Migraine 101: Inside This Debilitating Condition

Anyone who’s had a migraine knows these headaches can be extremely painful. In fact, migraines are the second most disabling neurological condition globally in terms of years lost to disability.

What Are Migraines?

Migraines are a neurological disease that occur as a result of complex neurochemical and neurophysiological processes in multiple areas of the brain. What a migraine typically feels like is severe throbbing pain which interferes with ability to function. Other symptoms include visual disturbances (aura), nausea, vomiting, light and sound sensitivity, fatigue and cognitive dysfunction.

For those suffering from migraines, the first step to appropriate treatment and management is identifying the particular kind of migraine. According to International Classification for Headache Disorders, the types of migraines include:

• Migraines without aura (but with nausea, vomiting or both, and frequent sensitivity to light, sound and movement).
• Migraines with aura (sub classified as migraines with brainstem aura, hemiplegic migraines and retinal migraines)
• Chronic migraines (15 or more headaches days for 3 months or more, 8 of which meet criteria for migraine or are treated with migraine-specific medication)
• Status migrainosus (persistent migraine headache that lasts more than 72 hours with secondary causes being ruled out)

Lifestyle Can Affect Migraines

Because several things can trigger migraines, lifestyle is an important part of managing migraines.

The most common triggers identified by patients include sleep disturbance, stress and foods/additives such as caffeine, alcohol, aspartame, and nitrates. To determine what triggers your migraines, it is helpful to maintain a headache diary.

Other Ways to Minimize Migraine Triggers

1. Maintain a regular sleep pattern. Sleep deprivation can worsen or trigger a migraine attack. It is important to check with your provider if you have symptoms of sleep apnea.
2. Exercise regularly. Aerobic exercise for at least 30 minutes three times a week can help reduce frequency and severity of migraine.
3. Eat regular meals, do not skip meals and eat a good healthy breakfast.
4. Reduce stress as much as possible. This can help decrease the frequency and intensity of migraines.
5. Avoid known triggers such as alcohol or certain foods.

What to do for Severe Migraines

For headaches that are not intense or severe, visit your primary care physician. For more severe headaches or headaches with unusual symptoms, a referral to a neurologist might be appropriate. You should seek immediate treatment for your migraines if:

1. Headache seems different from your regular migraines.
2. Headache is accompanied by any other symptoms:
   • Weakness
   • Dizziness
   • Sudden loss of balance
   • Speech difficulties
   • Mental confusion
   • Seizures
   • Vision changes (blurry vision, double vision, blindness)
3. Over-the-counter pain medications aren’t helping.
4. Headaches are hard to deal with and there is history of contact with someone who tested positive for COVID-19 or has symptoms (high fever, cough, difficulty breathing).
5. Severe nausea and/or vomiting limits use of oral medications.

Depending on the type, several treatments are available. Some medications are used to stop migraines from progressing, others are used to prevent them from happening in the first place.

Advances in Migraine Treatment

There is new hope for migraine sufferers as treatment advances have resulted from groundbreaking research in the field of migraine over the past few decades.

It is now known that a neuropeptide called CGRP (calcitonin gene related peptide) might play a role in the development of migraines. People with chronic migraine have chronically elevated levels of CGRP. Recent research suggests that giving a patient an infusion of CGRP can lead to a migraine attack. This set the stage for new migraine therapies that reduce the activity of CGRP and hence result in fewer migraine attacks.

Types of Treatments

CGRP inhibitors - Currently four different CGRP inhibitors have been approved for the prevention of migraines. CGRP inhibitors are unique because it’s the first category of drugs developed specifically for migraine prevention. Other migraine preventives were originally developed for other indications such as hypertension, depression and epilepsy and were later found to be effective for migraines.

These medications were tested for migraines with aura, migraine without aura, episodic migraine, chronic migraines and medication overuse headaches. They worked well for all of these indications. Drugs in this category were found to be safe and have rapid onset of therapeutic benefits.

These therapies are injections or infusions that are given under the skin once monthly or every three months. Three of the four monoclonal antibodies can be self-administered at home or if needed can be given at your doctor’s office.

The American Headache Society has indicated these medications should be initiated in adult patients with moderate to severe migraine who have failed a 6-week trial with two prophylactic medications or are unable to tolerate them due to side effects. Before starting these medications, please inform your healthcare provider about all medical conditions including allergy to rubber or latex, pregnancy or if you are planning to conceive, breast feeding or plan to breastfeed.

Gepants - work to block CGRP from attaching to the receptor and initiating pain signals. Unlike the CGRP monoclonal antibodies, these medications are used as needed only to abort a migraine attack.

Ditans - now approved for ending migraine episodes. It could be useful in patients who do not respond to triptans or have had side effects/ contraindications to using triptan therapies.

Neuromodulation - advanced medical tools that modulate the signaling activity that occurs in the brain. Neuromodulation devices can be electrical, temperature altering or magnetic. These are attractive alternatives for people living with migraine who have health issues or conditions that prevent them from taking medications or have tolerability issues with medications or who are worried about medication overuse headache.

Migraine Self-Care During COVID-19

If you’re struggling to manage migraines and headaches during this pandemic, it’s important to remember to try to stay positive. Reducing stress is key in keeping migraines under control. Mind-body techniques such as deep breathing, mindfulness and stretches can have a profound impact in countering the adverse effects of stress. Be mindful of routine and diet to reduce migraine triggers. It is important to remain hydrated and eat regularly to prevent migraine attacks.

I would also emphasize that it is important to stay connected with family and friends through video chatting, messaging or taking online educational classes (if looking at a screen is not a trigger). Continue practicing good hand hygiene and adopt physical distancing measures to curtail the spread of this highly communicable virus.

Talk to your healthcare providers and have enough refills of your migraine medications. If limited from an insurance standpoint, please contact your insurance companies to determine the best course of action.

If your headaches feel different, have been getting worse or are not responding to routine migraine therapies, contact your neurologist or primary care physician. It is also crucial to disclose to your healthcare provider if you have been exposed to anyone who tested positive for COVID-19 or if you are having symptoms such as fevers, cough, or difficulty breathing.

This might also be an appropriate time to consider alternate therapies, especially for those receiving Botox injections, to see if other preventive strategies including the use of CGRP monoclonal antibodies might be appropriate.

If you have more questions about migraines, reach out to the CHI Health Primary Care or Neurology team.