Finding the Right Migraine Treatment

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PHYSICIAN VOICES
An Expert's Perspective on New Migraine Treatments

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Dr Nathaniel Schuster

Migraine can be challenging to control, but new treatments have changed the game in recent years. Dr. Nathaniel Schuster, a neurologist and pain and headache specialist, explains what patients should know about treating migraine.

1. Q: How has our understanding of migraine changed in recent years?

A: Migraine is a complex neurological disease and we're still learning more about the underlying causes. Historically, people believed it was a disorder related to the blood vessels, calling it a "vascular headache." Then, over the last couple of decades, research started pointing in a different direction, towards the brain and nerves. Now, we believe migraine is closely related to certain areas of the brain that are hyper-excitable in people with migraine, such as the cortex and brainstem, as well as the trigeminal and occipital nerves. Not all migraines have identifiable triggers, but some common triggers include different foods, caffeine, alcohol, strong smells, sleep deprivation, and hormonal changes. Additionally, “medication overuse” or “rebound” headaches are now recognized to be another common reason that migraines may become worse; using some common over-the-counter acute (quick-acting) migraine medications more than two to three days a week can cause migraines to worsen.

2. Q: How have migraine treatments advanced?

A: Today, there are quite a few new treatments available for migraine. In 2010, onabotulinum toxin type A (Botox) was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic migraine, which is defined as having at least eight migraine days and at least 15 headache days per month. Since then, Botox has become a helpful and effective option for many patients. Additionally, other new technologies have been introduced to treat and prevent migraines, including neuromodulation devices that work by sending electric or magnetic impulses to different nerves or areas of the brain. Worn on the forehead, back of the head, or the neck, these neuromodulation devices stimulate different nerves or areas of the brain involved with migraine and have been shown to abort and prevent migraines for some, but not all, patients. Additionally, new CGRP-targeted therapies were approved by the FDA this year and have shown great success in cutting down migraine frequency for many patients. It’s a very exciting time to be in this field.

3. Q: What are the benefits of these new treatments?

A: The therapies that are now available are gamechangers for many patients. First of all, often they’re better tolerated with fewer side effects than some of the older medications. Of course, no treatment is effective for everyone, and I still use the older treatments often because they are effective for many people, are covered by insurance, and we know their long-term safety. But the fact that there are newer injectable CGRP-targeted monoclonal antibodies is a big benefit for patients. Now, they don’t have to remember to take daily or twice-daily pills; instead, they give themselves an injection once a month or once every three months, depending on which drug they’re prescribed. And the new neuromodulation devices are noninvasive—meaning they don’t need to be surgically implanted—which is a huge plus.

4. Q: How do CGRP-targeted therapies work?

A: CGRP stands for calcitonin gene-related peptide, and it’s a small protein that’s known to be involved in migraine. We know levels of CGRP are higher during migraines, which led researchers to develop CGRP-targeted monoclonal antibodies; these injectable drugs bring down the levels of CGRP in the body, thus lowering the frequency of migraine attacks. There are a few CGRP-targeted medications approved by the (FDA), including erenumab (Aimovig), galcanezumab (Emgality), and fremanezumab (Ajovy), with more on the way. In clinical studies, they’ve reduced migraine frequency by 50% in about half the people that tried them. It’s good to keep in mind that CGRP is a part of migraine, but it’s not the only part; these treatments are not a cure-all. However, for those who do respond well, CGRP-targeted monoclonal antibodies can make a big impact on quality of life.

5. Q: How do neuromodulation devices work?

A: In addition to CGRP-targeted monoclonal antibodies, new neuromodulation devices are also improving the landscape of migraine treatment. These devices are applied to different areas of the head or neck and work in different ways to impact the brain. They have been used as acute (quick-acting, pain-relieving) treatments for the last few years, but now one of them has been approved for preventative treatment. The Cefaly device, also called a transcutaneous supraorbital neurostimulator (tSNS), is worn every day on the forehead for 20 minutes to prevent migraine. Another device, the gammaCore device, is a noninvasive vagus nerve stimulator (nVNS), which is held up to the neck and is FDA-approved to treat migraine attacks acutely. The third device, the sTMS mini, is an occipital single-pulse transcranial magnetic stimulator (sTMS) held up to the back of the head; it is FDA-approved to treat migraine attacks acutely and to prevent them.

6. Q: What does the future look like for migraine treatment?

A: I’m very optimistic about the future of treating migraine. For a long time, there were few advances in migraine treatment, but in the last year we’ve seen several effective treatment options come to the market that were specifically developed to treat and prevent migraines. Most of the preventative therapies available before this were initially produced to treat other conditions; for example, doctors prescribe blood pressure medications, antidepressants, and anti-seizure medications to try to prevent migraines. Those don’t work for everyone, so these new prevention medications can offer options to people who really need them. There are also more and more physicians training to be headache and migraine specialists. A headache specialist will be the most knowledgeable about new treatments and discoveries about migraine, but historically there haven’t been many available. However, there are now more working in the field today than ever before, which is good news for every person with migraine looking for informed care and better quality of life.

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