The last decade has seen a great deal of migraine research that has revealed more about what actually happens in our brains during a migraine attack as well as the causes of the disease. This seminal research has also given pharmaceutical companies information they needed before developing better treatments. From showing that migraine is not vascular and instead neurological/electrical to revealing the role of CGRP in migraine, this research has far-reaching impact.
One of the best tools we can have in our migraine arsenal is current and accurate knowledge. We're well served if we utilize all the available sources to gain this knowledge, and we should recognize that the different modalities of learning come into play here. Visual learners do well reading information; audio learners do best when they hear information; and kinesthetic learners are best served when learning by doing.
On April 5 (2016), NPR's Diane Rehm Show presented an excellent show about the new CGRP medications that are in development for migraine. The segment was titled, "New Advances In the Understanding and Treatment of Migraines." Her excellent panel of guests were Dr. David Dodick, Dr. Jessica Ailani, and Dr. Peter Goadsby.
The main focus of the show was the new GGRP medications in development, a topic of great interest in the migraine community. Before getting to the discussion of those medications, Dr. David Dodick provided some background on how migraine works in the brain so the CGRP medications mechanisms could be better understood. Dr. Dodick explained:
"The prevailing wisdom used to be that migraine was a vascular headache disorder, and what was meant by that was the neurological symptoms that patients might experience before the pain was due to the constriction of blood vessels around the brain and low blood supply to the brain. And then the pain that patients would develop during a headache was due to the rebound sort of vasodilation or distention of those blood vessels, which would become painful. That was the conventional wisdom, but for the past 20 to 30 years, we now have a new understanding of migraine as a problem within the central nervous system itself, within the brain itself. And the problem is such that there's a problem with modulating sensory information that's coming into the nervous system. That sensory information could be normal pain signaling, it could be light, it could be sound, it could be odors. So the migraine brain processes that information differently."
One of the primary issues with the acute treatments we have that were developed for migraine - triptans such as Imitrex, Maxalt, Zomig, etc.; and ergotamines such as D.H.E. 45 and Migranal Nasal Spray - is that they constrict blood vessels. For that reason, they're contraindicated for migraine patients with a history of or strong risk factors for heart attack and stroke. Dr. Peter Goadsby addressed this:
"Now, the great thing about this new development with the CGRP treatment is that there's a -- and one other treatment that's coming along, the so-called 1F receptor drug -- is that they don't constrict blood vessels. So we're developing drugs that fit the problem and don't create another problem. I think that's what Jessica was mentioning very importantly. You know, at the moment, we give our patients a choice between putting on weight or losing their mind or having their hair fall out or having some other, you know, we give them a choice of side effects."
Potential side effects are always a concern, especially with new medications. Dr. Dodick explained how the new CGRP medications are different in regard to side effects:
"So they're highly precise medications that have an effect on the very thing we are trying to target. And so one wouldn't expect to have a lot of toxicity or a lot of side effects associated. The monoclonal antibodies, for example, are, in themselves, proteins that are broken down into their own amino acids when they get into the body so we're optimistic that we are ushering in a new era of disease-specific preventive therapy."
Dr. Goadsby explained why he's so optimistic and what we can expect from these new medications:
"I'm incredibly optimistic, because we're entering an era where we've got -- where we have therapy that's designed for the patients and based on understanding, instead of just pulling something from blood pressure or from epilepsy. That's optimistic. So people listening to this should know that research is delivering them something real. It's going to deliver them medicines and safer medicines. And it's going to deliver them within the next couple of years. It's certainly -- certainly, because at the moment these things are in what's called Phase III studies, so they're large studies where as much information is collected as possible. And then they'll go to the regulators (FDA)."
If you missed the show, don't worry! All of Ms. Rehm's shows are archived, so you can listen from the web site. There are also comments and discussion about each show on the site. Check out "New Advances In the Understanding and Treatment of Migraines on the Diane Rehm web site.
Dr. Goadsby very kindly discussed the CGRP preventives with us for a short video. You can view it in New CGRP Monoclonal Antibody Migraine Preventives.
This isn't the first Diane Rehm Show segment to focus on migraine. In 2012, a segment first aired, titled "Living with Migraine and the Search for New Treatments." The panel of guests for that show were Dr. David Dodick, Teri Robert (Yes, that's me!). Dr. Perry Richardson, and Story Landis director of the National Institute of Neurological Disorders and Stroke (NINDS)at the National Institutes of Health (NIH).
I recently listened to that show again, and find it still current and relevant and well worth a listen. In this show, there was great discussion about migraine as a disease with a full constellation of symptoms, our improved knowledge of how migraine impacts the brain, migraine triggers, and other topics. The show started out with Ms. Rehm asking Dr. Richardson one of the most important questions that could have been asked - the difference between a migraine and a headache. Dr. Richardson said:
"Well, actually, ordinary headache is a difficult topic for me because I always get suspicious if somebody is telling me that they have headaches that are disabling that are different from their normal headaches. If somebody reports headaches that they interpret as normal, but they occur on a continuing basis or an episodic basis, I actually start asking questions about migraine predisposition. The migraine, although classed as a headache, as you said, is actually a brain disorder. It's not a blood vessel disorder. It has phases that have been recognized to occur before pain, although it is the most disabling type of benign headache."
Ms. Rehm then posed another important question to Dr. Dodick, asking, "Has the entire outlook regarding migraines changed over the last decade?" Dr. Dodick replied:
"I mean, over the past three centuries, migraine has been considered to be a vascular disorder, a problem with dilation of blood vessels. But we now understand over the past decade or two that migraine is a neurological disorder. And that has tremendous implications for drug discovery for new treatments, if you will, because now, instead of targeting the blood vessel, the new pipeline of medications that will be coming hopefully available in the near future will target the brain and nerves themselves. So, yes, this is, as Dr. Richardson said, a genetically-inherited disorder due to sensitization in the brain or hyper-excitability of certain brain networks. Well, what it means to the patient -- and any patient will tell you that, you know, headache -- I often say we should take the headache out of migraine because migraine has been defined by the headache for millennia. But there are so many neurological symptoms that accompany the headache and disable patients almost equally as badly as the headache itself. So what it means for patients is that when we say that a patient has a disease, not only does it mean necessarily that they have abnormal structure of that organ but abnormal function."
If you'd like to listen to it, check out "Living with Migraine and the Search for New Treatments" on the Diane Rehm web site.
The Diane Rehm Show has a weekly on-air audience of more than 2.4 million people. When each of these shows aired, and when the second one aired a second time in December of 2012, they generated a lot of enthusiasm and helped get correct and current information to millions of people.
As we continue to learn about migraine, let's all try to be mindful of all the potential sources for information. Knowledge is a powerful tool in our migraine arsenal, and helps us build a firm foundation for working with our doctors as true treatment partners.