June 17, 2008
Will Migraine Ever Be Cured?
By Jeremy Laurance
It's notoriously hard to treat, but doctors are closer than ever to finding effective relief for this condition that affects millions. Jeremy Laurance offers a sufferers' guideWHO GETS IT?
An estimated six million adults in Britain, or 15 per cent of the population, are migraine sufferers. The condition affects one in four women and one in 12 men and is the commonest reason for consulting a neurologist. Up to a third of patients in some neurology clinics are seeking help for migraine.
It is three times more common in women than men and affects people in their most productive middle years. The peak prevalence is from the age of 30 to 39. It also occurs in children, though more rarely, affecting about one in 17.
The incidence rises sharply in women at puberty and falls again at the menopause, suggesting a hormonal cause.
WHY DO PEOPLE GET IT?
Migraine sufferers have "over-sensitive brains". That is shorthand for saying they react strongly to stimuli such as light, noise, motion, fatigue, hunger, and so on.
In different people, different parts of the brain are abnormally active. Researchers believe that the propensity for the brain to be over-sensitive and vulnerable to migraine is inherited. Most sufferers have a family history of the condition. There has been a transition in recent decades from thinking of migraine sufferers as sad and unhappy people to regarding the condition as a biological problem.
HOW BAD IS IT?
The World Health Organisation ranks medical conditions on a scale according to how badly they affect quality of life using a measure called a daly (disability-adjusted life year). On this scale, suffering diarrhoea for a day is ranked least disabling, with dementia ranked as most disabling. Having a bad migraine is considered equivalent to dementia, placing it at the worst end of the scale because, when severe, the condition prevents sufferers from going anywhere or doing anything.
Yet migraine generates little sympathy because there is no injury or outward sign of illness. If you break a leg, it is put in a cast, which makes it easy for people to see what is wrong. The cast serves as a kind of medal, awarded for enduring the injury. But a migraine sufferer has neither cast nor medal, they seem normal and the condition is difficult to get to grips with.
WHAT IS IT?
A type of headache. Headache is the umbrella term, and migraine is one sort of headache disorder. It is distinguished from other kinds of headache by being one-sided, throbbing, with moderate or severe pain which is worse with movement. There may be sensitivity to light and sound, nausea and a proportion of patients suffer visual disturbances, such as flashing lights, zig-zag patterns or seeing an aura around objects. Others experience aphasia - difficulty finding words - co-ordination problems or pins and needles and numbness in the hands, feet and tongue.
Attacks of migraine vary in severity but can last from anywhere between four hours and three days. If they occur on up to 15 days a month they are regarded as episodic. If the attacks are more frequent than that, they are defined as chronic.
WHAT TREATMENTS ARE THERE?
The first line of defence against migraine is to take ordinary painkillers such as paracetamol and aspirin. They are more effective, however, if taken at the first sign of an attack - when the headache has already become bad they are less effective. Anti- inflammatories such as ibuprofen may also help in an attack. And if you suffer from nausea, anti-sickness medicines are available, and can be used on their own or in combination with painkillers.
For more severe cases, triptan drugs are widely used, of which the best known is sumatriptan. They are only available on prescription and work by constricting the blood vessels around the brain (the dilation of the blood vessels is believed to be a cause of migraine). There are seven triptan drugs available in the UK and if you find that one does not work, then it is worth trying another.
Preventive treatments are also available. Beta-blockers, such as propanolol, which are normally used for high blood pressure, also prevent migraine attacks, though it is not understood how they do this. The anti-depressant amitriptyline has been shown to be effective in stopping migraines and works in a different way from its antidepressant effect. Anticonvulsants, prescribed for epilepsy to prevent seizures - another symptom of the over-sensitive brain - can also prevent migraines.
WHAT NEW TREATMENTS ARE ON THE WAY?
Scientists are poised to announce an advance in the treatment of migraine that will bring fresh hope to millions of sufferers. Improved understanding of the mechanism that causes the brain to overreact to stimuli has led to the development of new drugs that promise to transform the treatment and prevention of the condition.
They include the first preventive drug specifically designed for migraine. Experts say they will usher in a new era in the management of the condition.
One of the new drugs, known only by its code, MK0974, is the first of a new class of treatments that has been shown to be more effective and have fewer side effects than the existing triptan drugs.
Final (phase 3) trials, to be presented this week at a conference of the American Headache Society in Boston, will show that MK0974 reduces pain and is better at preventing the return of the migraine over 24 hours than the triptans. The new drug is expected to be on the market within three years.
Peter Goadsby, head of the Headache Group at the Institute of Neurology, University College, London and professor of neurology at the University of California, said: "It [MK0974] is very well tolerated and does really well compared with current treatments. It is going to be an important advance. We are well on the way to having a totally novel way of treating migraine."
Separate trials are under way of the first of a new class of drugs, called gap junction blockers, designed to prevent migraine. They are taken daily and are intended for the 20 per cent of sufferers who have more than four attacks a month. Existing preventive drugs are derived from other areas of medicine such as beta blockers (for heart problems) and anti-convulsants (for epilepsy) and have significant side effects.
Early (phase 2) trials of the first gap junction blocker, called tonabersat, show that it has fewer side effects than existing preventive treatments.
Professor Goadsby said: "If the studies are suitably positive it will be a step change for the good because its mechanism of action is different. It's clear that it is well tolerated, but whether it works [better than existing treatments] remains to be seen."
Lee Tomkins, director of Migraine Action, said: "These drugs will take treatment into a whole new era when they come through. Even if they are three years away, that is a blip in the lifespan of a migraine sufferer. It is very exciting."
Migraine Action: www.migraine.org.uk
What triggers it?
*Sleep - both too much and too little.
*Eating - skipping meals or going hungry.
*Foods - certain ones, but especially citrus fruits such as oranges, plus chocolate and cheese.
*Drinks - caffeine in tea and coffee, alcohol, dehydration.
*Atmosphere - stuffiness, smoky rooms, lack of fresh air.
*Weather - changes in humidity or very cold temperatures.
*Sensory - flashing lights, loud noises, strong smells.
*Stress /relaxation - both before and after.
*Periods - some women say an attack is more likely at this time.
*Drugs - sleeping pills, contraceptive pills, hormone replacement therapy.
'I get a heavy, sick feeling that will last all day'
Migraines have nagged Jennifer Purchase throughout her adult life. They started when she was 18 and have interfered with her work both as a lawyer in the City of London and as a mother of two children, who are now grown up.
"At best, I get them five or six times a month, at worst they happen 20 times. March this year was a terrible month - I had over 25 attacks. When that happens, you start to lose the will to live."
Now aged 52, the nature of Jennifer's attacks has changed. Once, they started at any time of day with flashing lights or tunnel vision followed by the headache. Now they wake her in the small hours.
"It happens between 4am and 6am - I get a heavy, sick feeling and unless I treat it, it lasts all day. I take a triptan and a couple of anti-sickness pills and it damps it down sufficiently for me to be able to go to work.
"But now my doctor thinks I have got into medication overuse and says the drugs are making the headaches more likely the next day. So I am at the stage of having to face withdrawal from all my painkillers."
The frequency of her attacks over the years has led Jennifer to experiment twice with preventive drugs, including an anticonvulsant popular with migraine sufferers.
"It didn't have much effect, it made me feel drowsy and I couldn't think straight. I have not come across any really effective preventive drug or treatment without side effects and I would welcome one. But I would be happiest if I could stop the migraines altogether."