Clinical Pearls & Morning Reports
Migraine is highly prevalent and is the seventh leading cause of time spent disabled worldwide, yet it has received relatively little attention as a major public health issue. Although often simplistically characterized as a “bad headache,” a migraine attack typically includes a variety of premonitory symptoms that may occur hours before the headache begins and postdromal symptoms that last for hours after the headache ends. Read the Clinical Practice report.
Q. Are there effective therapies to prevent migraine?
A. There is no evidence supporting a specific “threshold” migraine frequency for which preventive therapy is clearly warranted, although it is generally agreed that preventive therapy should be considered if migraine occurs at least once per week or on 4 or more days per month. Identifying a preventive therapy that is both effective and has few side effects in patients with migraine remains challenging. All currently available preventive therapies for migraine were initially developed for other indications and have been secondarily adopted as treatments for migraine. Adverse effects are common for most of the preventive therapies, and patients often report an initial response that “wears off” despite increasing doses. Adherence to treatment is generally poor.
Table 4. Selected Preventive Therapies for Migraine.
Q. What are some of the general guidelines for the management of migraine?
A. Current medications should be reviewed as possible exacerbating factors. Consistency of lifestyle factors (diet, caffeine intake, sleep, and exercise) should be encouraged. Administration of therapies for acute migraine early in an attack, before symptoms are severe, is associated with better efficacy than later administration. It is therefore important to educate patients to recognize premonitory symptoms so that they can initiate treatment as soon as pain begins, or even beforehand.
Table 3. Selected Therapies for Acute Migraine.
A: Many persons with migraine have not received a correct diagnosis, in part because of a traditional focus on the severity and quality of pain as the primary diagnostic criterion. Although migraine headache is characteristically severe, unilateral, and throbbing, it may also be moderate, bilateral, and constant in quality. The features of migraine other than headache, particularly sensitivity to light and sound, nausea, and interference with the ability to function, may be more useful in diagnosis than the character of the headache. Neck pain is another common symptom of migraine, but it is frequently misinterpreted as a manifestation of a disorder in the cervical spine, often leading to unnecessary scans of this region. Patients or physicians frequently believe that migraine is related to sinus disease, whereas the majority of patients who receive a diagnosis of “sinus headache” in fact have migraine.
A: The nature and source of neurochemical mediators that trigger migraine attacks are being actively investigated. Migraine is associated with the release of a number of neurotransmitters and neuromodulators, including the neuropeptides calcitonin gene–related peptide (CGRP) and pituitary adenylate cyclase–activating peptide (PACAP). Administration of these peptides can provoke migraine attacks in susceptible persons, suggesting a causative role. Small-molecule antagonists of the CGRP receptor have shown efficacy as therapies for acute migraine. Monoclonal antibodies to CGRP or its receptor have shown consistent efficacy as preventive therapies for migraine in multiple large phase 2 and phase 3 clinical trials. These monoclonal antibodies will probably soon be under consideration by the Food and Drug Administration for approval for clinical use as preventive therapies.