"In the past 10 years, the realization that migraine is a brain disorder rather than a vascular disorder has facilitated development of various treatments, ranging from innovative immunopharmaceuticals through to neurostimulation. Many clinical trials have been successful, and such considerable progress holds promise for the coming decade of migraine treatment."1
That’s the opening of a new paper by Dr. Peter J. Goadsby, “Decade in Review - Migraine. Incredible progress for an era of better migraine care.” Living with migraine day-to-day tends to make us focus primarily on how we’re feeling and how migraine is impacting our own lives. It makes us rather myopic. We don’t notice the progress being made or, if we notice it, we don’t realize its importance and potential impact on us and our future.
Migraine Disability Statistics:
- Migraine has been the sixth most common cause of disability in the world.
- Medication overuse headache, which seems only to occur in patients with migraine, has emerged from below 25th to rank 18th.
- At the same time, progress has been made with many of the other top causes of disability, including anxiety disorders, iron-deficiency anemia and diarrhoeal diseases.
Progress in Migraine:
- Research has steadily accumulated data showing the migraine is a brain disorder, not a vascular disorder. Imaging studies used in research clearly showed that no important vascular changes occur during the brain in migraine and that migraine can occur with no vascular changes.
- Investigation of the migraine prodrome also shows migraine to be a brain disease, highlighting the necessity of understanding the pathogenesis (the origin and development of a disease) of migraine attacks in order to develop new treatments.
- A solid study showed that light didn’t trigger a migraine in participants who thought light could trigger their migraines. This brings up the question of whether patients noticing light during the migraine prodrome could contribute to their thinking that light is a trigger for them. If this is the case, it could be linked to similar situations of migraine being triggered by food, sleep, or stress - each of these could be the result of alterations in brain function.
- With the evidence that migraine is not vascular, research into treatments has stopped focusing on blood vessels. Calcitonin gene-related peptide (GCRP) treatments have become the most researched new treatments, both acute and preventive treatments.
- Research of the CGRP monoclonal antibody for migraine is the first time immunopharmacology has used antibodies to target a molecular pathway rather than immune pathways. This is a huge development. If you’d like to know more about this, see New CGRP Monoclonal Antibody Migraine Preventives (video).
- Targeting the CGRP pathway is showing so much promise that it’s leading researchers to further investigation of the biology of migraine.
- "Targeting the CGRP pathway drives home the fact… that non-vasoconstrictors work."1
- The last decade has also revealed other possible targets for migraine therapy, including:
- nitric oxide,
- orexin (a neuropeptide that regulates arousal, wakefulness, and appetite) receptors,
- treatments that target dual receptors, and
Devices for Migraine Treatment:
- Confirmation of migraine as a disorder of the brain made neurostimulation seem to be a viable treatment option. The implanted occipital nerve stimulators were big news for a time, but failed Phase II clinical trials. There were problems with both the devices and the study design. No well-designed, placebo-controlled trial with positive outcomes has been completed at this time.
- Transcutaneous supraorbital nerve stimulation is far less invasive and is now being used in Europe and the United States. This is the Cefaly eTNS unit.
- Transcranial magnetic stimulation is also now in use in the form of the Spring TMS device, which is approved and in use in Europe and the United States.
Comments and Implications for Patients:
Advances in imaging technology facilitated recognition of one of the most significant changes in migraine research. With this advanced imaging technology researchers were able to see and verify that migraine is a disease of the brain itself, not the blood vessels. The “vascular theory” has been shown to be incorrect. Migraine can occur with no vasodilation at all. This is actually one measure we can use when reading information about migraine. Information stating that migraine is vascular is outdated and/or incorrect.
The future of migraine treatment appears to be promising and exciting:
"Experimental medicine offers a clear pathway from basic biology to the clinic. One hopes that, as next-generation genetics evolves, the upcoming decade will see the development of personalized medicine that will see migraine lose its position among the top of causes of global disability."1
"The review shows how much is going on and how much has gone on since the development of the triptans. We have exciting advances in acute treatment and in preventive management of migraine… And all this on a shoe-string budget in academic research. Why is it so slow to get to patients, even though the list of possibilities dwarfs all other neurology problems - there is simply not enough investment in the well-being of our patients. Its an era of better care dawning - lets get it moving!"2
More interesting information:
1 Goadsby, Peter J. “Decade in Review - Migraine: Incredible progress for an era of better migraine care.” Nature Reviews Neurology. Published online October 27, 2015.
2 Interview with Dr. Peter J. Goadsby. November 15, 2015.
_Reviewed by David Watson, MD. _
© Teri Robert, 2015. • Last updated November 16, 2015.
Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation’s Patient Partners Award and a Distinguished Service Award from the American Headache Society. Teri can be found on her website, and blog, Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.