The latest genetic and biological research shows that migraine is a neurological, not vascular, disorder and both acute and preventive treatments being developed target peripheral and central nervous systems, according to a prominent migraine expert addressing the American Pain Society (APS) on May 17.
Migraine is one of the most prevalent and debilitating medical conditions and afflicts an estimated 10 percent of the world's population. In the United States, the Institute of Medicine recently reported that more than 100 million Americans have chronic pain and some 40 million have migraine. Current acute migraine medications were developed to constrict cerebral blood vessels based on the prevailing concept that migraine is a vascular headache disorder.
David Dodick, MD, professor of neurology at Mayo Clinic in Phoenix, explained in his plenary session talk that triptan medications used to treat migraine patients are designed to constrict blood vessels, which for centuries were believed to cause migraine. "While migraine research has been massively underfunded and the disorder often is clinically dismissed as a 'headache,' its genetic and biological basis is increasingly coming into focus as the result of considerable scientific advances over the past two decades," said Dodick. "Today we know that migraine is a largely inherited disorder characterized by physiological changes in the brain, and, if attacks occur with high frequency, structural alterations in the brain."
Migraine sufferers experience diminished quality of life as well as impaired physical, social and occupational functioning. Dodick believes that advances in migraine knowledge have led to the development of promising new and selective compounds and therapies for both acute and preventive treatment of migraines. "This is a neurologic disease with systemic implications," said Dodick.
The basis for preventive treatment is understanding that underlying risk factors for migraine can be modified or eliminated before migraine attacks become more frequent. Dodick said major risk factors include overuse of acute medications, particularly opioids, barbiturates, analgesics and triptans, depression and other mood disorders, obesity, snoring, head trauma, and excessive caffeine intake. He believes that controlling risk factors can help prevent episodic migraine patients from becoming chronic pain sufferers.
"Migraine risk factors can be treated effectively in the primary care setting, and we need to educate practitioners about what they can do to help prevent migraine in their patients," Dodick said. "About 40 percent of migraine patients are candidates for preventive treatments but only 10 percent receive them. Doctors just want to treat the pain because they have little time to spend with patients to explore other options. They need to start thinking about the treatment of migraine in a disease model context, in much the same way as hypertension or diabetes."
For example, Dodick noted that obese people have a five-fold risk for developing migraine and depressed individuals have a three-fold higher risk. So treating these risk factors is an effective prevention strategy.
In April, the American Academy of Neurology and the American Headache Society announced new guidelines for migraine treatment. The guidelines endorse preventive treatments using a wide variety of medications from antidepressants to blood pressure lowering drugs to plant extracts. "The new AAN guidelines illustrate that there are many treatments for which there is substantial evidence to support their safety and efficacy for the preventive treatment of migraine," said Dodick. "Physicians should use the guidelines to individualize treatment, based on coexisting and comorbid conditions which may be present in their patients, with medications that have the highest level of evidence."
Acute treatments are taken when a migraine attack occurs, but preventive regimens should be taken every day to prevent attacks or to lessen their severity and duration. "Some studies have shown that that migraine attacks can be cut in half or more with preventive treatments," said Dodick.
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