The pursuit of migraine freedom

Migraine is a headache disorder considered by the World Health Organization1 to be the second leading cause of disability2 , and something that patients in the past had no choice but to endure.

Dr. Andrew Blumenfeld, the Director of the Los Angeles Headache Center with offices in San Diego and Los Angeles, recounted how one patient described herself as ‘imprisoned’ in her home, never knowing when an attack might destroy her plans. She drew her migraine experience as a construction ball hitting her head, leaving one side shattered, and painted prison bars in front of her face. Fortunately for such patients, there are now effective preventive methods to control migraine onset.

A migraine today brings on a migraine tomorrow

For many, migraine is a persistent illness that can be optimally managed with effective preventive treatments, however most patients simply take over-the-counter painkillers during an attack. As a specialist in neurology, Dr. Fong Ka Yeung points out,“If patients leave migraines untreated or recurring at regular intervals, they will become more frequent and severe. And with appropriate and effective preventive treatment, it will be able for us to change the condition from chronic migraine to episodic migraine, and then later on going into remission.”

Timely preventive treatment, however, requires awareness. Dr. Blumenfeld highlighted how difficult it can be for patients to conceptualize a daily medicine to prevent a migraine, as opposed to an analgesic taken when the headache happens. “Prevention requires some education; the patient has to understand that without preventive treatment, the condition can worsen over time.”

Four headache days per month require prevention

According to guidelines from the American Headache Society, preventive treatment should be considered for patients who experience four or more migraine headache days per month, as well as those for whom two or more migraines per month result in significant disability, even with acute medication.3

Conventional medications of the past often took months or weeks to show efficacy4, leading some patients to discontinue treatment before experiencing any benefits, or after encountering side effects.5 With the introduction of CGRP (calcitonin gene-related peptide) antibodies, the concept of preventive treatment has gradually gained wider acceptance.

CGRP treatment targets migraines

When a patient encounters migraine-triggering factors, the brain’s hypothalamus is stimulated, and the trigeminal nerve releases a significant amount of CGRP, which induces a migraine.6 By targeting the hypothalamus, monoclonal antibodies can potentially deactivate the entire process at that crucial location before the onset of symptoms.7

As per Dr. Fong, the demonstrable success of these treatments has people more inclined to embrace—and stick with—the preventive approach. “Some patients who have received CGRP antibodies say the treatment transformed their life, and gave them a normal life again,” said Dr. Fong.

Cost should not be the sole consideration in treatment selection

There are many factors to consider when choosing preventive treatment. Dr. Blumenfeld points out that conventional medicines like antidepressants and antihypertensives were not designed for migraines, and can affect memory and mood, since they target different receptors in the brain. In contrast, newer treatments are specifically targeted to tackle elevated CGRP during migraines, making treatment more precise and effective. However, this benefit comes at a higher cost.

When patients consider the cost, Dr. Blumenfeld urges them to weigh the financial impact against the mental and physical impacts. “You have to look at the total cost as you try and work out the value of these new medicines which help to control acute attacks and prevent the progression of the disease,” he explains.

Dr. Fong concluded that in most cases, doctors present the advantages and disadvantages of various treatments to the patient, allowing them to make an informed decision together. Having a wide range of choices available to patients nowadays is certainly beneficial, as it enables them to select the option that best suits their needs.

The above information is provided by Dr. Fong Ka Yeung and Dr. Andrew Blumenfeld.
HK-LU-2024-87

1 World Health Organization. WHO methods and data sources for global burden of disease estimates 2000-2019. 2020. [Internet] Available at https://www.who.int/docs/default-source/gho-documents/global-health-estimates/ghe2019_daly-methods.pdf. Accessed 24 June 2024.
2 Steiner TJ, et al. Lifting The Burden: the Global Campaign against Headache. Migraine remains second among the world’s causes of disability, and first among young women: findings from GBD2019. J Headache Pain. 2020 Dec 2;21(1):137.
3 Tzankova V, et al. Pharmacologic prevention of migraine. CMAJ. 2023 Feb 6;195(5):E187-E192.
4 Kumar A, Kadian R. Migraine Prophylaxis. 2023 Aug 28. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29939650.
5 Olesen A, et al.. Low adherence to the guideline for the acute treatment of migraine. Sci Rep. 2022 May 19;12(1):8487.
6 Iyengar S, et al. CGRP and the Trigeminal System in Migraine. Headache. 2019 May;59(5):659-681.
7 Muddam MR, et al. Efficacy and Safety of Anti-calcitonin Gene-Related Peptide (CGRP) Monoclonal Antibodies in Preventing Migraines: A Systematic Review. Cureus. 2023 Sep 19;15(9):e45560.