There are many articles on the site about migraine and other headaches. This update will show you an overview of both non pharmaceutical and pharmaceutical therapies. You are encouraged to explore further on this website and on www.DoctorRowe.com.
A quick look at non-pharmaceutical, non-device therapeutic approaches
There are many old and new device and pharmaceutical approaches, many of which are FDA approved, for both acute migraine treatment and for prevention. Many of these are detailed elsewhere on this website.
In addition, several conditions may trigger or worsen headache, even in established migraineurs. These include:
• “Pinched” nerve root in the neck (Cervical Radiculopathy, generally treated with physical therapy)
• Sleep Disordered Breathing (sleep apnea and related conditions revealed by sleep studies)
• Hypermobility syndromes (where joints in the limbs and spine bend further than normal, stretching joint capsules, ligaments, and tendons, causing pain)
• Dietary sensitivities (including sugar, gluten, dairy, and other foods and additives)
• Inflammatory conditions of arteries, nerves, and veins
• Dental Issues
Special mention of dental problems is in order, especially as an underappreciated cause of facial pain, headache trigger, and cause of recurrent sinusitis, as well as possible cardiovascular events:
Most practitioners are aware of the nightmare scenario of well-intentioned dentists and orthodontists extracting or treating one tooth after another in patients with facial pain from trigeminal neuralgia (a condition caused by irritation of a sensory nerve that supplies sensation to the face, somewhere along its path).
In my experience, however, very few are aware of the profound difference a single treatment by an experienced endodontist, if a root canal is needed, can make in atypical facial pain and recurrent sinusitis. In fact, dental problems (periodontal and endodontal) can themselves trigger the migraine cascade, as well as have profound effects on cardiovascular health.
Lastly, regarding all types of therapy for headache, patients must act as their own advocates when they see providers. Being ushered out of a busy office with a prescription for the latest and greatest drug is not optimal care for a complex patient with headache. Providers must always try to get to the root cause of a patient’s headache, whether that patient is new or established. Patients and providers must always ask themselves: “Are we missing something?”
A quick look at newer pharmacological and device therapies.
From the American Headache Society Consensus Statement, 2021.:
“Newly introduced acute treatments include two small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists (ubrogepant, rimegepant); a serotonin (5-HT1F ) agonist (lasmiditan); a nonsteroidal anti-inflammatory drug (celecoxib oral solution); and a neuromodulatory device (remote electrical neuromodulation). New preventive treatments include an intravenous anti-CGRP ligand monoclonal antibody (eptinezumab). Several modalities, including neuromodulation (electrical trigeminal nerve stimulation, noninvasive vagus nerve stimulation, single-pulse transcranial magnetic stimulation) and biobehavioral therapy (cognitive behavioral therapy, biofeedback, relaxation therapies, mindfulness-based therapies, acceptance and commitment therapy) may be appropriate for either acute and/or preventive treatment; a neuromodulation device may be appropriate for acute migraine treatment only (remote electrical neuromodulation).”
A Note About FDA Approved Therapies
When FDA approved, these therapies were largely approved based on comparison with placebos, rather than to existing therapies. Although this is common practice for regulatory approvals, in a perfect world, we would be able to compare them to existing therapy.
While these newer therapies hold some promise, they have not been extensively compared to existing medications in human trials. And their safety profiles and side effects have not been established in large migraine populations.
Again, in a perfect world, we would have randomized controlled trials (RCT’s) comparing these new therapies to existing therapies, like botulinum toxin, triptans, NSAIDS, and others. However, such trials are unlikely to occur in the foreseeable future using the gold standard RCT’s.
Thus, the decision to try these newer therapies will be made without that information. As always, it is wise to recall that while Pharmaceutical Companies have brought important drugs to market, they are big businesses, and thus in them the profit motive usually reigns supreme.
It is also worth noting that insurance companies so far tend to require treatment with more traditional agents first before using the newer ones, largely because of cost. And all new medications have side effects: those we know about, and those we don’t. These newer agents are no exceptions.
By Vernon Rowe, Elizabeth Rowe, and Elaine McIntosh