Migraine

🧠 Standard of Care

Migraine is a complex neurological condition, not just a "bad headache." It involves altered brain pathways and altered neurochemical levels.

• Diagnosis: Based on clinical history. Criteria include attacks lasting 4-72 hours, unilateral location, pulsating quality, moderate or severe intensity, and association with nausea, photophobia (light sensitivity), or phonophobia (sound sensitivity).
• Auras: About 25-30% of sufferers experience an aura (visual disturbances, tingling) before the headache phase begins.
• Two-Pronged Approach: Treatment is divided into "acute" (stopping an attack once it starts) and "preventive" (reducing the frequency and severity of attacks).

💊 Acute (Abortive) Therapies

These medications should be taken at the very first sign of a migraine for maximum efficacy.

Triptans

Drugs like Sumatriptan and Rizatriptan are the gold standard for moderate to severe migraines. They work by stimulating serotonin receptors to constrict blood vessels and block pain pathways in the brain.

Gepants

A newer class of drugs (e.g., Ubrogepant, Rimegepant) that block CGRP, a protein involved in pain transmission. These are particularly useful for patients who cannot tolerate triptans or have cardiovascular risks.

Ditans

Lasmiditan is a serotonin 1F receptor agonist that stops migraines without constricting blood vessels, though it can cause significant dizziness.

🛡️ Preventive Therapies

Considered when a patient has 4 or more migraine days per month, or if attacks are debilitating.

• CGRP Monoclonal Antibodies: Injectables (like Aimovig, Ajovy, Emgality) given monthly or quarterly. These specifically target the migraine pathway and have revolutionized prevention.
• Traditional Oral Preventives: Includes beta-blockers (Propranolol), anti-seizure medications (Topiramate), and certain antidepressants (Amitriptyline).
• Botox Injections: FDA-approved for chronic migraine (15 or more headache days a month). Injections are given around the head and neck every 12 weeks to block pain signals.

🔬 Active Clinical Trials

Research continues to refine targeted therapies, exploring new delivery methods and combinations.

• NCT06417775 (AbbVie): The UBRO MM study evaluating oral Ubrogepant for the preventive treatment of menstrual migraine.
• NCT06745648 (Hospital Municipal Pedro T. Orellana): A pilot study testing the effectiveness of carotid sinus massage in a modified Trendelenburg position for acute headache relief.
• NCT04930887 (Stanford University): A trial of endoscopically guided injection of Exparel (Bupivacaine) for craniofacial pain and intractable migraine.

🗺️ Next Steps After Diagnosis

Chronic migraines require a structured, proactive approach. Here is how to take back control:

1. Keep a Meticulous Diary: For 30 days, track every headache (duration, severity), what you ate, the weather, and your sleep patterns. Apps like Migraine Buddy can automate this and help identify your unique triggers.
2. Establish an Abortive Plan: Don't wait to see if it gets worse. Work with your neurologist to find an acute medication (like a Triptan) and take it at the very first sign of an attack or aura.
3. Discuss Prevention: If you have more than 4 headache days a month, you are a candidate for preventive therapy. Discuss the new CGRP inhibitors (monthly injections) with your doctor—they have far fewer side effects than older daily pills.
4. Manage "Trigger Stacking": A single trigger (like poor sleep) might not cause an attack, but combined with another (like skipping a meal or a weather change), it pushes you over the threshold. Focus on strict routine (sleep, hydration, meals) to raise your threshold.

❓ Patient FAQ

Q: What is medication overuse headache (MOH)?
A: Also known as rebound headaches, these occur when acute pain medications (like ibuprofen or triptans) are taken too frequently (typically more than 10-15 days a month). The brain adapts, and the medication actually starts causing more daily headaches.

Q: Are there dietary triggers?
A: Yes, though they vary wildly between individuals. Common culprits include aged cheeses, alcohol (especially red wine), artificial sweeteners, and MSG. Keeping a headache diary can help identify personal triggers.