What do you want to know
BB is a 32 year old female who has suffered from monthly migraines since she was about 15 years old. The first two days of her period were so intense that as a teenager she couldn’t go to school; as an adult, she cannot work on those two days a month either.
She tried several medications, but experienced too many side effects. Continuous birth control pills also failed to eliminate her period.
She was struggling until last year when we put her on a new drug, Nurtec ODT (rimegepant) from Biohaven Pharmaceuticals. For BB, it did the trick.
To understand how it works, we must try to understand what causes a migraine, although this is still up for debate. Migraines are a neurovascular disorder, possibly caused by a calcitonin gene-related peptide (CGRP). When this peptide is released into the brain’s blood supply, it causes an inflammatory response that causes intense pain (a migraine). Rimegepant is a small molecule CGRP receptor antagonist that prevents the peptide from triggering this inflammatory response and thus eliminates pain. It does not cause vasoconstriction, which may be important in patients with heart disease.
There are other drugs that treat migraines by a similar but not identical mechanism, including Aimovig (erenumab), Vyepti (eptinezumab), Emgality (galcanezumab), and Ajovy (fremanezumab). There are also triptans such as Maxalt (rizatriptan), Zomig (zolmitriptan), and Imitrex (sumatriptan), which are 5HT-1 (hydroxytryptamine) agonists and work like a chemical called serotonin.
There are also injectables, as well as simple opioids for pain relief. Some people benefit from acupuncture as well as biofeedback.
According to the American Migraine Foundation, more than 37 million men, women, and children in the United States suffer from migraines. It’s three times more common in women than in men, and about 10% of children will suffer from migraines at some point.
According to a study published in Clinical Neurology and Neurosurgery in 2022, migraines are the sixth most disabling disorder. Migraines are puzzling because they affect young, healthy people in their 20s and 30s. The above newspaper article also points out an interesting historical fact that “Hippocrates (c. 460 to ca. 370 BC) was the first to define migraine as severe discomfort in one of the areas of the brain related to distribution of sight”.
Migraines are different from what we call tension headaches. They can be severe, throbbing or pulsating and are usually felt on one side. Migraines can often be associated with nausea, vomiting, and sensitivity to light or sound.
Sometimes what we call an aura can precede the migraine. These auras can be blurry vision, spots in front of the eyes, or even a tingling sensation on the face. Not everyone with migraines has these symptoms.
Many migraine sufferers have triggers that the patient learns to avoid. I have suffered from migraines for over 50 years. My trigger is lack of sleep, not the best trigger for an obstetrician. I learned to adapt. There is also a feeling of exhaustion or exhaustion after some migraines.
Migraines are more than just a headache. It is a neurological event that can be disabling.
Headaches are divided into two basic categories: primary and secondary. A primary headache is not caused by a separate medical condition. Migraines are primary headaches. Examples of secondary headaches would be being hit in the head with a baseball, high blood pressure, or even a brain tumor. There is no blood test or imaging needed to diagnose migraines.
The 4 basic stages of migraines
1) Prodrome. This is a vague pre-event, which many people don’t have. It can last for days.
2) Aura. Again, not everyone presents this, but it can last anywhere from five minutes to an hour. It can take the form of sensitivity to light or sound.
3) The real headache. It can last from hours to days. The pain can be very intense, stabbing and usually one-sided. It’s not just a simple tension headache.
4) Postdrome. It can last a day or two and is usually just discomfort. Many migraine sufferers do not have this stage.
There seems to be a genetic predisposition to migraines. Most migraine sufferers have relatives with the same migraine pattern. If both parents have migraines, the children are much more likely to have them too.
The triggers are wide and varied. As mentioned, mine is lack of sleep, and I get an aura.
Others include emotional stress, missing a meal, or hormonal events (as in menstrual migraines). Certain foods, drinks and additives can be a trigger for up to 30% of patients. Migraine sufferers know what their triggers are and do their best to avoid them. Some patients are even triggered for a migraine attack by changes in weather conditions, possibly due to changes in barometric pressure.
The diagnosis of migraines is based on the history of the event. No blood test or imaging is needed.
Migraines have been with us for a long time. We are now seeing much better treatments to alleviate this debilitating disorder. I remember having migraines for a month straight when I was younger. Fortunately for many of us with migraines, these new drugs are helpful.
Most people don’t understand the migraine sufferer since migraines are invisible to people who watch. It’s because the pain is literally in our heads. But that doesn’t make it any less real.