HW: Is there still a lack of understanding about migraine in the public? DR. CADY: Absolutely. Change takes a long time. There’ s been a huge education effort that’ s been made to help other physicians get involved, particularly in the primary care field. When you consider that migraine affects 18 % of adult women— if you want to look at it in a more graphic way, probably one in five women in their reproductive years actually suffers with migraine— you realize that the real change is going to come when we get primary care physicians much more involved and active. I’ m happy to say I see that change occurring, albeit slowly.
HW: What’ s on the horizon for the headache field? DR. CADY: I think one of the things we’ re really missing is a diagnostic test. Migraine today is still a syndrome, meaning it’ s a collection of symptoms we recognize and say,“ This person has migraine because of these symptoms.” But the reality is that there are probably lots of types of migraine, and they all share these common symptoms. For example, you can have different kinds of infections in the lung that cause cough and fever, but there are still different ways in which that infection is being initiated or dealt with at a biologic level. I think for migraine what we’ re going to find is that these symptoms are a common final pathway for many different assaults on the nervous system. My hope for the future is that we will be able to subdivide migraine further, and we will be able to define and develop treatments for whatever it is that initiated migraine.
HW: You were integral in ushering in early intervention. How can this help patients? DR. CADY: It can help a lot. When I started in migraine, from a scientific point of view, we wanted to know that we were dealing with a“ true migraine.” In those studies, we would have people wait until a migraine was fully developed, so their pain was moderate to severe. They were almost inevitably nauseated. They had light and sound sensitivity.
Many of them were vomiting. They were very, very impacted individuals. That helped us, of course, be certain we were treating migraine. However, when we got into clinical practice— and especially when oral drugs came on, which aren’ t as fast-acting as the injection— the idea of allowing people to wait until they were in the throes of a severe migraine was just untenable.
Early intervention came about really as an observation made by my own patients. When they came in, they said,“ You know, the earlier I take this, the better it works.” So we did a study in which we actually looked at a group of people who didn’ t follow the protocol. They were asked to wait until the migraine was fully developed, but they didn’ t want to do that. They took it early. And what we discovered was that this group of people— for those specific migraine attacks— were almost twice as successful at being pain-free from migraine within two hours. They also had fewer side effects from their medicines because their nervous system wasn’ t so sensitized from the migraine itself. And they had less recurrence. So this is a very important paradigm, but it’ s not a paradigm that can be used every time and by everybody. Some types of migraines come on very quickly. Sometimes they come on when you’ re asleep. Sometimes you’ re in situation where you can’ t take your medicine early on. What people need is to have a multitude of tools so they have the right tool for the right headache.
HW: How much can this condition really be managed? DR. CADY: I think there’ s a lot that can be done with management. We always like to wait until the horse is out of the barn. People don’ t generally start to take this condition seriously until they’ ve had years and years of very severe migraine. Unfortunately, the more migraine you have, the easier it is to get your next migraine. I think a lot of this effort needs to be started earlier. At the same time, realize that you can’ t control everything that happens in your life. Even saints can get migraine. Sometimes things happen, so you need to have good tools to be able to treat it,
If you want to hear more from Dr. Cady, you can download the full podcast or read the transcript online at www. headwisemag. org. www
42 HEAD WISE | Volume 1, Issue 1 • 2011