I always wish I could come to you announcing that a cure for headaches has been found. But, because headache disorders are some of the most complex and multifactorial human maladies, it will never happen that way. But progress will come in small steps, a little here . . . a little there . . . until some day we look back and marvel how much better the world is than it was back in 2013 when many people were helped, but some still suffered from bad headaches.
I’ve talked before about a new chink in the armor of migraine disorders and that is a common pathway that uses one chemical. That chemical goes by the complex name of Calcitonin Gene Related Peptide (or CGRP). For over a decade, researchers have been trying to find a way to block this chemical, which the brain uses to create much of the pain of migraine. There are two approaches being studied now and both, I think, will eventually be on the market as effective abortive (stopping) and preventing treatments for migraines.
The abortive treatment is a man-made chemical that blocks the effects of CGRP and thus causes the headache to reverse. The efficacy of these CGRP blockers is similar to the triptans (Imitrex and that family). These CGRP blockers (we refer to at this time as the “pant” drugs because their chemical names end in “pant”) have an advantage over the triptans because they may work for an individual for whom triptans have failed, they seem to last longer than some of the more commonly used triptans and they do not constrict blood vessels, which would make them safer for patients with blood vessel diseases.
The approach to prevent migraines is what I call the “migraine vaccine” (while it is not a true vaccine, but I think patients will understand it better in those terms). This is a shot under the skin once a month (more or less) that prevents migraines from coming. It uses natural humanized antibodies to block the release of CGRP.
While there is great hope in these treatments, the first one will not be on the market for at least two years because of the intense FDA scrutiny that all new drugs must face. We are considering participation in a study of the later treatment, in order to offer our patients this treatment now.
A recent study looked at the role of sleep and headaches. While both sleep problems and headaches are common, there is still very little scientific evidence linking the two. Of course, someone with migraines may have sleep deprivation as a single trigger (as I personally do), but the point is that common headache disorders are not caused by sleep problems. So this is another one of those common myths that has little support in research. Other such myths include the thinking that headaches are caused by stress, needing glasses, having hair too long, not walking straight, TMJ problems, allergies and other simple explanations.
There was a great article in the Headache Journal this month about the genetics of migraine disorders. It is too complex to even to start to discuss here, but there are five genes identified so far that make someone vulnerable to migraine. Someday, genetic testing, and looking for other biomarkers will be helpful in not only identifying specific headache subtypes but also in predicting which treatments will work best for specific patients. At this juncture, it is trial and error, with some insight from experience, until you find what works.
Another study, which came out today, showed significant benefit of Duloxetine (Cymbalta®) in preventing migraines if used at higher doses, 60 to 120 MG per day. It was also interested to note that the patients selected for the study were not depressed (Duloxetine is an antidepressant) and still responded well, with a reduction of their headache by about fifty percent.
Recently on local and national TV news shows, major breakthroughs in headache treatment have been announced. I am quite disappointed in these news programs and I often write them, asking them to clean up their act. The treatments that they highlight are almost always considered fringe and unproven while there are many proven and even more exciting research news that gets ignored by them. The stories about unproven treatments give patients false hopes and creates distrust between them and their headache provider, who morally feels obligated only to tell the truth. Having done this for over thirty years I can say that most, if not all, fringe treatments end up being disproven later. If they are legitimate, eventually they will be mainstream.
Speaking of sub-types, the International Headache Society is working on a new catalog of headache types and just released their “Beta testing” list for us headache specialists to comment on. While this may sound frivolous, it is really important. We want to make sure that the entire world is on the same page when it comes to diagnosing headaches so when research is done in China on a specific headache type, they are talking about the same headache type as in the US or Europe. In this new catalog, there are over 130 headache types. It is interesting, that once again “tension headache,” “sinus headache,” “stress headache,” “TMJ headaches,” “dental headaches,” “needing glasses headaches,” and “sleep apnea headaches” were not mentioned.
Speaking of myths, I want to mention one last one and that is, because we are in a rural community, that we see only simple headache problems. That is absolutely not true. We see patients from throughout the Pacific NW and none are too complicated.
I am not an arrogant person, at least people who know me say so, but I am rational. I’ve worked in headache medicine for 32 years now. I spent over five years at Mayo Clinics’ prestigious “Headache Division.” It was ranked number one in the US for quality of care by US News and World Report. While I was there, I wasn’t serving coffee. I was doing exactly the same thing I’m doing now and was respected by my colleagues. Most of my referrals there were from Mayo Clinic neurologists, who believed that the level of headache care that their patients needed was beyond their own skill level . . . so they were confident to refer them to me.
Dr, Moren is the ONLY physician north of Seattle that attends the major research meetings of the American and International Headache Societies. I’ve seen no other physician from the state of Washington at the meetings except for Dr. Lucas, who directs the headache program at the University of Washington and Dr. Heidi Bloom, a neurologist at Children’s Hospital. No other regional physicians that I know of comes to these meetings. It is impossible to know the latest in headache and face pain treatments without attending them and reading the monthly research journals in headache disorders.
I’ve said over and over that there is no headache patient that is too complex for us. We do our best work with patients who have failed treatments by many neurologists and even other world-class headache clinics. We are not “headache-treatment lite.” We now have patients coming to us from California, Alaska, Idaho, Montana and Oregon. Since we are not in this to make money, we give patients the time that is needed to make an accurate diagnosis and the individualized, hand-holding care that is a rarity even among headache clinics.
Our staff, Kaaren, Brittany and Leanne all work exclusively with headache patients. Our headache patients are not pushed to the back of the line, they are our stars. I am saying this, not because we need more business (may God help us to keep up with what we have), but because I hate the thought of patients not getting well and not getting the treatment they deserve when it is right under their noses.
J. Michael Jones, MPAS-C