Migraines are not a one-size-fits-all condition, and there is no one-size-fits-all solution.
Migraines are the number 1 global cause of disability in women ages 18 to 50 years, and they are one of the leading causes of disability in general; however, migraines are not always recognized as a debilitating condition, which can lead patients to feel stigmatized or like they need to minimize their condition, said Fred Cohen, MD, headache specialist and assistant professor of medicine and neurology with the Icahn school of medicine at Mount Sinai, New York, in an interview with Pharmacy Times.
“Unfortunately for a lot of my patients, [migraines] get brushed off,” said Cohen in the interview. “[But] there are patients on disability from this. There are patients who are not able to go to school, go to work, or interact with their families [because of migraines].”
With headaches, people can experience pain or discomfort, but they can usually go about day-to-day activities, Cohen explained. However, this is not always the case with migraines, which are associated with moderate to severe (and often debilitating) pain.
Unlike mild to moderate headaches, migraines may also be associated with a myriad of other symptoms; for instance, patients can experience light or sound sensitivity, nausea, or aura, which consists of a series of neurological symptoms that occur before the migraine.1 Aura symptoms include flashing lights before the eyes, tingling in the extremities, dizziness, or vertigo.
Migraines can also have a deeply emotional and social burden, which Cohen has observed in his practice and which he experiences himself as a person with migraines. Further, migraines do not manifest the same as a traditional headache, despite ongoing social biases that may persist.
“[People will say,] ‘Oh, it's just a headache. Just take an ibuprofen,’” Cohen said. However, Cohen noted further that more often than not an nonsteroidal anti-inflammatory drug (NSAID) will not ameliorate symptoms of a migraine.
“If it was as simple as that, people would [take an NSAID] and there wouldn't be a need for doctors like me,” Cohen said.
Pharmacologic agents for treating migraine generally fall into 2 categories: abortive, which stop the migraine while it is happening, or preventative, which prevent future migraine attacks, according to Cohen. Triptans and gepants are classes of abortive medications that are often used for spontaneous, nonrecurrent migraine headaches.
Preventative migraine treatments are often administered to patients with 5 or more migraine attacks per month and include anti-seizure drugs (topiramate [Topamax; Janssen Pharmaceuticals]), beta blockers (propranolol [Inderal LA; ani Pharmaceuticals, Inc]), antidepressants (amitriptyline [Elavil; Zydus]), or even Botox (it’s not just for beauty).
Despite the commonness of the condition, people who specialize in the treatment of headache and migraine are rare. This means that many patients are going to their primary care providers for first line treatment, which can be limited by time constraints, Cohen explained.
“It’s the woes of the American health care system that, unfortunately, [providers] are under a lot of time constraints, and there’s a lot more we want to do [for our patients that we can’t do],” Cohen said. “Because of that, a lot of patients feel stigmatized and minimized.”
However, Cohen does make an effort to educate primary care providers and residents at Mount Sinai about migraine treatments so that they can better help patients who deal with migraines and headaches with first-line options.
Cohen explained further that during trainings, he guides his colleagues to consider a patient’s unique condition, medical history, and other medications when choosing a treatment to mitigate possible drug interactions or adverse events. For example, beta blockers are not ideal for patients with asthma and antidepressants are not a good treatment option for patients already taking an antidepressant.
Topiramate is a common first-line treatment for migraines that can also cause weight loss, so this may be beneficial for patients with obesity, Cohen explained. However, it is not an ideal treatment option for patients with a history of kidney stones. Background significantly helps in determining the proper course of treatment.
Providers should also have patients log migraine occurrences in a headache diary, explained Cohen. The patient can outline symptoms, duration, and medications that can guide caregivers on a next step, which could be starting a new medication, changing a current one, or referring the patient to a neurologist or migraine specialist.
Migraines can take a tremendous toll on a person’s physical and mental wellbeing. “Don't minimize [migraines or] shrug it to the side. It is a very burdensome, disabling, [and] painful condition that unfortunately doesn't get taken as seriously as other [debilitating conditions do],”Cohen said.