Jessica Ailani, MD, on Advances in the Acute Treatment of Migraine

Headache disorders are among the most common disorders of the nervous system. Most of the general population has experienced or will experience a headache or migraine in their lifetime. Because these disorders are so common, it is important for neurologists and other health care providers to stay up-to-date with advancements in therapeutics and technology for diagnosing and treating headache disorders, including migraine.

To answer our questions on this topic, Neurology Consultant reached out to Jessica Ailani, MD, who is the director of the MedStar Georgetown Headache Center and an associate professor in the Department of Neurology at Georgetown University Medical Center in Washington, D.C. She also recently spoke about this topic at the American Academy of Neurology’s 2019 Fall Conference.

NEURO CON: What therapeutic advancements have been made recently for the treatment of migraine?

Jessica Ailani: It has been a very exciting year for migraine. In May 2018, the US Food and Drug Administration (FDA) approved a new class of migraine prevention, calcitonin gene-related peptide (CGRP) monoclonal antibodies. This is the first class of preventive medications specifically targeting dysfunction that occurs in migraine. Our conversations with patients have changed. We now discuss what happens in migraine and how treatment works to adjust those changes. Having the opportunity to see patients who have not responded to any other preventive treatment coming in during follow-up with a reduced number of migraine attacks is hard to describe. Every day I get to hear stories of improvement and hope. This class of medications does not work for all patients, but the hope it brings translates, as patients realize there are more treatments in the pipeline and that migraine is something companies are investing in. 

October 2019 also saw the FDA’s approval of a new class of acute treatment for migraine. Lasmiditan was approved for acute treatment of migraine in adults. While it is not yet commercially available, it provides the opportunity to use medications working on the 5HT1 receptor, the same receptor triptans work on, but without causing vasoconstriction. This would allow patients who have contraindications to use of triptans because of vascular risk factors to have an option to treat migraines with a targeted drug.

In summer 2019, the FDA cleared a new device to treat acute migraine attacks in adults, called Nerivio. Nerivio is just becoming available for commercial use and works to reduce pain by activating the brain’s natural pain inhibitor. We are excited to see how patients will respond to the device, which has limited adverse effects and will not cause medication overuse headache.

NEURO CON: What has been your biggest challenge when diagnosing or treating migraine? How did you overcome that challenge?

JA: One of the largest challenges in making the diagnosis of migraine is having all the historical facts. Patients will often focus on particular details of their attack, which is understandable, as this is what bothers them most or what they think is important. To make a clear diagnosis, we need all the details, so guiding them through a history is important, while allowing the time to discuss their concerns.

I find that using an intake form to be very helpful for allowing many of the questions needed to make the diagnosis be completed prior to the visit. This way, we can focus the visit on the patient’s concerns, and I can take a history with the opportunity to clarify anything from his or her paperwork. 

NEURO CON: How have innovative technology developments impacted therapeutic options for migraine?

JA: Neuromodulation devices are a great addition to the treatment landscape, especially for patients who are overusing acute medication or need an additional improvement in migraine frequency without more medication. The trouble is that these devices are not often covered by insurance, so they can be financially limiting to some patients. The studies for neuromodulation devices are also varied, so it is hard to compare the devices with each other or even with other, more standard of care treatments.

There has been an expansion of headache apps in the field, the most focusing on headache calendars. Some of these apps can even help you predict your triggers, like the Curelator app. Patients tend to prefer either using a simple app, like Migraine Buddy (which is the most popular app in our clinic), or paper and pen to write down their headache frequency on a traditional calendar. In the end, I advise patients to use whatever device they think they can stick to. 

There are also several apps for mindfulness and meditation. Calm is one that I recommend to many of my patients, because it has a series of sleep stories and brief meditation bits that can be done when patients are feeling stressed at work. If this option is too costly for them, I will also recommend meditation podcasts, many of which are free if you have a music player like Spotify or iTunes. Taking a few minutes during stressful times during the day to do some guided breathing can help reduce their stress and potentially reduce a trigger for migraine. Deep breathing during an early stage of a migraine attack may also help, when layered with medication, to bring the severity down faster.  

There are also apps for biofeedback. So if a patient is trained in biofeedback techniques by a therapist, he or she can continue to practice on his or her own using an app at home. I do not have any specific apps I recommend for biofeedback.