By Stephen P. Raps, MD

Many individuals are surprised to know just how severe, disabling and frequent migraine attacks are to headache sufferers. Conversely, "migraineurs" are often perplexed to learn most people rarely, if ever, experience severe headache. Many individuals experience one or two migraine attacks during their lifetimes, suggesting that it is not the attack itself, but the tendency toward recurrent attacks that is abnormal.

Among adults in the United States, the prevalence of migraine is almost 18 percent in women and 6 percent in men.¹ This translates into a total prevalence of 13 percent, making migraine more common than diabetes, asthma or osteoarthritis. Despite its prevalence, migraine is felt to be underdiagnosed in the general population, as roughly 30 percent of chronic migraine sufferers have never consulted a healthcare provider for headache.¹

Most migraine sufferers experience substantial pain and find themselves incapacitated for hours to days with intolerance to light, noise and even routine physical and mental activity during an attack. This is one reason why frequent migraine becomes so disabling. Studies indicate that migraine attacks cause some type of functional impairment in 91 percent of migraineurs. In addition, 31 percent of migraineurs lose at least one day of work and 76 percent lose at least one day of household activities every three months.²

Migraine, once thought to result primarily from blood-vessel changes, now more properly is understood as a neurovascular disease characterized by recurrent attacks of severe headache and other neurological symptoms. It typically is thought of as an episodic disorder, although it may be more appropriate to view migraine as a chronic disorder with acute attacks which may be progressive in some individuals.

Risk factors for progression include frequent attacks (more than two per month), overuse of pain killers or analgesics, obesity, head trauma, female gender, earlier age of onset and habitual snoring.³

Recent scientific advances have produced a wealth of understanding about the brain events that result in migraine attacks and head pain in general. This has further led to newer migraine-specific analgesics called triptans, which target paingenerating mechanisms in migraine and significantly reduce or eliminate in under two hours headache and related symptoms. These agents are now the mainstay of acute therapy for many migraine patients who are eligible to use them.

Acute therapy often is used in conjunction with preventive therapy, the goal of which is to reduce the frequency, severity and overall disability associated with migraine. Preventive therapy also may improve responsiveness to acute treatments. Preventive agents consist of medications from several classes, including bloodpressure lowering beta-blockers and calcium-channel antagonists, antidepressants, anti-inflammatory agents, neurostabilizing agents and, most recently, neurotoxins, specifically botulinum toxin A. All of these agents have independent actions to modulate and reduce hyperexcitability and the thresholds for activation of pain systems in the brains of migraineurs.

Previous guidelines for preventive therapy focused on the number of monthly attacks. Given the wide choices for therapy currently available, however, newer preventive treatment guidelines also must consider patients' needs and preferences. These include unique patient disability, patient perception of responsiveness to acute treatment and the presence of coexistent medical conditions and medication use.

An important and emerging trend in migraine management is to use preventive therapy earlier and more aggressively in those individuals who are at risk for progression to chronic migraine, an increasingly recognized complication of the disease and a common form of chronic daily headache. Ultimately, the goal is to reduce disability and improve daily function for these individuals.

REFERENCES
¹ Lipton RB, Scher AI, Kolodner K, Liberman J, Steiner TJ, Stewart WF. Migraine in the United States: epidemiology and patterns of health care use. Neurology. 2002; 58: 885-894.

² Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001; 41: 646-657.

³ Scher AI, Lipton RB, Stewart WF. Risk factors for chronic daily headache. Curr Pain Headache Rep. 2002; 6:486-491.

Stephen P. Raps, MD

Stephen P. Raps, MD, is a board-certified neurologist with MedSchool Associates, an associate professor of neurology in the Department of Medicine of University of Nevada School of Medicine and a member of the American Headache Society. For more information, please call 784-7500.

Northern Nevada Medical Center 2375 E. Prater Way, Sparks, NV 89434 775-331-7000