Migraine knowledge increasing, but management lags

Mounting scientific understanding has triggered better strategies to diagnose, prevent and control migraine pain. But a gap exists between knowing and treating.

By Stephanie Stapleton, amednews staff. June 26, 2000.

Washington -- A flash of light. A blinding pain. Nausea. Sensitivity to sound and touch.

These are just a sampling of the symptoms associated with migraines, a disorder for which physicians have more and more treatment options.

A snapshot: the migraine gap
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But as scientific inroads continue to demystify how the headache pain takes hold of a patient's life, they also highlight the gap between those who suffer and those who seek care.

In an effort to improve the diagnosis and management of migraine conditions, the National Institute of Health's National Institute of Neurological Disorders and Stroke sponsored a two-day scientific conference earlier this month.

The first way the science can be "translated" is by offering proof that migraines "are not a disease that has a psychological basis," said panelist K. Michael Welch, MD, vice chancellor of research at the University of Kansas Medical Center, Kansas City.

"Research has shown distinct changes in the brain during the attack. It's a disorder to be taken seriously," he added.

"This is a very exciting time. Something has changed in migraine research," agreed Gerald D. Fishbach, MD, director of the NINDS. "But the health delivery system has to keep up. People have to be more aware of the need to treat."

About 28 million Americans suffer from migraines. The condition takes a toll on society -- causing about 157 million lost work days and costing $13 billion per year in lost productivity.

But the burden of pain is not uniformly distributed, according to Richard B. Lipton, MD, a conference co-chair and neurology professor at Albert Einstein College of Medicine, Bronx, N.Y.

Specifically, about 18% of American women and 6% of American men are afflicted, he said. Overall, the episodes usually begin when a patient is in his or her 20s. However, the age of onset is often earlier for males than females. After puberty, migraine is two to three times more common in women, and this prevalence increases up to about age 42 and then declines.

Still, Dr. Lipton said only about half of all sufferers know the headache they have is a migraine. Most attribute it to sinus pain or stress. "They treat themselves with over-the-counter medicines with the exclusion of prescription drugs," he said.

A large segment of sufferers who would benefit from better medical care do not seek it or get it. "There's a gap between the available care and the amount of treatment that people actually receive," Dr. Lipton said. And that gap is "a significant public health problem."

Consider the statistics. Of those people with migraine conditions, about 20%, or 5 million to 6 million, experience at least three disabling days per month. "They would benefit from preventive therapies," Dr. Lipton said. But only about 1 million receive it. At least half, or 14 million, would be candidates for other prescription medicines. But only about 3.5 million get them.

Part of the reason rests with the patient. "Consumers ... don't know that there are strategies available," Dr. Lipton said. A number of people also do not get diagnosed, usually because the subject is not broached with their physicians. "My sense is that if a patient explains the extent of the problem he or she has suffered with headaches, it will be taken seriously."

But getting to that point appears to be the greatest barrier. Rarely do patients specifically complain about headache pain, according to Dr. Fishbach. "It's going to take physician awareness," he said. Physicians have to learn to ask and to note subtle differences in pain and symptoms. "Treatments will be very specific to different types of migraines," and, as more therapeutic options emerge, "docs have got to keep up."

And the pace is quickening -- spurred by increased research investment at NIH.

"Thirty-five years ago, migraines were considered a disease of neurotic women," said Dr. Welch. Since then, advances in molecular biology and genetics have demonstrated that this is not the case. These advances, coupled with the development of such noninvasive imaging tests as magnetic resonance imaging, have allowed researchers to see the changes that occur in a migraine sufferer's brain. "Migraines are now believed to be a primary disorder of the brain -- a physiological disorder," he said.

And some researchers, including Dr. Welch, are looking to the brain stem, where a neuroelectrical phenomenon may start the problem.

Overexcited nerve cells -- those with a predilection for acting at a lower-than-usual stimulus -- fire off at the back of the brain; blood flow increases and then dramatically decreases. The event then ripples forward across the brain.

Still, as science continues to search for clues about the migraine's cause, experts say the prescription drugs now available offer tools that can help migraine sufferers manage.

"We've come a long way" in terms of good treatments and appropriate uses of treatments, said Stephen Silberstein, MD, a conference co-chair and director of the Jefferson Headache Clinic at Jefferson Medical College in Philadelphia. "We're not 100% there, but we're on the road."

The American Academy of Neurology joined with other medical specialties and patient advocates to develop comprehensive treatment guidelines. They were released earlier this year.

According to Dr. Silberstein, nonspecific treatments include OTC medications and prescription analgesics. More specific interventions involve the prescription of ergot alkaloids and triptans, a relatively new family of drugs developed to stop migraines.

Another important point is that women have unique migraine triggers, he said. Gaining a better understanding of these has led to a "near revolution" in prevention. For instance, oral contraceptives, hormone replacement therapy, menstruation and pregnancy all can play a role. A new strategy, then, takes advantage of hormone manipulation to control the headaches, Dr. Silberstein said.

Another important message: "We have to stratify care, but we haven't been doing it," he added.

ADDITIONAL INFORMATION:

A snapshot: the migraine gap

Some 28 million Americans (18% of women; 6% of men) are afflicted.
Only about half realize their headache pain is caused by a migraine.
About 20%, or 5 million to 6 million people, would benefit from preventive medications; only about 1 million receive them.
About half, or 14 million, would benefit from other prescription medications; only about 3.5 million receive them.
Migraine headaches cost an estimated $13 billion annually in terms of missed work and lost productivity.

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The American Academy of Neurology's Neurology journal features treatment guidelines developed by the U.S. Headache Consortium, a coalition of medical specialty societies and patient advocacy groups (http://www.neurology.org/).