A neurologist dishes on the migraine treatment landscape

Migraines are a prevalent condition, affecting about one billion people across the world. “In the U.S., about 13% of the population experiences migraine headaches regularly,” said Dr. Alexander Feoktistov, a neurologist at the Synergy Integrative Headache Center in Chicago. 

In the following interview, Feoktistov shed light on the prevalence of the condition and shares his thoughts on the overall treatment landscape. A forthcoming article will touch on how migraine treatments have evolved over the past two decades, focusing on the impact of recently introduced therapies. 

Could you briefly summarize how you diagnose migraines? 

Feoktistov: Migraine headaches typically start in childhood or during adolescence and frequently continue throughout most of the patient’s life. We sometimes see outliers when people start experiencing headaches later in life — in their 30s and 40s, but that’s rather unusual.

To diagnose migraines, we typically rely on clinical symptoms. Sometimes, we order blood tests or imaging such as MRI or CT scans. We request those scans not to diagnose migraine but rather to rule out other symptoms or other conditions like an aneurysm or brain tumor that could mimic migraine. 

A migraine is a primary headache disorder. It doesn’t result from aneurysms or pinched nerves, but from a genetic predisposition causes people to be susceptible and sensitive to certain triggers. Whenever patients come in contact with that trigger, it sets off a migraine. 

Migraines present in a variety of different ways. In fact, headache itself is only one small piece of migraine attacks, which typically start with a so-called prodrome. This prodrome phase could last maybe 24 hours or two days before the actual migraine headache. During that period, patients could experience irritability. Some patients have difficulty sleeping. Some patients crave certain foods, for example. And then, once this period passes, patients enter the migraine headache phase when the experience is throbbing, a stabbing sensation, pressure or aching. It is usually unilateral, on one side of the head, but not always. In about 30% to 40% of the patients, a migraine headache essentially affects their entire head. 

In addition to that, maybe 30% of patients with migraines may also experience migraine aura, which is a neurological phenomenon that is often visual. Patients can see spots of flashing lights or zigzags with squiggly lines. That phenomenon can typically last somewhere between five minutes and up to 60 minutes. Immediately after it resolves, the patient experiences a full-blown migraine headache. 

Usually, a migraine headache is throbbing in nature but not always. And frequently, it is associated with either sensitivity to sound or light, nausea or sometimes vomiting. We don’t see vomiting all the time, but it’s a prevalent symptom. The more severe the migraine headache is, the more likely patients may experience nausea and vomiting. 

The headache portion of the migraine typically lasts somewhere between four and 72 hours, statistically. In our experience, it’s usually for about 24 hours. It’s a one-day-long headache probably about 70% of the time, but it could last up to three days in some patients. Once the headache is gone, the patient enters this postdrome stage that could last another 12 to 24 hours. In that phase, patients may not necessarily experience a headache anymore — at least not a severe headache. But they often struggle to focus or perform any meaningful activities. They are recovering from a migraine attack, and that still may last another day after a migraine episode. 

In the worst-case scenario, if you count the duration of all of these different phases, including the migraine headache portion, the entire migraine episode could last up to seven days in some patients. Some patients may have, say, only one migraine attack per month, but that could be one week-long event. In a nutshell, that’s how we diagnose migraines. It’s a clinical diagnosis based on symptoms that patients describe.

How common is it for neurologists to specialize in headaches in general? 

Feoktistov: Every neurologist sees patients with migraines and other headache disorders regularly in their practice. Yet, for many neurologists, it’s not something that they do day and night. They might be familiar with the diagnosis, but they may not necessarily be very up to date with all the treatment modalities. That’s the sad reality. Only a minority of neurologists spend almost their entire time studying and treating headache patients.

Can you explain how early diagnosis can improve treatment for patients? 

Feoktistov: Migraines also appear to be extremely disabling. The disability of migraine comes from the pain itself, but it’s also disability from so-called migraine-associated symptoms such as sensitivity to light, sensitivity to sound nausea, all of those things. 

So, they are also very disabling. So the longer it takes us to diagnose someone with migraine, the longer those patients will experience this tremendous migraine-related disability. 

In fact, there was a study done several years ago that looked into the burden of disease from 2016. 

They looked into the overall disease-related disability and ranked migraine as the second leading cause of years lived with disability globally. 

Obviously, the longer it takes us to diagnose someone with migraine, the longer those patients might experience this tremendous disability for migraine. 

Misdiagnosis remains a challenge. We still see many patients who are not being accurately appropriately diagnosed with migraines. They are therefore also mistreated. They are sometimes receiving less specific treatment modalities or medications — sometimes nonspecific at all. And that delays these patients’ recovery.

Some studies show that if we treat migraines without migraine-specific medications that are proven to be effective, those patients have a higher risk of their migraines progressing from episodic to chronic forms. Chronic form means that patients experience migraine headaches 15 days per month or more. So this is a very complicated and devastating condition. So, early recognition and also appropriate treatment using specific migraine therapies can slow down that progression dramatically. Early recognition impacts patients’ quality of life first and foremost.

Can you provide a brief overview of acute versus preventative treatments for migraines?  

Feoktistov: With acute treatment, patients take certain medications intending to stop an ongoing migraine attack. Examples would include sumatriptan, rizatriptan and frovatriptan and so on so forth. 

There is a new class of medications called gepants. We have ubrogepant and rimegepant. So those are the medications that patients take as needed. It’s not a regularly taken medication. 

Typically, we recommend patients take these medications as early as possible at the migraine onset. Sometimes patients need a redose. Sometimes there are certain limitations in terms of how many doses per day a patient can take. Unfortunately, some of those rescue medications can also contribute to so-called rebound headaches or medication-overuse headaches. 

On the one hand, we want patients to use specific acute treatments because it slows down the progression. But then, if patients overuse those particular treatments, it could sort of backfire and could potentially make the situation much worse. 

We have a number of FDA-approved acute medications that could be used safely and effectively to treat the majority of migraine attacks.

Prophylactic or preventative medications would not stop an ongoing attack, but in the long run, patients might say that their headache frequency would go from, let’s say, 20 days per month down to maybe three days per month. Those medications should be taken regularly. It could be a daily oral medication. We have anti-seizure medications, blood pressure medications, antidepressants that could be tried for migraine prophylaxis. Patients will take them every day, and it takes about four to six weeks for those medications to become effective. There are also other medications such as Botox injections that we could use once every three months to prevent migraine headaches. 

We have this new class of calcitonin gene-related peptide (CGRP) monoclonal antibodies introduced a few years ago. Patients inject those medications either monthly or quarterly to prevent headaches. 

Just last week, we had another oral medication approved. It is a rimegepant tablet that patients can take every other day, continuously. 

Every patient with migraine should have access to a safe, reliable and effective acute medication.

Prophylactic medication should be considered for patients experiencing frequent or chronic migraine headaches or simply who experienced significant disability, even when they’re experiencing infrequent migraine attacks. For example, the American Headache Society and the American Academy of Neurology suggest considering prophylactic medication for those patients who experience four migraine headache attacks per month or more. And this is all derived based on our understanding of the disability patterns in those patients who experience at least four migraine attacks. That’s when disability becomes significant.

How commonly are prophylactic drugs used for migraines? 

Feoktistov: Prophylactics are significantly underutilized, unfortunately. I’d probably say fewer than 50% of patients who should be on prophylactic medications are currently taking them. 

That could be either a patient centered-problem or a provider-centered problem. A patient-centered problem could involve issues with side effects or simply compliance. It’s not easy to take medication every single day, sometimes multiple times per day, continuously. Patients forget. It’s a burden. But mainly, it’s the side effects that a problem. A lot of preventive medications produce a lot of side effects — especially our traditional oral medications. The side effect profile is significant with those drugs. Statistically, we know that whenever we prescribe a patient with chronic migraine a prophylactic medication, within the first six months, 60% of the patients will discontinue the preventative medication within six months. And 80% of the patients will discontinue the medication within the first year. So only 20% would continue on preventative medication past the first year. So the compliance is definitely not the best. The main reasons, in my experience, are side effects and lack of efficacy. Patients continue to experience headaches, no matter what. 

With that said, when we had this new medication class introduced — specifically those CGRP monoclonal antibodies, compliance with those medications has been significantly higher. Those medications are very effective. I do think they’re probably more effective than most other oral medications — at least in my experience. These medications are very well tolerated. That is probably the absolute biggest advantage of this new class of medications. We rarely see patients struggling with side effects from this new class of meds, so they’re very well tolerated. And it’s pretty easy to use those injectable medications. Patients administer them themselves in the comfort of their home. It’s a once-a-month injection most of the time with CGRP monoclonal antibodies. Some of them could be infused quarterly as well. So it makes it very easy for the patients to adhere to this medication, especially in the context of good efficacy and a low side effect profile.