Migraine

What's new in migraine?

More Americans — about 36 million — suffer from migraine than have asthma or diabetes combined.

• It affects women disproportionately (~18% of women vs 6% of men in the US)
• Migraine without an aura occurs in ~85% of patients; migraine with an aura occurs in about 15%-20%.

New therapies

October 2010: Botox (onabotulinumtoxinA; Allergan, Inc) was approved for the treatment of chronic migraine.

• Botox for injection is specifically indicated for the prophylaxis of headaches in adult patients with chronic migraine.

Recent research showing that migraine has a neurological, rather than vascular, pathophysiology has generated a strong pipeline of both acute and preventative agents targeting the peripheral and central nervous systems. Agents under investigation include:

Newer migraine medications are becoming available in alternate delivery forms, including nasal sprays, needle-free injection systems, oral dissolving films, sustained-release patches, and inhalers.

Updates on diagnosis

Evolving internationally accepted diagnostic criteria have facilitated the differential diagnosis among migraine subtypes, and neuroimaging studies have advanced the field in recent years.

What is a migraine? What causes migraines?

• Recently updated definition as an inherited neurological disorder
• A common type of headache that may occur with symptoms such as nausea, vomiting, sensitivity to light, or a throbbing pain felt on only one side of the head
• Some patients experience aura, or warning symptoms, before the actual headache begins
• Acute migraine attacks may be triggered by alcohol, stress and anxiety, certain odors or perfumes, loud noises or bright lights, smoking, or certain foods

In some cases, clinical manifestations of a migraine headache may resemble symptoms of a brain tumor, but in a patient with a normal neurological exam, the primary complaint of headache is rarely related to a brain tumor.

Management challenges

Nearly 40% of migraine sufferers are candidates for prophylactic therapy, but only about 10% currently receives it. In April 2012, the American Academy of Neurology and the American Headache Society published new guidelines outlining effective treatments that can prevent migraine attacks and lessen their severity. The guidelines state:

• Anti-epileptic drugs, such as Depakote (divalproex sodium), Topamax (topiramate), and sodium valproate, as well as several beta blockers can reduce the number and severity of migraine attacks
• Lamictal (lamotrigine), a seizure drug, was not shown to prevent migraine
• Data supporting the prophylactic use of calcium-channel blockers are insufficient
• Frova (frovatriptan) is effective against menstrual-related migraines
• The antidepressant Effexor (venlafaxine) has some preventative benefit
• OTC drugs and herbs, such as ibuprofen, naproxen, vitamin B2, and butterbur, may also play a role in prevention

Current challenges in the management of migraine involve using these guidelines to individualize treatment based on patient preference, comorbid conditions, dosing frequency, cost, and other factors.

Costs

Due to its disabling symptoms, migraine leads to both medical expenses and lost productivity and costs more than $20 billion annually in the US. However, managing chronic migraines with behavioral approaches (ie, relaxation training, hypnosis and biofeedback) could save a migraine sufferer about $500 per year over pharmacologic treatment, according to a 2011 study.