Neil Minkoff, MD: It seems to me that we’ve learned a great deal. The migraine analysis, the work-up, the understanding of migraine, and even the treatment options have changed dramatically since I was trained. How has our increased knowledge and understanding of migraine improved our ability to diagnose and treat it? Dr Dodick, do you want to start us off?

David W. Dodick, MD: Sure. For probably 2 centuries, migraine was thought to be a vascular headache disorder.

Neil Minkoff, MD: Yes.

David W. Dodick, MD: The neurological symptoms were believed to occur because the blood vessels would constrict and limit blood flow to the brain. Then the pain afterward would be due to the distension and dilation of those blood vessels. That could be painful, right? That’s how we operated for 2 centuries.

Now, we realize that migraine is generated in the brain. It starts in the brain, and it’s due to the abnormal activation or dysfunction of multiple networks in the brain. We understand now that the trigeminal nerve is the main sensory nerve, or the main pain nerve. It supplies and imbeds itself in everything inside of the head that’s pain-sensitive. That includes the blood vessels and the covering or capsule over the brain. Pain messages are sent along that system into the brain, and it can register as migraine pain when that brain is permissive and vulnerable to an attack.

We now know the molecular biology and receptor pharmacology of many of the neurotransmitters and neuropeptides within that trigeminal system. We have been able to design, develop, and get approved all of these new drugs that target 1 protein, or that 1 protein’s receptor. Right down to the molecular basis, we understand migraine that well. That’s why we’ve seen this emergence, or explosion if you will, of new therapies over the past 3 years. There is a pipeline of other therapies in development that target different proteins and neurotransmitters. Our understanding of the molecular biology, proteins, and neurotransmitters involved has allowed us to develop highly specific therapies that target the actual problem.

Neil Minkoff, MD: Dr Nahas, I’m going to ask you to pick up from there. Those discussions about the vascular nature of migraine certainly seem overly familiar from my training. Now that we’ve learned all this, how do you take that forward into treatment, especially preventive treatment? How do you discuss which patient should be on which drug? How do you talk to the patient about the need for prevention?

Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: We used to have relatively few options to treat migraine preventively. We still do, if you ask me. But now, at least we’re at least not borrowing drugs from other disciplines that we learned serendipitously happen to help migraine. Until a few years ago, we had basically 4 FDA-approved options for migraine prevention. Two of those were very similar, there were 2 β-blocker medications, and 2 anticonvulsant medications.

We also use others besides those, including antidepressant medications, because they work. But they weren’t designed from the ground up to treat migraine. You start the conversation with the patient and lay out these options of what medicines we use. They might say, “I don’t have high blood pressure. Why do you want to put me on a β-blocker?” or, “You think I’m depressed and this isn’t a real disease? You just want to give me an antidepressant and get me out of here?” Or they say, “a seizure drug sounds really scary.”

Our conversations these days, especially for patients who have already gone through that experience, are a lot easier. We now have treatments that are tailored directly to the pathophysiology of migraine, that work as well, if not better, and are better tolerated because they are precision tools. But I always start by getting an assessment and an acknowledgement from the patient as to how much of a burden their disease is. If they’re coming to see a specialist like me, obviously, it’s a major problem.

It’s not a hard job for me to have to convince them that they need to do more in managing the problem. But in primary care, it is more of a challenge. This is where we have to do some of the education on how to start the conversation. Ask open-ended questions, and just get a sense of what migraine means to that individual sitting in front of you. What are their values for how aggressively to manage it, and in what ways?

Thankfully, besides medication, which many people don’t like to take, we have other options. Supplements, lifestyle modification, and some of the stimulators that were mentioned earlier can also be used preventively. This is attractive to younger patients who don’t want to feel old by taking a lot of medication. Young women who might want to start a family fairly soon may not want to be on medication. Older patients who are already on a lot of medication may also want to avoid it.

It’s empowering to be able to teach an individual patient the things that they can do for themselves. Those include exercising more, hydrating better, changing their diet, taking some supplements, and being more attuned to their body and how the environment influences their body and brain. Then, they can identify what’s more likely to provoke migraine.

We have to instill in patients that migraine is a part of them. While migraine may be controlling their lives now, the goal is for them to be able to control migraine and take control back of their lives. When we frame it in that way, many patients are more willing and invest more time in trying out medications. They are more patient and understanding that No. 1, they don’t always work, and No. 2, they generally take time to work. That can be weeks, if not months. There’s a lot of trial and error, and all these expectations have to be set. Reasonable goals have to be outlined that a patient can achieve in a stepwise fashion. We’re not going to get you migraine-free in the next few weeks. It’s going to be a process. You’re training for a marathon here. You’re not just running a sprint down the block. It’s not like kids racing in the neighborhood trying to win the foot race. This is a long haul, and it takes a lot of preparation, planning, hard work, and dedication.

Neil Minkoff, MD: At what point do you start discussing preventive therapy with the patient? Is that done up front?

Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: In a way, it should be a part of the discussion for everyone with migraine, even if that’s not about medication. It’s about living a healthful lifestyle that’s conducive to keeping migraine attacks away. That means maintaining regular sleep schedules, learning stress management techniques, being prepared for when triggers may come, and knowing what those triggers are. These are simple things that anyone with migraine can do to better their lives without having to swallow a single pill.