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New Ways to Mitigate Migraines

November 4, 2008

By Anne Godlasky

Headaches distract. Migraines can debilitate. Nearly 30million Americans suffer from the throbbing pain, costing employers about $13 billion a year from missed workdays and impaired work function, according to research reported in the Archives of Internal Medicine.

“You can be out for three days — lie there and not move, feel nauseous but not throw up — it’s incapacitating,” says Jeanne Safer, 61, of New York, a psychotherapist who has had regular migraines for about a decade.

But new treatments in the pipeline may help control the pain. Some “exciting” new drugs are coming into the headache field, says Alan Rapoport, a UCLA professor of neurology who has studied headaches for 35 years.

Scientists still haven’t agreed on a single cause of migraines, although genetic and hormonal factors and some environmental triggers often play a part.

But wherever a migraine starts — whether with malfunctioning nerve cells deep in the brain stem or hyperexcited neurons in the cerebral cortex — it sets off something called the trigeminal nerve system, which carries sensory information from the face, head and meninges (membranes covering the brain and spinal cord) to the brain stem.

During a migraine, the trigeminal nerve releases a peptide called CGRP (calcitonin gene-related peptide), which causes dilation of blood vessels and increased pain signaling. A drug that would prevent the peptide from activating the neurons is in final trials: Merck’s telcagepant. Its latest study showed that about 55% of patients had marked pain relief, and 23% were pain-free after two hours, significantly better than placebo patients. Merck plans to apply for Food and Drug Administration approval for telcagepant next year. Other companies are starting trials on similar drugs.

New drug may eclipse triptans

Interest among migraine specialists stems from evidence that these drugs are at least as effective as triptans, the most commonly prescribed class of migraine drug, writes Stephen Silberstein in the October issue of The Lancet.

Triptans were considered a major breakthrough when they arrived about 15 years ago. But unlike triptans, the new drugs don’t constrict vessels, so they may be safer for patients with high blood pressure, high cholesterol and a variety of vascular diseases.

The heart warnings on triptans make some patients nervous, including Safer. But because she has about 15 headaches a month, she’s settled on taking her triptan, Maxalt, in addition to Botox injections every 2 1/2 months and — if the pain is unbearable and she has used up her medication — shots of lidocaine, an anesthetic. Patients who received Botox had fewer days with headaches compared with those who got dummy injections, according to two studies funded by drugmaker Allergan. Botox is FDA-approved for cosmetic use, and Allergan announced in September that it would seek approval for use against migraines.

Safer’s doctor, Alexander Mauskop, also gets migraines, and like about 30% of migraines patients, pain is sometimes preceded by a visual aura. “You see flickering lights, spots, zigzags, sometimes in color,” he says.

For patients who experience aura, which many scientists believe is caused by an electrical abnormality called cortical spreading depression, a new device may stop it before it signals pain.

“If you have a fire that starts in a forest, then the fire would spread from one tree to another until it reaches your house,” says Yousef Mohammad, a professor of neurology at Ohio State University. “But if you cut a few trees in the middle, it won’t reach your house.”

That’s the theory behind the transcranial magnetic stimulator, a hairdryer-sized device that creates a magnetic pulse that, when held against the back of a patient’s head, interrupts the electrical activity during the aura, according to a study funded by the manufacturer, NeuraLieve. The firm is applying to the FDA for approval, says Mohammad, the study’s lead author.

A healthy lifestyle can help

Mauskop, director of the New York Headache Center, believes most patients could control their migraines with over-the-counter medications and “headache hygiene,” including sleeping, eating and exercising regularly.

Mohammad agrees. “Healthy lifestyle — exercise, yoga, hydration to alleviate tension — is important because we know stress can trigger an attack,” he says.

Safer has tried her share of alternative treatments, including feverfew (a plant in the sunflower family), acupuncture, massage, hypnosis, magnesium injections, biofeedback, wearing a bite guard and listening to Bach. “I offer myself for any treatment that doesn’t involve cutting off my head,” she says.

She encourages other patients to see a doctor and “be activists in their treatments.” (c) Copyright 2008 USA TODAY, a division of Gannett Co. Inc. <>




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