Prevention: The Future of Migraine Therapy

Taking a shower hurts. Shaving hurts. Even your hair hurts when you're in the throes of a migraine headache.

Until a few decades ago, people had little more than aspirin to fight the throbbing, debilitating pain of a migraine headache. Then, in the 1980s, researchers developed strong drugs to halt migraine pain once it begins. But those drugs have serious side effects. Some people cannot take them if they are at risk for heart disease or other conditions. Also, if the drugs are not taken within the first hour of migraine headache pain, they don't help much.

These older drugs are still prescribed. But more recently, the approach to taming this lion has made a 360-degree turn. Now, prevention is the focus. It involves disabling a migraine headache before the pain ever begins. One method is to take non-migraine drugs daily to help prevent a migraine from starting. The drugs affect brain chemicals or blood vessel inflammation that lead to migraines.

Another is to fine-tune treatment for each patient. The goal is to take fewer drugs, avoid many side effects, and have better control of the beast. For example, you become aware of your pattern of getting a migraine headache, learn what triggers it, and take certain drugs during your own window of vulnerability - that is, the brief window of time you can most benefit from a drug.

Finding Your Migraine's Window of Vulnerability

The FDA is currently reviewing a new migraine drug called Trexima, which combines the migraine drug Imitrex (sumitriptan) and naproxen sodium (a nonsteroidal anti-inflammatory drug) contained in Aleve and other over-the-counter medications. The triptan prevents blood vessels from dilating. This dilating leads to migraine pain; the anti-inflammatory drug prevents release of an inflammation-triggering enzyme, according to product developers.

Also in the pipeline: A drug that shows promise as both in preventing migraines and in stopping a migraine once one starts, says George R. Nissan, DO, director of research for the Diamond Headache Clinic in Chicago. The drug works by inhibiting a protein released during inflammation, called calcitonin gene-related peptide (CGRP). CGRP is found in high levels in migraine patients.

"We're looking for migraine drugs that don't have the limitations or side effects of antiseizure or blood-pressure-lowering drugs," Nissan tells WebMD. "CGRP doesn't cause constriction of blood vessels, so there would be fewer worries for patients with heart disease, and fewer limitations on its use. However, it may take years until we see it FDA-approved."

Stephen Silberstein, MD, professor of neurology and director of the Thomas Jefferson University Headache Center in Philadelphia, has led pioneering studies into this "window of vulnerability" during a migraine headache.

For certain people, especially women with menstruation-related migraines and others whose triggers are well-defined and predictable, this pre-emptive approach is indeed the future, he tells WebMD. "More studies are looking at taking preventive drugs during that brief window. For patients, it's a matter of getting tuned into your particular pattern."

For those who can't take medications or aren't happy with them, a few supplements also show promise for preventing migraine headaches. "In my own practice, I recommend these if there are at least two well-controlled clinical trials showing benefit," says Sarah DeRossett, MD, a neurologist and migraine specialist in Atlanta. "Magnesium, riboflavin (vitamin B-2), and coenzyme Q10 all fit those criteria."

Migraine Headaches Connected to Hormones, Lifestyle

To understand how all this works, it's helpful to know how migraine headaches develop. The tendency to get them is inherited. They plague teen girls and adult women especially, although a small number of young boys and adult men get migraines as well, researchers say.

Female hormones such as estrogen influence migraines, though it's not clear why. The drop in estrogen levels that occurs a few days before a normal menstrual period seems to increase the chances of a migraine, possibly by priming blood vessels in the brain.

If a woman is taking birth control pills, her headaches are most likely to occur during her "off week," when estrogen levels drops. Some women start getting migraines only at menopause, when their period stops. For others, menopause is the first real relief from migraines.

Lifestyle and environment can also trigger migraines. Weather changes, altitude changes, bright lights, sleep problems, stress, smells, cheeses, caffeine, monosodium glutamate (MSG), nitrates, or aspartame are just some of a long list of potential triggers. Every migraine patient has his or her own headache trigger pattern.

The evolution of a migraine starts with this trigger: When your brain perceives the trigger, it begins a cascade of events. The headache will start developing within two hours or two days. In the beginning, blood vessels in your forehead start to swell up. This causes nerve fibers, which are coiled around the blood vessels, to release chemicals causing pain and inflammation.

A vicious cycle develops: The inflammation makes the blood vessels enlarge even more, making the pain only worse. When this chain-reaction process goes on for an hour or two, it achieves a new threshold.

"It's called 'central sensitization,' and it tends to perpetuate the headache," explains Seymour Solomon, MD, director of the Montefiore Headache Unit at Albert Einstein College of Medicine in the Bronx, N.Y. At that point, the chain-reaction of pain begins traveling along nerve pathways throughout the head, to the base of the neck and to the spine.

That's when everything starts hurting, Solomon tells WebMD. The pain-nerve cells are stuck in the "on" position. The slightest touch or movement hurts. Even the pulse of blood in your brain causes pain. Your intestinal system gets thrown out of whack, too, by the onset of nerve chemicals. You feel nauseous, you throw up, you get diarrhea. Your hands and feet grow cold. The color drains from your face.

There's nothing pretty about having a migraine.