By Merle L. Diamond, MD, as told to Kara Mayer Robinson
As a physician and lecturer specializing in headache medicine, I’m always looking for ways to help patients better manage chronic migraine. Chronic migraine means you have more than 15 days of headache per month, with eight that are migraine.
In the past decade, the FDA has approved many new therapies, including drugs and alternative treatments. There’s been an explosion in migraine research. So there are many new ways to target chronic migraine, with more on the horizon.
The Challenge of Finding the Right Treatment
When you have chronic migraine, finding the right treatment can be challenging. It usually involves a treatment plan that includes more than one approach. Not everyone responds to treatments the same way, so the process often involves trial and error.
This has been a major challenge in treating chronic migraine, but it’s changing.
One major development is that we now have a much clearer picture of what’s happening in the brain of someone with migraine.
Our newer therapies are much more targeted. That means they take direct aim at the changes in the brain and nervous system that happen in migraine. Some targeted treatments work by blocking pain receptors or binding with chemicals that cause pain. Others stop pain signals from being transmitted.
With these advancements, we can develop treatment strategies that are easier to tolerate and more effective for each patient.
New Preventive Medicines
One of the most exciting changes is the explosion of new preventive medications. These drugs aim to prevent migraine so you have more headache-free days.
The drugs that are leading the way block calcitonin gene-related peptide (CGRP). CGRP is a peptide (a string of amino acids) that causes inflammation and transmits pain.
These preventive medications include eptinezumab and rimegepant. Eptinezumab is an IV infusion you get every 3 months. Rimegepant also treats acute migraine pain (once an attack begins).
Everyone’s different, so these medications may or may not work for you.
New Acute Medicines
There are also several new acute medications. Not only do we have triptans, which help with migraine symptoms, but we can now use CGRP medication to stop migraine pain.
Two CGRP medications that help with acute migraine are ubrogepant and rimegepant.
Rimegepant is interesting drug because it’s the first drug we’ve had that can both prevent migraine attacks and stop then once they start.
A big advancement is that some new medications that block or bind to CGRP don’t cause rebound headaches from medication overuse. They’re also incredibly easy for people to tolerate. In the past, patients often had lots of side effects from acute medicines, so they put off using them.
Nerve Stimulation (Neuromodulation) Devices
In addition to medication, there are also wonderful new FDA-approved devices. These can help stop attacks once they start, as well as reduce how many you have.
They’re called neuromodulation devices. They use electric impulses or magnetic pulses to stop migraine from progressing. They’re available by prescription and are very easy to use.
There are two types of neuromodulation. External neuromodulation devices deliver currents to various nerves from outside your head. This type includes:
- Noninvasive vagus nerve stimulation
- Supraorbital transcutaneous stimulation
- Transcranial direct current stimulation
- Transcranial magnetic stimulation
Invasive neuromodulation requires surgery to implant the device. It includes:
- Deep brain stimulation
- Implanted vagus nerve stimulation
- Occipital nerve stimulation
- Sphenopalatine ganglion stimulation
External modulators have very little risk, but invasive methods may have more.
The main issues are cost and access. Some, but not all, of these devices are expensive. While the FDA approved some devices last year, the rollout has been difficult.
Lifestyle Choices Make a Difference
You don’t necessarily need a pill to manage your chronic migraine better.
We now understand that behavioral choices make a difference. I call it meticulous self-care. It starts by managing your triggers.
By identifying triggers, you can change your behavior to reduce migraine. I’ve seen people find 10 different triggers, like fluorescent lights or certain smells. For others, it may be one or two. Triggers are very individual, and vary a lot.
Biofeedback, which I like to call mindfulness with a computer, can also be effective.
We’re starting to identify and study more and more things that may help with chronic migraine. For example, someone is developing a lamp with a green light to reduce light sensitivity and help with chronic migraine.
What's on the Horizon?
We’ve come a long way and there’s more to come in chronic migraine treatment.
New studies are exploring other inflammatory peptides, as well as more sophisticated neuromodulation devices. We hope to have even more information about individual differences so we can find what may work best for each patient.
The explosion of knowledge in migraine will hopefully reduce the burden of the disease and allow patients to fully be present in their lives. We hope one day to have medications and treatments that can stop the disability of migraine.
Merle L. Diamond, MD, president and medical director, Diamond Headache Clinic, Chicago.
Frontiers in Pain Research: "Chronic Migraine Pathophysiology and Treatment: A Review of Current Perspectives."
University of Utah Health: “What’s Next for Migraine Treatment?”