Migraine Treatment and Prevention
About 38 million Americans have migraines and migraines are most common from the teen-age years through the 40s, but can occur at any age. About 20% of women and 6% of men are affected. About 20% of the population have migraine with aura and 80% of people have migraine without aura.
Migraine is a genetically inherited disorder with unpredictable and episodic flare ups. It is a diagnosis of exclusion when other secondary causes of headache are investigated and ruled out.
During a migraine, there are abnormal neurochemical changes which leads to one sided throbbing pain, nausea, vomiting, light and sound sensitivity. Attacks can last from 4-72 hours or longer in which case a condition called status migrainosis occurs. They can be debilitating and chronic (15 or more days of headaches per month).
At the Bellevue Headache Clinic, Dr. Issa’s approach is holistic. Her goal is to identify any modifiable triggers for migraine such as menstruation, medication overuse, sleep disturbances, dietary sensitivities and mood disorders. Once identified, these triggers can be minimized and treated with appropriate interventions. Alongside identifying triggers, medications and non-medication approaches can be initiated with a clear and expected benefit target. Empirically, preventive measures are expected to decrease the frequency and severity of migraine by 50% or more but at the Bellevue Headache Clinic, Dr. Issa’s goal is to tailor a patient specific-plan which goes beyond the expected 50% success outcome.
Oral medications such as antidepressants, anti-seizure, blood pressure lowering drugs have been traditionally used to prevent migraine. More recently, newer treatments offer moderate to significant benefits for patients. These injectable treatments include onabotulinumtoxinA (Botox) and calcitonin gene-related peptide (CGRP) inhibitors. These have been successful in the prevention of migraine. CGRP inhibitors disrupt a protein called CGRP, which is particularly active in people with migraines. Three CGRP inhibitors erenumab (Aimovig), fremanezumab (Ajovy) and galcanezumab-gnlm (Emgality) are injected once a month. A fourth, eptinezumab-jjmr (Vyepti) is the first drug for migraine prevention administered through IV infusion.
Minerals and vitamins play an important role in preventing migraine. Adding these to a preventive regimen can help augment migraine prevention, reduce the doses of prescription medications required (thereby diminishing unwanted side effects) and may also help with mood and sleep disorders. Dr. Issa customizes her treatment plans by elegantly combining both prescription medication and vitamins and minerals to give her patients the best chance at migraine prevention.
Treating the Migraine Pain
Acutely, migraine pain deserves accurate and quick treatment options. Most patients fail to get rid of their migraine because they initiate step-therapy- taking medications at lower dose or taking one type of medication at a time and waiting over several hours for a migraine attack to stop. Usually the opposite happens; the migraine pain lingers on for hours and may even go on for days.
At the Bellevue Headache Clinic, Dr. Issa educates her patients to successfully stop a migraine attack by taking fast acting medications (nasal, sprays, oral dissolving formulations) and also supplementing with the correct treatments right at the onset of the migraine attack. This approach puts the patient in control of the migraine rather than the headache disabling them. Dr. Issa also believes in empowering her patients with rescue plans so that if the first medication does not work as expected, there are rescue options that can be employed to get rid of the pain and associated symptoms.
Recently, two new CGRP inhibitors ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) have been FDA approved. These are pills designed to stop a migraine when it occurs. They block the flow of CGRP to the brain, disrupting the signal that causes migraines. Unlike traditional migraine medications such as the triptans (sumatriptan (Imitrex)), CGRP inhibitors don’t constrict blood vessels, so they’re safe for people who’ve had a stroke, heart attack or are risk for vascular disease. In addition, Lasmiditan (Reyvow) is the first in a brand-new class of drugs that stimulates the serotonin 1F receptor, believed to be involved in causing migraines.
Three new, noninvasive medical devices are available for migraine patients. Cefaly is placed on the forehead to stimulate a nerve that blocks migraine pathways. SpringTMS is a magnetic stimulator placed on the back of the head to disrupt migraine signals in the brain. Both can be used as prevention or when a migraine strikes. A third device, gammaCore Sapphire™ (non-invasive vagus nerve stimulator) is indicated for use in adult patients for the preventive and acute treatment of migraine headaches
Menstrually-related migraines occur with changes in hormones which trigger a migraine. These migraines can be severe, prolonged and more treatment resistant. These migraines require a strategic approach prior to their onset to lower their intensity. Dr. Issa educates her patients about this and implements strategies to prevent and successfully treat menstrual headaches.
Pregnancy and Lactation
During pregnancy and while breast–feeding, many women prefer not to take medications which may cross the placenta or pass through breast milk to their infant. At the Bellevue Headache Clinic, Dr. Issa offers solutions and strategies to manage headaches within the mother’s comfort zone. Nerve blocks may be utilized to break a headache cycle and lower the burden of headaches while topical nasal sprays may be used to stop a migraine attack.