Migraines often do not receive the respect they deserve as a debilitating neurological medical condition. Too often, the ‘headache’ is dismissed as a minor inconvenience or the punch line of a joke. For those who suffer from migraines, however, it is achingly evident that ‘take two aspirin, and call me in the morning’ is no solution at all.

 

“For individuals who have diabetes or asthma or severe heart disease, families, society and physicians are usually very supportive and understanding; but with chronic headache, suffers are often made to feel that the headache is their fault,” said Jan Lewis Brandes, MD, director of Nashville Neuroscience Group, which is affiliated with Saint Thomas Health Services. “I call it the migraine myth,” she continued. “’If I were taller, thinner, smarter, nicer to my mother-in-law, more organized, handled stress better’ … and the list goes on. In reality, migraine is a genetic, biological disorder/disease, which is often under-diagnosed and under-treated.”

 

Brandes, who is also an assistant clinical professor in the Department of Neurology at Vanderbilt University, added, “It doesn’t kill you. It just makes you wish you were dead. It’s kind of the stepchild in neurology.”

 

Despite the misunderstanding surrounding migraines, research has opened new doors to effectively managing the chronic disorder. Fortunately, Brandes noted that for the vast majority of migraineurs, attacks are infrequent. However, one in four migraineurs have attacks on more than 15 days per month. “And there is clear evidence now from long term studies that frequent attacks cause permanent damage in the brain,” she said.

 

Before age 12, migraines are more prevalent in boys. However, after puberty, this severe form of headache is increasingly more common in women. At age 20, the ratio of female to male migraineurs is about 2:1; the rate peaks between ages 42-44 at 3.3:1 before decreasing to 2.5:1 by age 70.

 

However, cluster headache is more common in men throughout life and is attached to a higher incidence of suicide. For both men and women, Brandes said, “Psychiatric co-morbidities, depression and anxiety are typically more common in severe migraine, which may lead to misattributing depression as a cause … not recognizing it as a separate disorder.”

 

For women, there is considerable evidence linking the female sex hormones estrogen and progesterone to migraine. In a scholarly paper, Brandes said the female preponderance of migraine appears largely related to hormonal milestones — menarche, oral contraceptive use, pregnancy, post-partum, perimenopause, menopause, and the use of hormone replacement therapy. At each hormonal milestone, she noted, opportunities for therapeutic management abound. Interestingly, she added, “It’s one of the only neurological disorders that actually gets better with age.”

 

For those with migraines associated with the menstrual cycle, Brandes said a cornerstone of management is to clearly identify the relationship between the cycle and headache days. In addition to a thorough history, a patient diary is a helpful approach with a marked calendar that can be compared over a series of months. In addition to medication, patients should be educated to avoid personal triggers at times of peak vulnerability to migraine.

 

On the other side of the equation, Brandes said, “The very erratic behavior of the ovaries in perimenopause may be the first time women realize they’re migraineurs.” She noted that two-thirds of women who go through natural menopause actually see improvement in migraines. Conversely, she added, “Two-thirds of women who have surgical menopause actually have their migraine worsen.” As for the effect of HRT, Brandes said it could have a significant impact on migraine but is equally split as to whether it makes the condition better or worse — 45 percent of women report improvement, 45 percent worsening, and 10 percent see no change.

 

In addition to minimizing diet, exercise and lifestyle triggers, drug research has made major inroads to reduce migraine frequency, duration and intensity. “Imitrex (sumatriptan) completely changed the face of migraine in this country,” Brandes said of the drug, which received FDA approval 15 years ago. Using triptans was a revolutionary breakthrough in the treatment of migraines, and Treximet soon followed Imitrex into the marketplace.

 

A major concern for migraineurs, however, is the associated risk of stroke. “We’ve long known the risk between migraine and stroke in certain populations — migraine with aura, smoking and oral contraceptives. The relative risk for stroke is 13.9,” explained Brandes.

 

While the pathopysiology of migraines isn’t completely understood, researchers do know episodes typically involve the activation of the trigeminal system and dilation of cranial vessels. Since calcitonin gene-related peptide (CGRP) is present in every area described in migraine origin and levels are increased during a migraine, it has been thought this peptide is significantly involved in the vasodilation. If a medication could inhibit this process, then perhaps the migraine could be aborted.

 

Now, Brandes and others are preparing to launch a menstrual migraine trial using telcagepant, an oral CGRP antagonist, to see if this novel mechanism achieves the desired outcome. “That drug has the potential to be revolutionary because it doesn’t constrict any vessels,” she noted, adding that it would make it safe for patients with vascular disease and might mitigate some of the stroke risks for migraineurs. In Phase I and Phase II trials of telcagepant, the efficacy has been similar to that of triptans, which do not stop vasoconstriction.

 

In addition to seeing new hope with CGRP antagonists, Brandes said neurologists are taking a hard line on preventive measures for patients with elevated heart attack and stroke risks. By taking aggressive measures to treat risk factors, such as hypertension, the hope is that migraine-associated stroke risk will begin to drop.

 

For researchers and clinicians like Brandes, helping patients not just survive … but be able to thrive … with this condition is the biggest payoff. “Very few people understand what incredible work patients have to do to manage their chronic migraine,” she said. “The best it gets for a headache specialist is when someone in an effective treatment program says, ‘I have my life back.’”