Tackling migraine: a new defensive player

Anne’s migraines started in her 20s. During an evaluation as a fledgling flight attendant, she developed a blinding headache during final descent and threw up all over her supervisor. That was the memory of her first migraine.

One in five women (most common between ages 18 and 44) suffers migraines – twice the frequency of men.  

Doctors tackle migraines using two lines of attack: mitigate and prevent. To mitigate acute pain, many drugs (or combinations) work. Two stand out: fast-acting NSAIDS (ibuprofen, naproxen sodium) and triptans.  

Most migraineurs have their own cocktails. The problem I see often is taking drugs too late.  

The moment you feel a migraine brewing, take drugs. Take enough drugs. There’s a narrow window of an hour or so, before pain and nausea set in, when drugs are maximally effective. There’s no waiting out a migraine like there’s no waiting out a growling, junkyard dog to see it means business.

Concerned about overusing medications? Sure.

Taking pain meds regularly can potentially worsen and transform migraines into medication overuse headaches (previously called rebound headaches). To avoid this complication, or if you have more than four headache days per month, consider preventative drugs.

“Preventative” drugs, taken regularly, can reduce the frequency and severity of headaches. They’re underutilized. The four most commonly used are drugs for seizures, blood pressure, depression and Botox. Others like magnesium, feverfew, acupuncture, etc. might work; they’re worth trying.

Two weeks ago, the FDA approved the first of a new class of drugs for migraine prevention – Aimovig (erenumab), a once-monthly self-injection.

How well does it work? In people with frequent migraines, Aimovig adds, on average, two headache-free days per month compared to a placebo. By number, it isn’t much better than the others. But it’s new, well tolerated, designed specifically to block calcitonin-gene-related peptide (CGRP), a molecule believed to incite migraines.

The catch: It lacks long-term data. Aimovig works partly by constricting blood vessels, a theoretical concern for those with heart disease.

Anne muses that she remembers and associates each pivotal event in her life with a particular migraine. There were 15 years in her 30s and 40s when her migraines – triggered by work-related stress and weather change – would’ve been better managed with preventative medications. But not now.

She sticks to her own Good Book of Low-Stress Living: no skipping meals, missing sleep, sleeping in late, and no matter where’s she’s at, the first drop of coffee will touch her lips at 7 a.m. EST. She uses OTC drugs (ibuprofen-caffeine, acetaminophen) which work as well as prescription drugs. At 58, she has migraines but only one severe one per year. She’s grateful.

She’s curious, why migraines?

Pain is essential for self-preservation, I said. Our ultimate protector. Skin relays a pinprick with laser-sharp precision. But why does a healthy brain excoriate, extort and exhaust its host until he/she’s laid up in a dark room, eyes shut, stomach upturned, unable to process the slightest sound, light or movement?  I can’t think of a single evolutionary advantage it serves, not even a warped one.

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Volume 10, Issue 11, Posted 10:07 AM, 06.05.2018