Lancaster Physician Fall 2021 - 21

FALL 2021
of the population and has a greater impact on
quality of life than episodic migraine does.
Personally, I make an effort to educate my
patients regarding headache hygiene. We review
the importance of maintaining regular sleep
patterns. I typically recommend at least eight
hours. If falling to sleep is an issue, I counsel my
patients to start a low stimulating routine 30
minutes before bedtime. This means avoiding
computers, smartphones, and television before
bed, and instead, reading a book, meditating,
taking a bath, or stretching/doing yoga before
bed. Eating regular meals, not skipping meals,
and starting the day off with a nutritious breakfast
is beneficial. I also recommend drinking
64 oz of non-caffeinated liquids each day and
limiting the intake of caffeinated beverages.
Studies have proven that regular aerobic activity
(at least 30 minutes, three times per week) can
help lessen headache frequency and intensity.
Avoid confrontations and resolve disagreements
gently to alleviate stress. Reduce tension by taking
slow, deep breaths, concentrating the mind
on a calming image or scenario, experimenting
with mild relaxing sounds/lighting, reading a
book, having a bath, or just strolling outside.
Avoid aggravating your headaches by avoiding
triggers. Also, I typically recommend keeping
a headache journal to ascertain an individual's
migraine triggers.
Given the tremendous impact that migraines
have on individuals as well as society at large,
considerable advancements in migraine therapy
have been made. Many of my patients inquire
about natural migraine therapy alternatives.
After educating my patients that vitamin supplements
can help lessen the frequency of attacks, I
emphasize that they are not generally long-term
therapies and can take up to three months to
demonstrate benefit. With this in mind, here
are some of the vitamins and supplements that
I typically recommend to my patients.
* Vitamin B2, also known as riboflavin, has
been shown to be beneficial in doses of 400
mg a day.
* Feverfew has been used to treat migraines
and is believed to decrease blood vessel irritation.
The recommended daily dose is 50 to
100 mg a day.
* Magnesium is an essential mineral that is
active in nerve transmission and other critical
brain processes. I recommend 400-600 mg each
day to prevent migraines.
Even though these vitamins and supplements
are available over the counter, there are still
potential side effects associated with them. It is
important to make sure your physician is aware
of which supplements you are taking.
Prescription migraine medications can be
broadly characterized as either preventative or
abortive. Preventive therapies aim to prevent
these debilitating headaches from occurring.
Blood pressure-lowering medicines, antidepressants,
anti-seizure drugs, and Botox injections
have been effectively utilized to prevent
migraines for many years. Triptans and dihydroergotamine
(DHE) are examples of drugs
that block pain pathways in the brain and have
been utilized as abortive migraine treatments. In
the brain, triptans bind to serotonin receptors,
amplifying serotonin's effect on pain and mood.
DHE also increases serotonin's effects while also
acting on dopamine receptors. However, these
medications constrict blood vessels and are not
typically recommended for patients at risk of
heart attack or stroke.
The newest medication class for migraine
prevention consists of monoclonal antibodies
to calcitonin gene-related peptide (CGRP),
three of which were authorized in 2018 for the
treatment of migraine. An additional CGRP
medication was authorized in 2020 for the
prevention of migraines.
For years, researchers have known that CGRPs
are involved with migraine headaches; when
produced around the nerves associated with
the head, they cause blood vessels to dilate and
inflammation to occur. This new medication
class inhibits the peptides or receptors to which
they bind. Four CGRP inhibitors are injected
or infused to treat migraine: eptinezumab,
erenumab, fremanezumab, and galcanezumab.
Two other CGRP antagonists, ubrogepant and
rimegepant, are referred to as gepants and are
used orally as an abortive treatment to treat an
acute migraine episode. Recently, rimegepant has
also received authorization as an oral preventive
treatment. Lasmiditan is the first drug of a new
class of migraine medications known as ditans.
LANCASTER 21 PHYSICIAN
Due to the fact that this family of medications
does not produce vasoconstriction, it may be an
alternative for individuals with vascular disease.
Along with natural and prescription drug
therapies, migraine patients have the option
of using neuromodulation devices alone or in
conjunction with medicines to receive migraine
relief. Cefaly Dual is available without a prescription.
It adheres to the forehead with adhesive
electrodes and administers an electric current
to the branches of the trigeminal nerve (which
regulates facial feeling) to prevent migraines or
cure an acute attack. The gammaCore device
is the size of a cell phone and can be applied
directly to the neck and transmits electrical
stimulation through the skin to reduce pain.
Nerivio is an armband that delivers electric
pulses to stimulate small nerves in the upper arm
through a smartphone. The Relivion headband
relieves migraine symptoms by stimulating
the occipital and trigeminal nerves (occipital
nerves affect the base of the skull). It has been
approved in Israel but is not yet available in the
United States.
While the new migraine medications and
devices are exciting, they do not automatically
supplant the more established, less expensive
migraine medicines that have proven effective for
many patients. Having various alternatives and
a larger range of therapies, on the other hand,
should result in a greater number of individuals
being effectively treated and suffering fewer side
effects as a result of their treatments.
As you can see, migraines are a very complex
disorder to treat. As neurologists, we do our best
to educate our patients on the treatment options
but also the importance of self-care in managing
migraines and headaches in general. Personally, I
have utilized all the treatments that I have mentioned
in this article for my patients. Choosing
the appropriate treatment for my patients takes
careful consideration and is influenced by their
other co-morbidities, insurance coverage, and
the patient's needs and desires regarding how
comfortable they are with potential side effects
and the impact migraines have on their quality
of life. Hopefully, this article has been helpful
in providing some background information
regarding migraines, the treatment options,
and treatment advances.

Lancaster Physician Fall 2021

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