Anyone who has lived through a migraine never forgets it. A ruthlessly incapacitating brain disorder, they have plagued women from Virginia Woolf (whose writing could halt for months due to “wearisome headache”) to Princess Diana to Serena Williams. Over ten percent of Americans are afflicted, which cost the economy 30 billion dollars annually in missed work. Yet research is dismally underfunded: in the last half-century, triptans are only class of drugs developed specifically for migraine.
“You want my real feeling as to why?” says Robert Cowan, MD, director of the new Stanford Headache Clinic. “It’s a bit of sexism, because migraine is three times more common in women, and women’s chronic diseases have traditionally not gotten much attention. And for many years, it was seen as a psychological issue – an excuse for not having sex, or going to work. Also, nobody dies from it.”
The good news for migraineurs, as sufferers are called, is that headache centers at major medical centers are proliferating, and despite limited funds, several promising new treatments have been developed.
Doctors used to tell patients to delay medication until pain was moderate to intense—the point when many people are already en route to the emergency room (migraines being one of the leading causes for visits.) But there are a host of new drug delivery systems under development that patients can deploy themselves at the first sign of pain. Cambia, for instance, is a new formulation of the older NSAID diclofenac, but this one is a powder that dissolves in water so that it enters the bloodstream more rapidly, giving a migraineur crucial extra minutes of relief.
And take the common medication dihydroergotemy, or (DHE), which Cowan calls “the gold standard” in emergency rooms. It’s traditionally given via IV because it causes nausea, but a new inhaling system called Levadex, which has completed trials and is awaiting FDA approval, is controlled by a gate. This is crucial, says Cowan (himself a migraineur) because without the gate, “the medicine slams into the back of your throat and drips into your stomach and you get nauseated. But this way, like, 97 percent is absorbed into your lungs, and you don’t get the nausea. It’s a huge advance because it can be easily delivered at home.”
RELIEF BY REMOTE
One of the more exciting nondrug treatments is the occipital nerve stimulator, a small, pacemaker-like device (about the size of three AA batteries) that’s implanted under one’s collarbone or above the pelvis (as it can be visible beneath the skin, the pelvic area may be better for those who favor low-cut tops.) It sends electrical impulses up thin wires placed under the skin near the occipital nerves, which originate in the spinal cord and supply sensation to the head and upper part of the neck. These impulses quiet pain neurons with astonishing effectiveness: According to recent studies from University of California, San Francisco and the National Hospital for Neurology and Neurosurgery in London, it improved the experience of pain by 80-95 percent.
David Dodick, MD, a neurologist at the Mayo Clinic in Arizona who advises patients on the procedure, warns that it definitely has complications. The wires can become displaced or infected, and it comes at a whopping price—“50,000, give or take ten,” he says. But given the effectiveness rate, patients who have cycled through every conceivable medication and are still utterly disabled will gladly take the risk.
NO HEADACHE—OR FROWN LINES
In 2009, the journal Plastic and Reconstructive Surgery caused a stir when it published a double-blind study of patients who underwent plastic surgery in one of three migraine “trigger sites.” Over half of those who had the real surgery said their headaches completely vanished, versus four percent of the placebo group. Lead study author Bahman Guyuron, chairman of the plastic surgery department at University Hospitals Case Medical Center in Cleveland, says inspiration struck after he performed a forehead lift on a migraineur. Six months after the surgery, she told him she had not had a migraine since. Guyuron theorized that the forehead lift deactivated muscles in the trigger points, and developed surgical techniques to do the same, which he has taught to 37 doctors around the country.
Many neurosurgeons are openly skeptical of plastic surgery, but Guyuron claims a high success rate. “We at least reduce the headaches by half on around 90% of the patients,” he says, “and eliminate the headaches in two out of five.” Botox, which was approved by the FDA last year for treating chronic migraine (meaning at least 15 days a month) is another method which deactivates trigger sites by reducing inflammation. Studies on its effectiveness are decidedly mixed, but many doctors such as Cowan use it “quite a lot,” he says. “For a lot of patients, it works well, with few side effects.”
For the knife-averse, alternative therapies for migraine abound, from biofeedback to cognitive therapy to meditation. Recently, researchers at Wake Forest Baptist Medical Center discovered that when subjects underwent a few twenty-minute sessions of meditation training, they reported a 40 percent decrease in pain when they were jabbed with a thermal stimulator. But it wasn’t just their perception: MRI scans showed that their brain activity changed, too—with barely a blip in their pain sensors.
And now experts know that a predictable, well-modulated lifestyle—eating, exercise, regular sleep— is key to controlling pain. Exercise not only releases pain-killing endorphins, but aids in weight loss, which may also REP ease migraines. A 2009 Drexel University study of over 20,000 patients ages 20 through 55 found that those with larger waist circumferences had a significantly higher rate of migraine (they’re still determining why.)
And of course, it reduces stress, a common migraine trigger. Richard P. Kraig, Ph.D., M.D., a neurologist at the University of Chicago Medical Center, says, “There is nothing more fatiguing, or stress-inducing, than intellectual fatigue,” he says. “But it’s hard to get my patients to shut down.” Step away from the computer and take a walk, he urges them. Good advice, even if you’re not a migraineur.
ON THE HORIZON
One eagerly anticipated drug which commences phase 3 trials this spring is Lasmiditan, also known as COL-144. Administered via IV, it has been wonderfully well tolerated in studies and has not significantly demonstrated triptan’s alarming side effects of heart attack and stroke. Then there is the so-called migraine vaccine, currently under development at multiple drug companies. ‘Vaccine’ is a bit of a misnomer, as vaccines usually target proteins. This one, explains Dodick, “is an antibody directed against a neurotransmitter that’s thought to be very important in the generation of migraine pain.” The key is that it has the preventative effects of a vaccine. “A once a month injection could actually suppress the attacks from ever beginning,” he says. “That’s something I’m really looking forward to seeing, and I believe studies will be underway within the next year, I believe.” Might he be involved? “I might be,” he says with a laugh.