Migraine — Treatment and Preventive Therapies | NEJM

Summary

Migraine, affecting up to 40 million Americans, is a common yet complex chronic illness with varying severities. Historically misunderstood as psychologically influenced, research now points to neuroinflammation and blood vessel involvement. Treatments range from simple analgesics to newer CGRP antibodies, with a focus on individualized care due to the condition's multifactorial nature. Despite advancements, accessibility to effective treatments remains a challenge, highlighting the need for systemic change.

Takeaways

• 👩‍⚕️ Migraine is a common condition affecting up to 40 million Americans, with a higher prevalence in women (25-30%) compared to men (9%).
• 🏥 Migraine is best managed in primary care due to its chronic nature, benefiting from the longitudinal care provided by a consistent healthcare provider.
• 🧬 Research has evolved our understanding of migraine, moving away from psychological causes to recognizing it as a complex neurological disorder.
• 🚫 The historical misconception of migraine as an excuse for avoiding work has been debunked with the development of effective biological treatments.
• 🔍 The cause of migraine is multifactorial, involving neuroinflammation and activation of neurons leading to central brain area involvement.
• 📉 Migraine severity varies widely, from a few attacks a year to daily occurrences, with most people experiencing moderate frequency.
• 🤔 Misdiagnosis is common due to the non-uniform presentation of migraine symptoms, which can mimic tension-type headaches.
• 💊 Treatment options for migraine are diverse, including simple analgesics, triptans, gepants, and ditans, each with their own benefits and side effects.
• 🔄 Preventive treatments aim to reduce the frequency and severity of migraine attacks, using a variety of medication classes tailored to individual needs.
• 🤰 Migraine management during pregnancy requires special consideration, with some medications being contraindicated and alternative treatments needed.
• 🌐 Migraine has genetic components and is influenced by environmental triggers, necessitating personalized lifestyle and treatment approaches.
• 💸 The cost of newer migraine treatments can be prohibitive, limiting access for those who need them most, highlighting the need for systemic changes in healthcare.

Q & A

How common is migraine in the United States?

Migraine is estimated to affect up to 40 million Americans, with about 25 to 30% of women experiencing migraine over a lifetime and about 9% of men.

Why is primary care considered the ideal setting for treating migraines?

Migraine is a chronic illness, and primary care doctors who have seen a patient over a long period of time have a better view of the longitudinal changes, making them well-suited to treat migraines.

How has the understanding of migraines evolved over time?

Initially, migraines were thought to be an excuse to avoid work or heavily influenced by psychological factors. However, with the advent of effective biological treatments, the understanding has shifted towards neuroinflammation and activation of neurons in the brain.

What was the initial theory about the cause of migraines?

The initial theory was that migraines were caused by blood vessels dilating or becoming bigger, leading to headaches due to the expansion of blood vessels.

Why is it incorrect to think that all migraines involve blood vessel dilation?

While some medications effective for treating migraines do have effects on blood vessels, many other effective treatments and medications have no apparent effect on blood vessels, indicating that the cause is more complex.

What is the spectrum of severity for migraines?

Migraine exists along a spectrum of severity, ranging from people who have only a couple of attacks a year to those who have daily or near-daily headaches, with the majority of people falling somewhere in the middle.

Why is migraine often misdiagnosed?

Migraine is often misdiagnosed because its characteristic features are not uniformly present, and it can present with symptoms that overlap with other types of headaches, such as tension-type headaches.

What are some common misconceptions about migraines?

Migraines are often thought of as a disorder that principally affects women, and there's a misconception that there's one best treatment for everyone, whereas treatment needs to be individualized considering benefits, side effects, and potential long-term complications.

What are some of the newer treatments for migraines?

Newer treatments include gepants, which are small-molecule oral medications that oppose the actions of CGRP, and ditans, which attempt to improve on the side effect profile of triptans.

How often should acute migraine therapy be used before considering preventive treatment?

If someone is taking acute therapy more than 2 to 3 days a week, it might be appropriate to consider preventive treatment to reduce the number of headache attacks.

What is the goal of preventive treatment for migraines?

The goal of preventive treatment is to achieve at least a 50% reduction in the number of attacks, and sometimes to also reduce the severity of the attacks.

How do genetic influences and environmental triggers interact in migraines?

Migraine has many genetic influences that interact with both internal and external environmental triggers, some of which are controllable and others, like hormonal fluctuations, are not.

What concerns does the speaker have about the accessibility of effective migraine treatments?

The speaker is concerned that newer, effective treatments for migraines are often priced out of reach for many patients who would benefit from them, and even those with insurance may struggle to access these medications.