As the Migraine World Summit begins to wrap up, Day 7 covers Treatments – specifically pharmacological treatments and devices that require your doctor’s approval. These interviews dig into new developments, provide more understanding of CGRP medications, touch on migraine surgeries, and explore a unique multi-disciplined approach to migraine care.
The Latest New Treatment Innovations – Interview With Peter Goadsby MD
The amount of excitement and anticipation in this interview was honestly a bit contagious. According to Dr. Goadsby we are ushering in a new era when it comes to migraine treatment. We’re leaving behind the last thirty years where Triptans have reigned, and entering in a “molecular era” full of medications not only designed specifically for migraine, but also highly targeted, on a molecular level. With the abundance of new options, both medicinal and devices, he echos the sentiment that we’re shifting to focus on treating the specific problem on an individual level, rather than working towards what the medicine wants.
The focal point for this interview was on the new CGRP monoclonal antibodies, devices, and new acute treatments in the ditan and gepant classes. I’ve written specifically about the new medications, so you can read more here. One thing that stood out to me regarding the new CGRP intravenous option, was Dr. Goadsby’s argument for why someone would want to use that route. Simply put, the opportunity to be migraine free or experience the benefits of the antibody rapidly rather than waiting a few weeks, has a tremendous draw for some patients.
This interview also brought up a new device called Nerivio – the fourth neuro-modulation device approved to treat migraine. Unlike the previous devices approved, Nerivio is a device that is placed on your arm, rather than the forehead or neck.
You can read the summary of the other devices on Part 3 of the 2019 Migraine World Summit and my personal review of the Cefaly device here.
Are Migraine Surgeries Worth It? – Interview with William B. Young MD
Migraine surgeries may very well be the most controversial area in headache medicine – most neurologists and headache specialists are heavily against them being performed, while surgeons often advocate for them as cures. My favorite doctor, William B. Young, covers what migraine surgeries are, the risks, along with some alternatives in this interview.
There are four types of migraine surgeries: implants of stimulators, nerve decompression surgery, PFO closure (a heart surgery that plugs a small hole), and chiari malformation surgery.
The implanted stimulation devices are essentially neuro-modulation done from underneath the skin. These devices wrap around the head and work to electrically stimulate the nerve endings. Dr. Young advises that many external devices, such as Cefaly may be excellent alternatives and that new devices that do wrap around the head – externally – will be available within the next year. This means that pursuing the surgery may not be worthwhile when the stimulation differences on the outside of the skin vs under a few layers don’t have a demonstrated difference.
One interesting thing to note about the surgeries is the one specific to a chiari malformation. This malformation is something you can see on an MRI, and for individuals specifically with a “cough” headache, the surgery removes a small section of bone, providing extra space for the sagging portion of the brain, and the headache is often resolved. The controversy with this surgery is that it is often done on individuals who do not have a “cough” headache or a malformation to begin with, therefore providing no relief.
Migraine surgeries are heavily talked about, but highly misunderstood because of how opposite the viewpoints of headache specialists and surgeons tend to be. All in all, the consensus is that they often are not worth it, and if they do provide initial relief it may not be long lasting.
Real World Use of CGRP Medicines – Interview with Brian Grosberg MD
Expanding upon previous interviews, Dr. Grosberg dives into how CGRP antibodies are being utilized in practice, along with some of the challenges being faced. The largest area of mention involved patients who would have been excluded from clinical trials and their response to these new medications. Although vague, it was made clear that parsing through patients who have been through numerous medications, are taking CGRP in combination with other treatments, and are managing other conditions has proven to be difficult. The response rates for these patients tends to be different than the more generalized headache population.
One area I thought that was critical that Dr. Grosberg brought up was the side effects that we are seeing now that these medications have been available and in use by a large population. Although typically well tolerated, he emphasized the importance of listening to patients and understanding potential side effects even if they aren’t as common. The main ones mentioned were fatigue, hair loss, memory changes, and in some cases mood changes. These are side effects that have been brushed off by many doctors, including my own, so I think it’s a huge step in the right direction acknowledging that 1) a connection does exist, and 2) although they may be clinically insignificant, they are substantial side effects for individuals.
The one large issue with CGRP continues to be one of access. Insurance companies either won’t pay, discontinue coverage if relief is acquired, or won’t cover it in combination with other more expensive treatments like Botox. Dr. Grosberg indicated their is a substantial population that benefits tremendously from these new medicines because they are filling the final gap in treatment – meaning they are using it as an additional medication, not on its own.
He also mentioned that one approach for keeping continued coverage was to keep a detailed headache diary that documents improvement, that you can submit with an appeal to insurance to show the medication is effective while in use. I think this is an important demonstration that doctor’s are on the patient’s side when it comes to getting the best care, and they can – and want to – help us when it comes to fighting for insurance coverage.
Multi-Disciplined Approach to Migraine Management – Interview with Tine Poole MD
This interview provides some critical insight into the treatment and management of migraine outside of the US, specifically in Norway. On average, 19 of 20 individuals are either misdiagnosed or not seeing a doctor regarding their migraines – a statistic that has baffled me in my own experience here in the states. However, in understanding the global lack of headache doctors and family physicians who have an understanding of migraine, it becomes crystal clear.
Dr. Poole is the founder of the Headache Clinic in Norway and has adopted a unique, multi-disciplinary approach to care, specifically for harder to treat patients. The clinic has a long initial visit where you’ll likely meet with a team of specialists from neurology, psychiatry, physiotherapy, to dietitians and even gynecologists. The goal is to treat migraine from every possible angle, and as improvement occurs, various therapies and treatments can be scaled back.
This interview was fascinating, as the type of clinic being described is a rarity. There are options across the country that do offer this approach, but they are few and far between, and as I discovered, often inaccessible to most patients.
Day 7 was an incredibly hopeful day full of interviews that shined light on advances for treatments that are now more widely available to migraine patients. The deeper evaluation of CGRP medications to me was a critical area that needed to be addressed as it gave more attention to why different administration routes are necessary – both intravenous and acute therapy options – along with acknowledging the existence of side effects that aren’t regularly discussed.
I also really enjoyed the discussions surrounding multi-faceted treatments, and believe that more doctors need to embrace a combination of therapies and strive to have good communication across different disciplines in order to best serve each individual patient. The focus on individualized therapy seems to be increasing which is a promising shift in the migraine world.
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If you’re interested in watching the Migraine World Summit interviews you can access them with an Access Pass on the migraineworldsummit.com. The views in this blog are solely my takeaways and are not intended to be a summary of any of the interviews.
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