If you live with or work with someone who suffers from migraine, there’s something very important you should know: A migraine is not “just a headache,” as many seem to think. Nor is it something most sufferers can simply ignore and get on with their lives.
And if you are a migraine sufferer, there’s something potentially life-changing that you should know: There are now a number of medications available that can either prevent or alleviate many attacks, as well as a newly marketed wearable nerve-stimulating device that can be activated by a smartphone to relieve the pain of migraine.
Migraine is a neurological disorder characterized by recurrent attacks of severe, often incapacitating headache and dysfunction of the autonomic nervous system, which controls the body’s myriad automatic activities like digestion and breathing. The throbbing or pulsating pain of migraine is often accompanied by nausea and vomiting.
Translation: Migraine is a headache, all right, but with body-wide effects because the brain converses with the rest of the body. It is often severe enough to exact a devastating toll on someone’s ability to work, interact with others, perform the tasks of daily life, or even be in a normal living environment. When in the throes of a migraine attack, sufferers may be unable to tolerate light, noise, smells or even touch.
Dr. Stephen Silberstein, a neurologist at Thomas Jefferson University and director of the Jefferson Headache Center, told me “There are 47 million people in this country with migraine, and for six million, the condition is chronic, which means they have more than 15 headache days a month,” he said.
“It’s time to destigmatize migraine and provide sufferers with effective treatment,” said Dr. David W. Dodick, neurologist at the Mayo Clinic in Scottsdale. “They’re not fakers, weak individuals who are trying to get out of work.”
In addition to the price paid by individuals with migraine, the cost to employers can be exorbitant. For example, in a recent survey by the Japanese Headache Society of more than 2,400 workers at Fujitsu, an information technology company based in Tokyo, the productivity of one employee in five was impaired by migraine, at an estimated cost to the company of nearly 150,000 employees of $350 million a year.
For the United States as a whole, the economic burden exacted by migraine is staggering — at least $11 billion in direct medical and related costs and at least another $11 billion in indirect costs from the disability it causes, according to Dr. Wayne N. Burton of Chicago, former global corporate medical director at American Express.
Not only does migraine result in absenteeism, but also what specialists call “presenteeism” — people who are at work but unable to function effectively. A former editor of mine with migraine had to go home as soon as he sensed an impending migraine or he would be unable to get home until it resolved.
Though that was decades ago, today there still several reasons migraine is poorly controlled for so many people. One is a lack of appreciation by both doctors and the public for what it entails, which can discourage patients from seeking treatment. Another is a tendency for migraine sufferers to assume they can or should be able to deal with the problem on their own, either with over-the-counter or prescription drugs.
Resulting from that assumption, Dr. Silberstein said, is yet another stumbling block — an abuse of medication, which can actually make the condition worse. “Half the patients with chronic migraine overuse the treatment based on surveys we’ve done,” he said.
On the other hand, he added, when an attack is imminent, many people wait too long to initiate treatment “because they’re in denial and hope the headache will go away on its own. But the longer you wait, the harder it is to get relief.”
But perhaps the main problem is a paucity of medical experts — 580 specialists, or one doctor for every 80,000 people with migraine, who are conversant with the condition and available therapies, Dr. Dodick said. Even if patients can find an expert, a lot of insurance plans don’t cover certified headache specialists.
Thus, too often, patients with an excruciating migraine end up in a hospital’s emergency room, which Dr. Silberstein called “the worst place to go when you have a migraine, with all the lights, noise, activity and the wait.”
As Dr. Dodick explained, “The brain amplifies the signals coming in, intensifying the pain and symptoms throughout the body.”
There are four oral drugs in two different classes that have been approved by the Food and Drug Administration for the prevention of migraine: two anti-seizure drugs and two beta-blockers. In addition, patients with chronic migraine who have symptoms every day or every other day can get injections of Botox.
“Forty percent of people with migraine should be on preventive medication,” Dr. Silberstein said, “but only 13 percent get it.”
To treat an attack of migraine, doctors have long relied on drugs called triptans that act like the nervous system chemical serotonin to quiet nerves that transmit pain signals. There are now also biologic drugs, monoclonal antibodies that can be given once a month or once every three months, Dr. Dodick said. They were specifically developed to treat migraine by targeting a protein or its receptor that transmits pain signals.
Unfortunately, the biologics are expensive, and insurance companies usually insist that patients fail to get relief from three months of treatment with each of two other drugs before they will cover the cost. However, for some patients, including some with heart conditions, insurance coverage can be more readily obtained if their doctors document that the older drugs are medically hazardous for them. Still, too often, doctors have to pursue a time-consuming appeal process to get the coverage their patients require.
Dr. Silberstein urged patience when trying a new drug for migraine. He and his colleagues studied patients who had little relief after a month or two on a biologic, but by six months had almost no headaches.
The new nondrug option is a neurostimulator marketed by Theranica as Nerivio Migra. Worn as an armband with a rechargeable battery, it transmits weak electrical pulses on the skin and can be turned on and off as needed through a cellphone app. The base price of the device is about $99 for 12 applications.
Also on the horizon is a new class of compounds called gepants to treat migraine attacks. In a study of one such drug, ubrogepant, recently published in The New England Journal of Medicine, for example, there was a significant reduction in pain and other migraine symptoms in patients taking 50 milligrams of this oral medication.
