Priyanka Chaudhry, MD, Fellowship Program Director-Headache Medicine and Clinical Assistant Professor at Texas A&M Health Sciences Center and Baylor Neuroscience Center-Headache Center, Baylor Scott & White Health, talks about a potential once a month migraine treatment.
Interview conducted by Ivanhoe Broadcast News in September 2018.
I want to know about these migraine headaches. Do we even know what causes migraine headaches?
Dr. Chaudhry: I wish I could say there’s a clear reason why somebody has headaches, but there are actually several reasons.
Diagnosing a headache is often important, especially if it is affecting your ability to function. You first need to identify what kind of headaches you have. Any number of factors such as hormones, food choices, and stressors can bring on a migraine. Migraine also has a genetic component, which means they can be hereditary. So the true pathophysiology is complex, but we do know several mechanisms which can induce migraine in patients.
Is there a difference between a headache from being stressed out and a migraine headache?
Dr. Chaudhry: There is a big difference. A lot of patients do not know this, but not every headache is due to sinus or tension. Migraines are very disabling and, in fact, 36 million people in the U.S. suffer from migraines. Headache can be a tension-type, sinus related or migraine. It can also be a sign of something ominous like brain aneurysm. The most important thing to remember is, if headache is sudden, severe onset or simply if headache is new, you need to get it checked out immediately. Focusing on where exactly your head hurts and the accompanying symptoms can help you and your doctor determine what type of headache you suffer from, resulting in a more effective treatment plan and fewer painful days.
If you don’t have migraines then it might be hard to understand someone who does.
Dr. Chaudhry: That’s true. If you have migraine headaches, most often you’re having a throbbing one-sided headache accompanied with nausea. You will have some light and sound sensitivity with the headache and moving around will really bother you. These patients often tell me that they want to be in a quiet zone, probably away from bright light. They often cannot work or they have to go home from work if they’re having a migraine. Seeing a headache specialist and finding the right treatment will really benefit these patients.
People don’t understand that right? They think, how can a headache be that bad?
Dr. Chaudhry: That’s true. A lot of patients just pop some acetaminophen or ibuprofen and try to go on with their day. A lot of moms will say that they just cannot stop; they have to be functioning for their kids. So as much as they would like to rest, they just have to keep going. Often, I see that patients will remain functional to a point, but the symptoms can really be disabling for some. Then they have to stop taking their medicine or often have to retire to bed in order for the headaches to get better.
You are coming up with some new techniques, some new developments that are proving to be quite helpful to people with migraines, is that right?
Dr. Chaudhry: Yes. We used to rely on preventive medications which were borrowed from other specialties like antihypertensive, antidepressants, and antiepileptic. We have been using these for several years for most of the patients, especially if they have chronic migraines, which mean they have headaches 15 or more days per month for 3 months or more. These new anti-CGRP drugs are a big breakthrough in headache medicine world.
Tell me again what these new treatments are.
Dr. Chaudhry: CGRP is defined as calcitonin gene-related peptide. It’s one of the molecules or inflammatory markers involved in pathogenesis of migraine. Now when we block CGRP mechanism, we are targeting one of the important pathways of migraine. Blocking CGRP mechanism is the primary action of these new preventive medications. Until now, we did not have any specific medications which were working on this mechanism. We now have three new medicines out there which are considered preventive treatment, which will help decrease the frequency, duration, and intensity of migraines. In some cases, they may even help eliminate migraine.
These have just been approved and I assume they’re self-administered through injection?
Dr. Chaudhry: Yes. All of the anti-CGRP are once a month injection, that patients self-administer at home. One of approved anti-CGRP, can also be given once every three months at home.
What do these medicines actually do?
Dr. Chaudhry: Calcitonin gene-related peptide is one of the inflammatory markers in migraine. These drugs basically help to block the mechanism of CGRP, which is a very important pathophysiology control in migraine.
That’s not the only way that headaches form, right?
Dr. Chaudhry: The neuropeptide calcitonin gene-related peptide (CGRP) has long been postulated to play an integral role in the pathophysiology of migraine. It is not the only one, but yes it is an important one.
Would you say this is a medical breakthrough?
Dr. Chaudhry: Absolutely. We have not had a migraine-specific preventive drug in several years. So this is the most exciting phase in the headache world right now. All the medicines we used to use are very nonspecific preventive agents and this is the first time that we have a preventive medication actually targeted for migraine.
What do you think of it and why are you so excited about it?
Dr. Chaudhry: This is probably going to change the course of migraine therapy. There are some patients who have side effects with traditional preventive medication. Also, there are handful of patients who don’t respond or get suboptimal benefit from preventive medication. It also takes at least six to eight weeks to see any benefit from these preventive agents.
Patients have a hope that these newer options may work for them. The side effects which were noted were mainly injection site reactions. Also, most patients would see benefit within a month, unlike waiting for several weeks while they are on oral preventive medications.
The anti-CGRP have this effect, and because they have a long duration of action they can be administered much less frequently than typical migraine medications that are taken daily (with the exception of botulinum toxin, which is injected every 90 days.
However, if patients are have infrequent migraines, and doing good with oral preventives, I would recommend them to stay on the current treatment plan. Not everyone is a candidate for these new drugs, so make sure to check with your physician.
What did they do to come up with this research? What was the big discovery?
Dr. Chaudhry: So we knew all along that CGRP is involved in migraine pathogenesis. The CGRP antagonist did work to decrease migraine pain based on certain measures, but there were some serious side effects including liver toxicity
The research was developed over the years and now they have come up with a drug which is more specific and much better against CGRP. This is a big molecule so it has to be given by injection rather than as a pill.
We have a patient, Karen, whom we’re going to meet in a little while. Has this made a huge difference for somebody like Karen?
Dr. Chaudhry: I’ve been seeing Karen for several years and she has tried multiple preventive medications. She has had some benefit from those, but she’s never been impressed with the results. She still has headaches so she uses her rescue medications quite often. She’s has done nerve blocks and botulinum toxin injections, neuromodulation devices for her headaches, but none of them had much benefit. She feels her quality of life has tremendously improved after starting this new medication, which is a once a month injection. She is getting almost 50 percent less headaches than she used to in the past, and is a lot more functional.
You hear these stories about how people have these crippling migraines and they have to stay in bed or they can’t go to work. It’s like their life comes to a halt. From your point of view, you’ve got to be very excited about the potential here.
Dr. Chaudhry: That’s true. One thing I would tell all the patients is when you have headaches, it’s important to know what kind of headaches you have. These drugs are not for everyone. It’s important to first see a neurologist or preferably a headache specialist in your area to identify if you truly have migraine. If you do, then there is a possibility that you would be approved for this drug or that this drug would be helpful for you. Since it’s still a pretty new drug out there, there will be some pushback from the insurances and we do know that. So first identifying what kind of headaches you have and what kind of treatment you’ve already tried will help your headache specialist or neurologist to determine if you are a candidate for the new drug.
Is it expensive?
Dr. Chaudhry: The cost of the medications that we Karen is using is $575 per month. As of now, that company is providing two free samples which means you get to try it for two months free. I think it’s worth it because then patients can really know if it’s even worth the cost if it does not get covered. Medicare does not cover these injections as of now, but I do have some patients who find the cost is worth it because after a long time, they have found a therapy which works for them. There are more incentives being offered by all 3 companies who are making these drugs.
It sounds like it’s a real puzzle to find something that works. I guess you spend a lot of time trying to figure out a therapy that’s going to work for somebody.
Dr. Chaudhry: That’s completely right. I do spend a lot of time with our patients, particularly to find what kind of triggers they have. I always tell them to keep a headache diary because that’s the best way of knowing the frequency and duration of their headaches. Then we come up with a treatment plan which may consist of medication, procedures or infusion. Using a preventive allows them to decrease the frequency and duration of their headaches. Besides medications, other alternative therapies like biofeedback, physical therapy may be an option for some of my patients.
And these new drugs are preventives?
Dr. Chaudhry: Yes, they are preventive medications.
So they still may have to use the rescue medication?
Dr. Chaudhry: Yes. This medicine may not completely cure their headaches, but will help to decrease the frequency, intensity, and duration of their migraine.
What are the rescue medications? Did you say pain killers?
Dr. Chaudhry: A lot of patients will often use pain killers if the headaches are mild. They will use acetaminophen, ibuprofen, and Excedrin migraine or pretty much anything available over the counter. I have patients who use conservative measures like ice packs and heat packs to help with their headaches. The main medications we use for rescue are called triptans, which are a prescription medicine that we prescribe to our patients. Those medicines are good for when they have a breakthrough migraine, but they should not be taken every day because these can make patients have rebound headaches or medication overuse headache. I would highly recommend checking with your physician and understanding before taking these medications.
END OF INTERVIEW
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