several options for treatment including monoclonal antibodies for prevention and oral small molecules for acute treatment ( with others on the way for preventive treatment – see table below ).
For our patients , CGRP targeted therapies offer new and different hope for treatments that will help their pain and other symptoms , reducing the disabling miseries . More importantly for patients , the development of the CGRP-targeted therapies offers an understanding of the underlying cause of migraine . For decades , migraine has historically been viewed as a condition that was in some way the patient ’ s fault – something that they had been doing wrong to bring this condition upon themselves . For so many patients that I meet , the number one question that they have is why – why do I have this problem ? What did I do to cause this problem ? Now , we can have a discussion with patients that for a reason we do not yet understand , your brain releases this protein called CGRP that leads to the development of many of the symptoms that you experience . We now have treatments that specifically treat the problem that you have – we ’ re now not only using antidepressants or blood pressure medications to treat your migraine , we are using migraine medications to treat migraine .
My hope as a headache specialist is that we will continue to see progress made for our patients that will in turn make their lives better and filled with less disability . While I am in no way suggesting that CGRP-targeted therapy is a one-size-fits-all approach to treating migraine and helps every patient , I am suggesting that these therapies will revolutionize the way that we should approach migraine . They will result in changes in the way that we see our patients and how we treat them . We owe it to our patients as physicians to be on their side and to want better lives for them . Recognizing that there are nearly 40 million people in the US living with migraine , there ’ s no way that they could all be seen by a specialist ( there are only 600 physicians who are board certified in headache medicine nationally ). But ! - we can all approach migraine with our patients with the same tenacity we use to confront other disabling medical conditions . We can re-engage those patients in our practice with migraine who might not be talking about it anymore at their visits . Maybe they have experienced stigma in medical settings , maybe they feel like they ’ ve “ tried everything ” or perhaps worse , maybe they simply have just given up and only try to “ live with it .”
The drugs mentioned include :
CGRP monoclonal antibodies ( preventive ) Aimovig – erenumab Ajovy – fremanezumab Emgality – galcanezumab Vyepti – eptinezumab
CGRP small molecule ( acute treatment ) Rimegepant – Nurtec ODT Ubrogepant – Ubrelvy
ALL IN THE HEAD
non-headache features ( light and sound sensitivity , dizziness , nausea and / or vomiting , etc .). It may have a stereotypical onset for each person , or not . It may be triggered or worsened by various insults ( environmental allergens , neck pain , barometric pressure changes , lack of sleep , and so on ). It may run in families . Migraine is not diagnosed by MRI scans – we just need to talk with our patients and ask them these questions . Never offer them an adjective for a headache or a dizzy symptom : you are just shooting yourself in the foot . The only way you can diagnose is by their detailed description ; never , ever put words in their mouths .
We must let them know that we care , that we are on their side . Once they know that we do care , and once they know that we understand that this is a real problem and one that seriously impacts their lives , then we will be able to work together . With our patients , we can create a plan to make this disease more manageable , to get them back to the lives they want and need .
For so long , patients with migraine have been left alone without our support and without good treatment options . This is changing and will continue to improve as we better understand what our patients are experiencing .
The migraine revolution is starting .
Dr . Plato is a practicing neurologist and is the Medical Director , Headache Medicine at the Norton Neuroscience Institute .
I would encourage everyone reading this article to become comfortable with diagnosing migraine . Ask open-ended questions - how they describe it is the only way you can diagnose it . Remember that always . Ask , what is it like / where is it / how long does it last / what all do you experience / does anything you do help it / tell me everything you know about it / etc . Migraine is a clinical diagnosis that consists of headache features ( unilateral pain , throbbing pain , moderate or severe pain , causes the avoidance of physical activity , etc .) and
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