Patients often ask what does the future of headache treatment look like. For many of them, the future will be too late. This is not just a negative thought (meaning that they will not live long enough to see these things) but that many will eventually “outgrow” their headaches before these are available. After age 45 there is a slow decline in the number of people who still suffer . . . and of course that is a good thing.
No one can use a crystal ball to predict the future of care for any disorder. There are unexpected breakthroughs that no one could have predicted. There are also set backs. For example, a new generation of medications to stop (and maybe prevent) headaches looked very promising in 2008. I would have predicted that they would be on the market by now. One of those was Telcagepant ( https://en.wikipedia.org/wiki/Telcagepant ). However, two patients (out of hundreds) had liver enzyme elevation while taking the drug and the research for the whole class of drugs was stopped. This would not have happened 20 years ago but now with the constant ads for things like “Bad Drugs Dot Com” that drug companies are now scared for bad PR, not to mention millions of dollars in lawsuits. So while these medications may have helped millions, it was not worth the risk of causing harm to a handful. People can debate the pros and cons of those decisions.
So, looking ahead, it appears in 2017 0r 2018 a new class of preventative treatments will come to the market. This is for what I call, in laymen’s terms, the “migraine vaccine.” This is an injectable antibody against the most powerful chemical (CGRP) that the nerves use to create headaches. In some ways, this will be a game changer (the side effects so far are almost non-existent). However, it will not be a miracle cure. There will be some people getting the once every 2-6 month vaccine (the time frame has not been determined yet) and become headache free. Some will only see a drop in their headaches by 20-50%. Still others will not see any change.
Then there are the socio-economic issues of these new treatments. If a drug company spends a decade and up to one billion dollars developing a new treatment, then that treatment is used only once every 2-6 months, then that injection will have to be expensive to cover their cost. It would be at least $1,000. The insurance companies, who are working hard to control their cost in the wake of the Affordable Care Act, will most likely deny payment (especially because it is “only for headache”). If they do pay for it, they will make the road to getting coverage very difficult, somewhat like getting Botox approved now.
There is a growing interest over the past decade on “neuromodulation.” This is using electrical stimulation or magnetic energy to control headaches. We have on the market now the Cefaly and the Spring TMS. The Cefaly gives relief to many patients, mostly as pain reduction but for some it prevents headaches. The Spring TMS was brought to the market to stop a migraine with aura in its tracks. However, it is showing great promise as a drug free preventative, even for patients who have failed many other treatments. There is work going now on a variety of implantable electrical stimulators. They often work very well but are complex and can malfunction. In the future these implantable ones may be much better.
All patients and clinicians wish that headache disorders were simple. That is why patients are often lured into treatments based on simple explanations. “You have headaches because you are too stressed.” “You have headaches because your cranial bones have moved.” “You have headaches because of allergies.” The list could go on and on. However, in reality, the more that headache research moves forward, the more complex the disorder seems to be.
If you were to lump all headaches together, the estimate is about 67% of the cause is a genetic defect in the neurons that start headaches. We know of about 5 genes so far that are responsible. In about ten years (maybe sooner) on the first visit the patient will have a genetic profile done (blood or other tissue) to map out their particular headache type. That profile will not only sub-type the headache but predict what will work best to treat them. This would save the patient a lot of time and misery of doing the trial and error method of finding the best treatment.
In about 2026 (maybe a few years sooner) the first real “cure” for migraines would be available. This cure would be gene therapy. This where the gene with errors is replace by the correct gene. This is done now in research and a few disorders by using a virus to carry the new, good gene into the body by IV infusion. If this works, a person would go from a headachey person to a normal person with no headaches ever again within a few weeks. But this is a complex process.
If you don’t lump headaches together, and we really can’t, the future will show more of a complex spectrum of disease rather than one simple title such as “migraine.” Just this year there is growing evidence that chronic migraine (more than 15 days of month of headache) is very different than regular migraine. What this new classification for headache will mean is not clear. We hope that by twenty years it would mean far better treatments.
By twenty years from now, we all hope that disorders such as cluster headache and new daily persistent headache would be much better understood. At this juncture, despite decades of research (in the case of cluster headache) no one has a clue as to what causes them. If someone figures it out, then it would be a new window into treatment.
What we all hope and pray for is a “wild card.” This is where something totally unexpected provides a major new treatment. In some ways Botox came about this way. It was being used for cosmetic reasons in the 1990s and patients noticed their headaches were better. On one predicted that response. But Botox is not a panacea. It does not work for episodic migraine (less than 15 days per month) and even for the chronic migraine suffer, it only works about 60% of the time.
So we all hope this wild card to come out of the blue. As much as we all wish, I doubt it will be a new ear piercing. It won’t be a new massage technique. It won’t be a new fad diet. It could be a medication developed for a totally different disorder, seizure, autoimmune diseases, MS or who knows. Then, once on the market and people with that disease and also with migraine finds their migraines are totally eliminated by that treatment.
We all wish that it would be a new nutritional supplement that works like a magic cure. That is unlikely because, despite popular legends, there are not a lot of new supplements in the jungle that have not been tried by someone. But again, who knows. Maybe a discovery of a new magic fungus will cure headache as the ergot fungus almost did.
I had to type fast again without proof-reading so please ignore any typos.
- Michael Jones, MPAS-C