Migraines are Often Debilitating, But New Treatments Offer Hope for Sufferers

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July 29, 2020


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A migraine isn’t just a garden-variety headache. This neurological condition is the third most prevalent illness in the world. Affecting one in 10 Americans, migraines not only affects quality of life, it has serious social and economic consequences as well, with an estimated 157 million workdays lost each year in the U.S. due to migraines.  

“A migraine is often debilitating, it’s often worse when you exert yourself in any way and a patient may have to lie in a dark room,” explains Brad Herskowitz, M.D., a neurologist with Miami Neuroscience Institute at Baptist Health South Florida. “The unpredictability of migraines affects patients as well. I fill out a lot of FMLA (Family and Medical Leave Act) forms for patients with migraine at the workplace, because they often have to miss time and they’re worried about keeping their jobs.”

A wide variety of treatments offer hope to migraine patients, from over-the-counter pain relievers to prescription medicines and injections — to a new class of medications called CGRP antagonists. Dr. Herskowitz discusses these alternatives in the latest episode of the Baptist HealthTalk Podcast, hosted by Jonathan Fialkow, M.D., deputy medical director, chief of cardiology and a certified lipid specialist at Miami Cardiac & Vascular Institute.

Their discussion also covers migraine symptoms, causes, diagnosis and a warning about taking too many doses of over-the-counter medications. Check out the Q&A highlights below, and listen to the complete podcast, which is available on your computer or smartphone or via Apple Podcasts and Google Podcasts.

Dr. Fialkow:
“What are the signs and symptoms that one may have or feel that would make you say, ‘Yes, this sounds like a migraine headache?’”

Dr. Herskowitz:
“Migraines have certain classification criteria. And the headaches, the classic headaches or migraines are usually one-sided or unilateral throbbing or pounding. And then there are associated features which are nausea and/or vomiting, light and noise sensitivity, sometimes smell sensitivity. So, these are the classic features that would categorize someone’s headache as a migraine.”

Dr. Fialkow:
“What are the kinds of symptoms that someone would feel that would make you feel it is a tension headache which is very common, or a sinus headache?”

Dr. Herskowitz:
“A tension headache is sort of a headache that is more of like a band constricting the head. It’s fairly constant pressure versus the migraine, which is throbbing. A tension headache is more of a dull kind of headache at the end of the day. You know, not terribly bothersome. You can kind of go about your activity. A lot of people confuse sinus headaches with migraines. And I find (some) patients who think they have sinus headaches actually have migraines. So, you know, that distinction is important to decipher in patients.”

Dr. Fialkow:
“When the headache goes away, does the person feel well? Aren’t there circumstances where there’s a more debilitating aspect of a migraine? Can you elaborate on that a little bit?”

Dr. Herskowitz:
“Yes. Well, migraines can often have an aura prior to the headache where they feel the headache coming on, whether it’s a visual symptom, whether it’s flashes of lights or zigzag lines followed by a headache, which can last from hours to days. And then, often, what we call the post drone, which is after the headache is over, there’s this sort of hangover effect or feeling the brain is often heavy and sloshy. They just don’t feel normal.”

Dr. Fialkow:
“Do you diagnose migraine basically on getting a good history of the symptoms? Are there any tests or anything that say, ‘Aha, it’s a migraine?’”

Dr. Herskowitz:
“It’s based on clinical criteria, the patient’s symptoms, if they fit the criteria that I discussed earlier, which is the throbbing pounding one-sided, headache, nausea, light, and noise sensitivity. That’s pretty much a migraine. That’s enough for me. I think that any patient who has migraines or headaches, who’s never had a brain imaging study, such as an MRI of the head ,should have one, at least once in their lifetime, just to make sure there’s nothing else. But there is no imaging study that tells me this is a migraine.”

Dr. Fialkow:
“How about who’s at risk for migraines? Are there age groups where it more likely to start? Is it gender related?”

Dr. Herskowitz:
“We find that women are three times more affected than men. I think about 18 percent of the United States females have migraine headaches. And the age group is generally young, 18 to maybe the 40s. So, it’s kind of that age group, more common in females than males, which is representative of my practice. You are more likely to have a migraine if you have a family member with a migraine. So, there is some genetic preponderance. However, that doesn’t come in to clinical practice very much… we don’t do genetic testing. Maybe some time in the future, this will be clinically relevant but at this point it’s not.”

Dr. Fialkow:

“What about causes of migraines? Can you speak to what we know scientifically or don’t know?”

Dr. Herskowitz:
“We don’t know why people get migraines. Again, we think there’s this genetic component to it, but a lot of patients do not have a family history. I would say most patients probably don’t have triggers, even though we look for them, they don’t have them. However, patients that do have triggers and that’s something that I do in my office – every patient who comes in with migraines, they get a headache calendar to record their headaches, the frequency of them, the severity, the duration of them. Then we give them a food trigger list. And I discuss with them to look at these different foods. So common triggers would be stress, would be not sleeping well, not drinking enough fluid, maybe not staying hydrated. And then foods like red wine, certain cheeses, nuts, excessive caffeine, things like that are common triggers that patients find that may be causing their headaches. And it’s important because if you limit the triggers, you limit the frequency of headaches.”

Dr. Fialkow:

“What are the treatments that are available that you’ve found have an impact and for which scientific studies show there is a benefit?”

Dr. Herskowitz:
“In general, there are two ways to treat migraines. One is the acute treatment. When you get a headache, you take a medication. And then there are preventative medications to take to prevent the frequency and severity.

“So as far as the acute treatment of migraines, there’s the simple over-the-counter stuff that people try that work for them. Excedrin, Fioricet, Tylenol, Advil, Advil migraine … those things. And if that works for you, great. But (for) a lot of migraineurs, that’s not effective.

“There’s a new class of migraine medications called the CGRP antagonists, which stands for ‘calcitonin gene related peptide.’ And that is a peptide that is released by these nerves called the trigeminal nerves in and around the brain that cause inflammation. And they cause dilation of the blood vessels in the brain, which cause the pounding throbbing headache. And scientists have shown that if you affect the CGRP or limit the activity of the CGRP molecule, that that will limit migraines.

“We found that in both acute treatments, with two new medications called Ubrelvy and Nurtec — and those are taken at the onset of a headache — what they do is they antagonize the CGRP molecule and/or receptor … not allowing the CGRP to cause this basal dilation or dilation of blood vessels or the inflammation we see … thereby limiting the severity of the migraines and the duration. So those two have been very effective.”

Dr. Fialkow:
“What about preventative treatments?”

Dr. Herskowitz:
“The patients who require prevention are the ones that have a significant frequency, more than two a week. Those medications, there’s kind of old-school stuff that you know about Jon, like the beta blockers and calcium channel blockers. I don’t, that’s not my first line, but those are something that can be effective. Antidepressants can be effective. There’s a drug called topiramate or Topamax, which is an antiepileptic, but also FDA-approved for migraines, which can be very effective. But (with) this new class of preventative CGRP injections, there’s three of them on the market called Aimovig, Ajovy, and Emgality. And they are injections that people inject every 28 days themselves into the skin. And they have been very effective for patients with episodic migraines, less than 15 days per month.

“Also, not to be too long-winded, but Botox injections are FDA-approved for migraine headaches as well. I happen to be an expert injector for Botox and for the company Allergan. Patients with chronic migraines, meaning migraines more than 15 days per month, meet criteria for Botox injections. And these have been unbelievably effective in a certain population with the chronic migraine aura, going from 15 or 20 headaches per month to none, which is remarkable. So, these are the different options that patients can discuss with their neurologist.”

Dr. Fialkow:
Any final comments you’d like to make?

Dr. Herskowitz:
“I think one last topic I would address would be medication overuse headaches, or we call them a transformed migraine, and this is very common in patients. Migraineurs who are undertreated or not treated sufficiently can take a lot of over the counter medications… and they actually cause more headaches by a withdrawal effect. And we find that a certain percentage of patients who come to the office have this almost chronic daily migraine, where they have a regular migraine that is transformed into this type of chronic headache… So, I would tell anybody out there listening; if you’re taking excessive amounts of these medications, more than a couple of days per week, you can do harm to your body. You can make your headaches worse. Go see a neurologist. There’s a lot we can do for these patients.”

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