Emerging Treatments in Episodic Migraine

Purpose of Review

The purpose of this review is to evaluate and describe recent and emerging treatment options for episodic migraine.

Recent Findings

Recent advances have been made in better understanding the pathophysiology of migraine, which has led to further investigation of potential new pharmacologic and non-pharmacologic treatment options.

Summary

A number of new medications are emerging for the acute and preventive treatment of migraine, including CGRP monoclonal antibodies, CGRP receptor antagonists, serotonin 5-HT_1F agonists, and PACAP receptor monoclonal antibodies. Additionally, newer studies on existing non-invasive neuromodulation devices including transcranial magnetic stimulation, supraorbital transcutaneous nerve stimulation, and transcutaneous vagus nerve stimulation have recently received FDA approval for use in migraine. Neuromodulation devices including percutaneous mastoid electrical stimulation, non-painful remote electrical stimulation, and caloric vestibular stimulation are undergoing further investigation and have shown promising results thus far. These new developments are expected to contribute to better treatment and decreased disability in migraine.

     

Change and Persistence: A Paradox in Promoting Health Behaviors

The idea for the block system of nursing care evolved during a project that studied home care for the dying child. The concept of using the nurse who lives closest to the family needing care and can respond promptly to requests for nursing services was tested and found workable during that project (Moldow &; Martinson, 1980). The senior author, in an effort to make health care cost-effective while retaining high quality care for all citizens, particularly for the elderly, decided to test whether the block nurse model would work in her own community. This article describes the background, initiation, and ongoing process of a block nurse program.     

Unique Populations with Episodic Migraine: Pregnant and Lactating Women

Purpose of Review

Migraine is a disabling and prevalent neurological disease, commonly affecting women during their reproductive years. It is crucial for providers to be able to adequately counsel women who are pregnant, planning pregnancy, or nursing, regarding preventive and abortive treatment options for episodic migraine. This review will discuss (1) the expected course of migraine during pregnancy and the post-partum period, (2) recommended preventive therapies for migraine during pregnancy and lactation, and (3) recommended abortive medications for migraine during pregnancy and lactation.

Recent Findings

Recent research has indicated safety for triptan use during pregnancy and ibuprofen use during the first trimester of pregnancy. Considerations for use of emerging migraine-preventive treatment, such as non-invasive neurostimulators, are discussed.

Summary

For clinical decision-making and patient counseling, it is important to understand both the limitations in determining teratogenic effects in humans and the principles affecting medication transmission from mother to breast milk.

     

Triggers,Protectors, and Predictors in Episodic Migraine

Purpose of Review

A wide variety of triggers prompt attacks in episodic migraine. Although experimental triggers such as glyceryl trinitrate reliably produce migraine, natural triggers are much less predictable and vary in importance between individuals. This review describes the most common triggers in episodic migraine and provides strategies for managing them in clinical practice.

Recent Findings

Multiple migraine attack triggers have been established based on patient surveys, diary studies, and clinical trials. Stress, menstrual cycle changes, weather changes, sleep disturbances, alcohol, and other foods are among the most common factors mentioned. Clinical studies have verified that fasting, premenstrual periods in women, “letdown” after stress, and most likely low barometric pressures are migraine triggers. Premonitory symptoms such as neck pain, fatigue, and sensitivity to lights, sounds, or odors may mimic triggers.

Summary

Multiple studies clearly demonstrate triggers in episodic migraine, often related to change in homeostasis or environment. Many common migraine triggers are not easily modifiable, and avoiding triggers may not be realistic. Healthy lifestyle choices such as exercise, adequate sleep, stress management, and eating regularly may prevent triggers and transformation to chronic migraine over time.

     

Transformation of Episodic Migraine Into Daily Headache: Analysis of Factors

SYNOPSIS
Seventy-six percent of patients with daily headaches were found to have a history of episodic migraine in the past, more than half of them hormone dependent headache such as menstrual migraine. Various factors possibly influencing the transformation of episodic migraine into daily headaches were analyzed in a series of 61 patients who presented with daily headaches. Abnormal personality profile, especially neuroticism including depression, excessive stress, excessive use of medications such as caffeine containing analgesics, narcotic analgesics and ergotamine, and development of hypertension were found to be significant in the transformation of episodic migraine into daily headache.
The problem of daily headache is discussed. It is suggested that the majority of daily headaches are a continuum of episodic migraine, influenced and perpetuated by various factors such as neuroticism, excessive medication, stress, and development of hypertension. It is pointed out that diagnosis of tension headache under those circumstances is not justified.     

Bilateral Episodic Mydriasis as a Migraine Equivalent in Childhood: a Case Report

We report a 14-year-old girl who presented with yearly attacks of bilateral internal ophthalmoplegia, nausea and headache, since the age of nine. The episodic isolated bilateral mydriasis in this child is believed to be a migraine equivalent.     

Italian Experience of Electromyographic-Biofeedback Treatment of Episodic Common Migraine: Preliminary Results

SYNOPSIS
Electromyographic biofeedback is commonly used successfully to treat tension-type headache, while thermal biofeedback is considered the best behavioral therapy for migraine. Ten female patients with episodic common migraine (age 20-35 years, age of disease onset 16.2 ± 5.1 years, illness duration 13.6 ± 10.7 years) were treated by 16 twice-weekly electromyographic biofeedback and relaxation training sessions with breathing exercises. Follow-up sessions were held 1, 3, 6 and 12 months after the end of treatment. A significant decrease in migraine episodes was noted after therapy. More importantly, pain episodes continued to decline up to the last follow-up 12 months later. Electromyographic activity was within the normal range throughout treatment and follow-up, and there was no relationship between electromyographic activity and pain index. It is concluded that the results, particularly after a year's follow-up, are encouraging for the use of this technique to treat migraine. However, the behavioral changes and increased well-being did not correlate with muscular tension. Control of breathing, peripheral temperature and muscle activity are probably important common factors mediating learned ability to influence sympathetic activity; it is probably the latter which leads to reduced pain in migraine patients.     

IT Matters in Behavioral Health

While behavioral health faces the same barriers to widespread implementation of information technology, it has several unique needs that make such implementation critical. This article provides a look at the unique challenges of, and opportunities for, IT ubiquity in behavioral health.     

Qualitative Change in Migraine Prevention?

A new generation of drugs that target calcitonin gene‐related peptide (CGRP) pathways offers a unique opportunity to explore the relationship between responder rates (RRs) and improvement in patient outcomes. The authors hypothesize a “tipping point” exists for patients with a ≥75% migraine response. They propose higher RRs reported in trials with CGRP inhibitory antibodies deliver not only a quantitative change in monthly headache days, but also a qualitative change in function, for a clinically meaningful subpopulation of patients.