migraines will tell you it is a night and day difference. Individuals with true migraines often have symptoms that are debilitating and can be for hours to in some cases days. The migraine can cause nausea and vomiting, severe sensitivity to light and sound and essentially put you in a condition where you are unable to function at work. So although we all have had headaches in the past, only a portion of us suffer from true migraines. That portion of the population is not insignificant, 39 million individuals suffer from migraines in the US. The vast majority of those individuals are women, making up 28 million of the total. Unfortunately 4 million have chronic daily migraines.
We really don’t have a great understanding of what causes migraines, we know there are some genetic factors, some environmental factors but overall the cause is still being studied. Migraines are similar and yet different in all patients so a singular cause is probably not the case
The spectrum of migraines is wide, for some individuals they may suffer one migraine a month, for others though it can be much more severe, with some individuals with chronic migraines suffering 15 days a month.
Many patients actually have a trigger for migraines, it may be a certain food, bright lights, lack of sleep, hunger, hormones, barometric pressure…….. the list goes on. Knowing what your trigger is and avoiding it is great but often not practical.
We also know that women suffer from migraines much more commonly than men, some estimates are that women suffer at a rate 3 times higher than men. This may be do to less men consulting a physician for this problem
How do we diagnose migraines? Well as pain is subjective, meaning I cannot look at you and see pain, the diagnosis is made from the symptoms, the history of migraines in the past and the description of the pain. For most migraine patients the pain will be localized to one side of the head, usually described as throbbing. Some cases can be on both sides but the majority are located on one side. The attacks are often accompanied by nausea, visual problems, vomiting, sensitivity to sound and light and in some cases numbness in extremities and face. Migraines will usually last anywhere from 4- 72 hours. Twenty five percent of individuals who suffer from migraines will have an aura just before the migraine starts, this is often seeing spots or having a visual disturbances. Twenty percent will have the nausea and vomiting before the start of the headache as well.
You can imagine what the impact of this is to the patient and their family. There is also the public health impact which has estimates that lost productivity alone is estimated at $36 billion a year, couple that with over $5 billion a year in healthcare costs and you can see the financial impact. Migraine suffers receive over $1 billion dollars’ worth of CT and MRI scans each year.
A few quick things before we talk about some new treatment options that have recently come out. For most a bad headache is a nuisance, but when do you go to the doctor, when do you go to the emergency room. Headache is one of the mostcommon reasons for an Emergency Room visit. Sometimes this due to a migraine but other times it can be much more serious and needs to be evaluated quickly. If you are not one to get headaches and you get a headache, one of the questions you will be asked, “is this the worst Headache of your life” “did the headache start suddenly”?? Those are signs that this may be due to a bleeding stroke and must be dealt with quickly. Fever, weakness, vision problems or confusion with the headache are all signs that this may be due to other medical conditions. Women who are pregnant and have severe headaches also need to be evaluated for other concerning illnesses associated with pregnancy.
One thing patients have to understand is that the ER doctor is not a migraine specialist, their goal is to make sure that there are no other life threatening illnesses causing the headache. Emergency Room physicians will treat headaches differently as there is no set protocol for treating a migraine. Physicians are using less and less opioid medications as the addiction problem is highlighted daily. The medications given in the ER often will not give long lasting results so it is important that you have a relationship with a primary care physician in the community who is treating you for this condition on an ongoing basis. Your primary care doctor will discuss preventive plans with you and be up to date on the newest treatments.
Treatment in the past was focused on medications that would treat the headache after it started. The goal was to get the headache to at least decrease to a point where the nausea and vomiting had resolved or that the headache had decreased to a point of some comfort. The bad thing about the medications are the side effects associated with them. Sure we can often lower the headache level but if the medication makes you so tired that still can’t function, we have made the patient more comfortable but not more functional. For years this was essentially the goal of treatment, break the cycle or lower the symptoms of pain.
We all know that taking blood pressure medication on a daily basis and exercising will keep our blood pressure low and decrease our chance of having a stroke or heart attack. The goal over the past 10-20 years was to work on prevention for migraines as well, be it eliminate triggers or find medication that may prevent the migraine from advancing. There are drugs that can be taken daily to prevent migraines from occurring. These medications do not work in all patients but having that discussion with your doctor is important. It is even more important now as some new medications have just come out in the past few months. In fact earlier this spring a whole new class of drugs was approved that will fight migraines before they start.
The goal for the migraine patient is to eliminate the chance of a migraine from even starting. In May the FDA approved a new class of drugs to fight migraines before they start. This new class of drugs actually doesn’t stop the headache, it essentially blocks the chemical that increases the pain in the brain. Studies of patients with migraines found this compound increases within the course of a migraine, so researchers thought if they could block this compound that headaches would decrease. Think of it as the chemical that essentially is a volume control, as it increases the pain increases, so if we can keep it lower the pain is not allowed to advance. There are 4 drugs now in this class that hopefully will eliminate or minimize the migraine symptoms. As with all new medications it does come with some cost, currently it costs around $600 a month. Now we may think that is high but from a patient point of view or an employer point of view that may not be the case. One would hope that insurance companies would cover this knowing the patient will be more comfortable and functional. The value of lower or no pain allows the quality of the patient’s life to improve.
So these drugs are new, how are they working? Is this a “cure”. It is not a cure, but it has been shown to decrease the frequency in many individuals and also as important is that this new class has far fewer side effects than current options. Studies have shown that up to 25% of patients will not take preventative medications due to cost and side effects. Having an affordable drug with lower side effects will make a big impact in the quality of the patient and their families lives. These new drugs are not for everyone and in fact the safety in pregnant patients is a concern as this class of medication can cause elevated blood pressure.
You may have heard that Botox may also be used to treat migraines. You may want to know how having your wrinkles removed could help with a headache. It actually works in a different way. Botox is approved for chronic migraines, that means more than 15 days of suffering each month. Botox temporarily reduces muscle contractions, thus no wrinkles. Well it also blocks the release of chemicals that aid in the transmission of pain between nerves, so it is able to prevent the activation of pain networks in the brain. It is not for everyone but for those it works for this series of injections may block migraines for up to 3 months.
Other novel treatments, include nerve stimulators, these handheld devices were approved by the FDA earlier this year. This device is placed on the neck and it releases mild stimulation to a specific nerve. This treatment was studied with good results and is a treatment option for the patient who has episodic migraines.
Overall I think the medical field had been frustrated with the advances made in the treatment of migraines over the past 10-20 years, however the advancements made in the past year are encouraging and perhaps we are hitting a tipping point and these patients may be closer to a time of less suffering