Continuing Research Into the Biology of Migraine

Kathleen B. Digre, MD, the chief of the Division of Headache and Neuro-Ophthalmology at the University of Utah, and the president of the American Headache Society

Kathleen B. Digre, MD

The field of migraine has long needed new therapies to help address the issues that the patients with the condition face. With some estimates showing more than 30 million people have migraine in the United States alone, there is a huge pool of patients to treat.

For Kathleen B. Digre, MD, the chief of the Division of Headache and Neuro-Ophthalmology at the University of Utah, and the president of the American Headache Society, that makes the recent developments and approvals even more exciting. However, as a member of the field who treats this condition, she recognizes that many of these patients may not see specialists with a great understanding of these treatment options.

To provide some insight to what may still need to be elucidated about these new therapies, such as the calcitonin gene-related peptide (CGRP) inhibitors, and what the primary care community should be aware of, Digre spoke with NeurologyLive in an interview.

NeurologyLive: Is there anything the clinician community needs to know that hasn’t really been discussed about the new therapies?

Kathleen Digre, MD: Every provider who prescribes this should just be on the lookout for any adverse effects that we’re not aware of. Each of these medications have a very favorable adverse effect profile, and all providers should just, at least, be on the lookout for anything that’s unexpected.

Providers may be limited in using these medications, which I think is unfortunate. Managed care organizations and all the people who hold the pharmacy purse strings make it more difficult for patients to receive these treatments. I hope that’s not a struggle because providers are already stretched, and I hope that we can find the right patient for getting the right drug. As far as differentiating between all of these medications—I don’t know if we have enough information to do any kind of comparisons between any of these medications at all.

What do the primary care providers need to know?

One of the things I see frequently is primary care providers sometimes underdiagnose migraine because they don’t look at the whole picture. They may fail to understand, or they may consider, tension-type headache and not migraine. However, in most cases, the people who are coming to a provider are going to have migraine, not tension-type headache. That would be one thing, maybe working on increasing diagnosis of migraine by being aware that, if a patient has nausea or vomiting and they don’t have any other causes than their headache, then it’s probably going to be migraine. If they have photo- and phonophobia, they’re going to have migraine. If it’s making them disabled, it’s most likely migraine. I think getting the right diagnosis is always a challenge for them.

The second thing is, many primary care providers are stretched so thin to take care of colds and flus that it’s hard to stay up on all the treatments for migraines. I would just hope they will consider that there are many, many treatments. They should be treating migraine somewhat aggressively to prevent it because the more headaches and migraines the person has, the more they’re going to get. Working on prevention right at the start, not just with medications but lifestyle interventions as well is really important.

Are there any remaining challenges in migraine?

One thing to be thinking about is the science of migraine. We need more research. These drugs came about because people started to understand that CGRP was elevated in migraine and then they started to look into the science and biology of it. To me, this is just scratching the surface of trying to understand migraines. There are many, many features of migraine and we don’t understand the biology [completely]. Research is really the only way we’re going to move forward—understanding what the biology of this, and what are other factors that are feeding into migraine and playing a major role and making migraine severe for some people.

We have to keep our eyes on is the biology and the science of migraine because that’s how we’re going to get these breakthroughs in the future. And this is only one piece of migraine, there are many other parts of it that we need to be studying.