Let's talk about migraines

If you suffer, here's what you need to know — including that there are new, promising treatments you may not have heard about.

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I’ll be perfectly honest and admit that today’s Dear Melinda column is in response to my own question, which is basically: WTF migraines? I have been getting migraines since I was 20, but I can’t really complain because mine are mild compared to most. I regularly get visual auras (which prevent me from driving and working) along with mild headaches, and I also (more rarely) get strange atypical migraines with memory loss. Once in the grocery store during one of those bizarre migraine attacks, I had to ask my son how old my daughter was so I could buy her diapers in the right size. Talk about weird.

You might be wondering why I’m writing about migraines in a parenting newsletter, but here’s the thing: Migraines are absolutely a parenting — and especially a mom — issue. Migraines or other severe headaches afflict 15 percent of the population, and two to three times as many women as men. Most women who get migraines are in their childbearing years, in part because the hormone estrogen plays a big role: Many migraines are incited by hormone fluctuations during our menstrual cycles (often due to estrogen drops right before our period).

Considering that migraines are often triggered by stress, fatigue, hunger and changes to routine, mothers are among the most susceptible people on the planet — and that’s been especially true over the past 18 months. Several studies have reported increases in migraine frequency during the pandemic. When researchers surveyed migraine sufferers in one study, 60 percent said that their migraines had become more frequent during the pandemic, and an additional 10 percent reported that their migraines had evolved from occasional to chronic (meaning, essentially, that headaches began afflicting them or more than 15 days of every month).

Although migraines are considered one of the most debilitating diseases in the world, only a small percentage of sufferers seek help from doctors, and an even smaller percentage actually get treatment. I encourage those of you who get migraines to consider seeing a neurologist, because at the very least, doctors can help you identify your triggers so that you have them less frequently. Also, there are some exciting new drugs on the market that you should know about.

Here are some answers to common migraine questions, and more info about those new drugs.

Are your headaches migraines?

There are several kinds of headaches, and none of them are fun. But migraines are typically the worst: They throb or pulsate, they often cause light or sound sensitivity and/or nausea, and they last a long time (4 hours to several days). Sometimes they’re preceded by visual auras or other disturbances (my auras sometimes involve feelings of déjà vu), and they’re often on one side of the head.

Whereas people with tension headaches can continue to go about their day, “migraine headaches are generally pretty disabling, and they don't let you really continue to do whatever it was you were planning on doing unless you treat them,” said Kathleen Mullin, a neurologist and headache specialist at the New England Institute for Clinical Research. Cluster headaches are another nasty beast that can cause excruciating pain, but they afflict men more than women, and they usually last 15 to 90 minutes.

What are common migraine triggers?

In addition to the triggers I’ve already mentioned — lack of sleep, stress, hunger, and changes to routine or hormones — here are some other things that can trigger migraines. If you get migraines, you might want to avoid or cut down on some of these things. (Keeping a headache diary can help you identify possible triggers. There are also apps for this, like Migraine Buddy.)

• Caffeine

• Alcohol (sometimes a specific kind)

• Chocolate

• Aged cheese

• MSG

• Artificial sweeteners

• Cured meats

• Dehydration

• Light

• Strong smells

• Medication overuse (even from over-the-counter drugs like Advil or Excedrin, if you use them regularly)

  

What migraine treatments can help?

Before I talk about drugs that are approved specifically for migraine treatment and prevention, it’s important to know that birth control — especially the kinds of oral contraceptives that provide the same small amounts of hormone every day, known as “monophasic” low-dose pills — can help control some migraines. The hormones they provide help regulate hormone levels, preventing migraine-triggering fluctuations.

If you tend to get migraines right before your period, pills that do not (or only rarely) include placebo pills can be especially helpful, because these circumvent the typical pre-period estrogen drops. (You can also just skip your pill’s placebo pills, Mullin said, but talk to your doctor first.) Oral contraceptives containing estrogen aren’t recommended for women who get migraines with aura, because they slightly increase stroke risk, but I am somewhat skeptical of these concerns for low-dose pills, for reasons I explained in this piece I wrote for Vice a few years ago.

Lifestyle changes can control migraines, too. In addition to avoiding the triggers mentioned above, try your best to sleep at least seven hours a night, eat regular meals, and manage stress. (Again — no wonder moms get so many migraines, right? JFC.)

Now onto the treatments that are recommended specifically for migraines. Migraine drugs come in two types: Drugs that treat migraines once they start, and preventive drugs that people take on a regular basis. Whether you’re a candidate for these drugs depends on how many migraines you get and how debilitating they are; also, many “old school” migraine medications, both for treatment and prevention, weren’t originally intended to treat migraines, so they often have side-effects, and they aren’t suitable for patients with certain risks or pre-existing conditions.

The drugs that have been around a long time for migraine treatment include NSAIDS (like ibuprofen) and triptans (there are a lot; here’s a list). Preventive medications include anti-seizure drugs (valproate and topiramate), blood pressure reducers (propanolol, metoprolol, and verapamil) and antidepressants (amitriptyline and nortriptyline).

But! Here’s where the exciting news comes in. Since 2018, at least a half dozen new drugs have been approved by the FDA to treat migraines. Many block the activity of CGRP, a protein that carries pain signals along key headache-related nerves. The discovery of CGRP “changed how we look at and treat migraines, because it's specific — it's a specific protein that we all have circulating that plays a role in the inflammatory cascade that causes headache,” Mullin explained. This specificity is important, because it means that the drugs also cause also fewer side-effects.

The new drugs that target CGRP include monoclonal antibodies (erenumab, fremanezumab, galcanezumab and eptinezumab — brand names Aimovig, Ajovy, Emgality and Vyepti) that are periodically injected, or given by IV, to prevent migraines. There are also drugs called gepants (rimegepant and ubrogepant, brand names Nurtec ODT and Ubrelvy) and dipans (lasmiditan, brand name Reyvow), which can be taken as pills at the onset of a migraine to help treat it. One of these drugs, rimegepant (Nurtec ODT), was later approved in 2021 to also prevent migraines, making it the first drug that can both treat and prevent migraine attacks.

There were a lot of long words in that last paragraph, sorry. But this is all to say: If you’ve assumed that your migraines were a lost cause, or you’ve been frustrated by the available treatment options, you may want to make an appointment with your doctor. The treatment landscape has changed, and relief may be closer than you think.

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