As a neurologist who has cared for many patients experiencing
migraines and chronic
headaches, I can confidently state that rarely are two patients’ experiences
the same. What one person may find debilitating, another may experience
as only a nuisance. Some people can maintain a high quality of life with
specific headache symptoms, while others may be unable to work or live
well while experiencing those symptoms. Alas, migraine headaches can be
as unique to the individual as a fingerprint.
With June designated as Migraine and Headache Awareness Month, it feels
like an appropriate time to discuss the current standards of care for
migraine headaches, the advantages and limitations of available treatment
options, and ways for people who experience migraines to determine what
the “right” treatment is for their unique set of circumstances.
A basic tenet of any migraine treatment is the need to understand that
this can be a progressive condition, which may escalate and worsen if
not treated appropriately. The “Stratified Care” approach
to migraine treatment that this
neurologist prescribes advocates for individualizing the intensity and aggressiveness
of intervention based on the severity of the headache in the individual.
Less aggressive and more conservative approaches are reasonable if there
is mild or moderate effect on an individual’s function, quality
of life, or safety. However, as the severity and consequence of the migraines
increase, it is reasonable to be more aggressive in treatment –
without adhering to a “stepwise” approach of intervening with
conservative measures, then evaluating response and escalating after proving
a failure. In other words, bringing out the big guns (aggressive intervention)
may be recommended with severe or potentially consequential migraine headaches
– even early on. Also, attention is paid to abortive treatments
(to stop a migraine that has started) and prophylactic treatment (daily
or routine intervention for prevention and reduction in severity or frequency).
I also round out this approach with a recommendation to include holistic
treatment approaches. That means avoiding triggers, optimizing
sleep and overall well-being, reducing
Traditional medication treatments are many and also fall into the abortive
and preventive categories. Migraine medications aim to either stop an
episode quickly once it has begun or to prevent it from happening in the
first place. Medication therapy for migraine headaches, like medication
for most other conditions, diseases, or illnesses, can come with plenty
of side effects that patients may find as undesirable as the migraine
itself. However, a relatively new and promising category of medications
act on specific brain receptor - the Calcitonin Gene-Related Peptide Receptors
(CGRP). These drugs are developed specifically for migraine treatment.
They may more directly impact the pain and symptom pathways specific to
migraine than other medications that have historically been available.
In addition, there is increasing interest in
neuromodulation (applying electrical or magnetic stimulation to nerves) as a treatment
for migraine that doesn’t require prescription drugs.
All these approaches augment and build on current practices. The migraine
treatment toolbox is expanding for patients and caregivers alike–
and that’s a great development. It must, however, be accompanied
by improved education, recognition, and access for all to the emerging
options. Too often, there are recommendations made that may be helpful
to a wide range of individuals. Yet, plenty of migraine sufferers lack
insurance coverage or the financial/economic ability to pursue state-of-the-art
treatments available to everyone who needs and deserves them.
Additional work is needed to level the treatment playing field by addressing
some of the
health equity issues we see in the diagnosis and treatment of migraine. There is also
a need to further refine our approach to migraine treatment that results
from or increases after
concussion and other forms of
traumatic brain injury. Finally, the emergence of modern pain science provides an opportunity
to influence migraine treatment by recognizing how migraine mechanisms
compare to other forms of chronic pain and the role of social and environmental
risk factors in the development of migraine. If they haven’t already,
those who suffer from chronic migraines should make it a priority to seek
out medical attention. A neurological expert can help find ways to cope
with migraines so that patients don’t suffer in silence.