Migraine is a neurological condition characterized by recurring headaches felt as a throbbing pain on one side of the head.
Other symptoms include nausea, dizziness, and increased sensitivity to light and sound.
Between 14% and 15% of the world’s population are affected by migraine. Women are 2 to 3 times more likely than men to have the condition.
Recently, several new ways of treating migraine have emerged, including pharmacologic and non-pharmacologic interventions.
In this story, Medical News Today spoke with five experts to understand more about the status of different treatments for migraine.
What is migraine?
The exact cause of migraine is unknown. However, the condition is thought to have a strong genetic basis.
Pain during a migraine headache occurs due to temporary changes in the nerves and blood vessels in the brain. Migraine episodes can be broken down into five phases:
-
Prodrome: A “pre-headache” signaling the headache will start. Symptoms may include mood changes, food cravings, and constipation.
-
Aura: Sensory disturbances such as temporary loss of sight, flashes of light and numbness, and tingling in a part of the body.
-
Headache: throbbing, drilling, neck pain, and stiffness.
-
Postdrome: Last stage of a migraine episode, including fatigue, inability to concentrate, and depressed mood.
-
Interictal: the interval between two migraine episodes.
Not all patients experience all five phases. For example, just 25 to 30% of people with migraine experience aura. The phases also do not necessarily occur in this order. ie. aura and headache can occur at the same time.
Current standard of care for migraine
MNT spoke with Dr. J. Wes Ulm, a bioinformatic scientific resource analyst and biomedical data specialist at The National Institutes of Health, about the current standard of care for migraines.
“The mainstay of treatment for acute migraine episodes is an empirically-determined regimen of non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen, ibuprofen, or diclofenac [and] standard over-the-counter analgesics like aspirin or acetaminophen,” Ulm explained.
“A longstanding class of prescription drugs known as triptans, such as sumatriptan, almotriptan, and frovatriptan [are also considered standard of care],” he added. “Triptans belong to a drug class known as serotonin-receptor agonists, which counteract the physiological processes that bring on migraines, for example, by diminishing the increased blood flow (vasodilation) of blood vessels around the brain. [They also mitigate] the pain signals that register as the pain itself- the so-called trigeminovascular mechanism.”
Ulm noted that all of these drugs tend to be well-tolerated, although their efficacy varies, especially for severe migraine.
He added that prolonged or high doses may have adverse effects. NSAIDs can cause peptic ulcers and kidney damage, while triptan use can cause unpleasant sensations.
MNT also spoke with Dr. Vernon Williams, a sports neurologist, pain management specialist, and founding director of the Center for Sports Neurology and Pain Medicine at Cedars-Sinai Kerlan-Jobe Institute in Los Angeles.
He noted that holistic approaches are also recommended, which mean avoiding triggers, optimizing sleep, maintaining overall well-being, reducing stress, and exercising regularly.
Emerging treatments for migraine headaches
When asked about emerging treatments, Ulm noted that two new drug classes known as gepants, including rimegepant, atogepant, and ubrogepant, as well as ditans such as lasmiditan have recently gained approval by regulatory bodies.
“Gepants essentially target one of the primary underlying causes of migraines – a molecule known as calcitonin gene-related peptide (CGRP) – while ditans more selectively home in on the same serotonin receptors targeted by triptans, with fewer side effects,” Ulm noted.
Studies show these drugs can be used in people with cardiovascular disease who cannot take triptans.
“There is also interest in the potential for a liquid form of celecoxib – another NSAID which may be of value in some cases of migraines – and improvements in anesthesia,” Ulm added.
Dr. Vanessa Cooper, a neurologist at Yale Medicine in Connecticut, told MNT that non-pharmacological neuromodulation devices, which stimulate the nerves electrically or magnetically, may also be effective:
“The remote electrical neuromodulation (REN) device (Nerivio) activates peripheral nerves in the upper arm ultimately leading to conditioned pain modulation and provides a nonpharmacological option for patients,” she said. “A second device that combines occipital and trigeminal external stimulation (Reviolon) also provides a nonpharmacological option for patients who may have been unable to tolerate traditional pharmacological therapy.”
Nonpharmacologic therapies for migraine
“There are many people who do not respond well to any of the medications or have side effects to them, even the newer ones. And the newer medications are generally quite expensive and some people do not have access to them. There are also people who prefer an approach that does not use medications,” Dr. Howard Schubiner, an internist and clinical professor at Michigan State University College of Human Medicine, told MNT.
For these patients, Schubiner said he has found that therapies such as pain reprocessing therapy, emotional awareness, and expression therapy can effectively relieve pain from conditions such as migraine.
“There is a strong relationship between migraine and stressful life events and are more likely in people who have had traumatic experiences early in life. Some people can readily see those connections and are interested in exploring them,” he said. “Our brains can respond to stressful life events by generating a variety of physical responses, including anxiety, insomnia, abdominal or pelvic discomfort, neck or back pain, and different types of headache, of which migraine is one. These symptoms are 100 percent real; not imagined.”
New vs. old treatments
When asked about how emerging treatments compare to the current standard of care, Williams said:
“All of these approaches augment and build on current approaches. The toolbox is expanding – and that’s a good thing. It must, however, be accompanied by improved education, recognition, and access to the emerging options. Too often, there are recommendations made that may be helpful to individuals, but they lack coverage or the financial/economic ability to pursue state of the art treatments.”
Cooper added: “According to the American Headache Society, surgical procedures for the treatment of migraine are not the current standard of care as these results have not yet been confirmed by a large clinical trial, these procedures are expensive and complications from implanted hardware are common.”
Dr. Howard Pratt, D.O., the behavioral health medical director at Community Health of South Florida, Inc. (CHI), told MNT that as a physician, he enjoys having as many treatment options available as possible.
He noted that new methods make treatment more accessible to those who previously had limited options, such as those with cardiovascular disease.
When asked what research is needed to improve migraine treatment options, he said:
“It’s very important to find, if possible, the underlying conditions for migraines that are treatable, and to identify for the individual patients, what their potential triggers for migraine are, as well as following standard of care and reassessing data.”