This is the second part of the Association of Migraine Disorders’ two-part series on migraine prevention. Listen to Part 1 here.

TRANSCRIPT

Molly O’Brien: There are many aspects of migraine prevention. Lifestyle interventions, vitamins and supplements, drug and drug-free treatment options, behavioral therapies. 

Hi, I’m Molly O’Brien, and this is Spotlight on Migraine. In this episode, we are continuing our conversation with Dr. Jessica Ailani, diving into specifics about migraine prevention treatment options. And if you missed it, make sure to check out part one, where we discussed what migraine prevention is, when it should be considered, and what success looks like.

I’d like to introduce Dr. Jessica Ailani. She’s a neurologist and headache specialist. She’s Director of MedStar Georgetown Headache Center  and Professor of Clinical Neurology at MedStar Georgetown University Hospital. Dr. Ailani is on the Board of the American Headache Society and an advisor to the National Headache Foundation. Thanks so much for being here today.

Jessica Ailani, MD: Oh, it’s my absolute pleasure.

O’Brien: Really thrilled to talk to you, and we have an excellent topic. We’re getting back to basics about migraine prevention. Can we talk a little bit more in depth about some of the options that we have out there? There are now more options than ever, which is exciting. There are now migraine-specific drugs. So can you talk to us a little bit about what some potential options are for people, kind of run us through the gamut here.

Ailani: Let’s start with lifestyle discussion. As I said, it’s the foundation of all changes we make when it comes to migraine. I think it’s really important to understand that’s not everything, and if you leave the room and you didn’t get any discussion about prescriptions for your attacks or prescriptions in other ways, you got to get back in there because these things happen simultaneously. So lifestyle changes really will focus on a couple of things. The main thing is that a migraine brain, the reason you have migraine is it doesn’t like changes. It really hates any kind of variability.

So a lot of lifestyle shifting has to do with keeping things stable. This is the hardest part of the treatment. I will just tell you, it is very easy to take a drug and get side effects, stop the treatment or take a drug and not have side effects, right? But it is so hard to maintain life stability. Because I don’t know anybody whose life is the same every single day, all the time. It just doesn’t happen.

So we talk a lot about things like, when do you go to sleep and when do you wake up? Is that within the same timeframe every single day of the week? Or you’re like me who, on a weekend, maybe sleeps in a little bit, and that’s not so good for the migraine brain, but it happens. Is your caffeine intake the same time every day? We often will see people having more attacks on a weekend or a day off because they delayed their caffeine intake. 

I’m not opposed to caffeine in my patients. I just think that you have to keep the timing very regular. And if you have trouble sleeping at night, well then you shouldn’t be drinking caffeine after 12 p.m. because it breaks down into other things and that will all keep it difficult for you to sleep.

Besides sleep, another big, important factor is exercise. Now, of course, if you have terrible attacks, it can be tough to exercise on a routine. So what I tell my patients is aim for 150 minutes per week, and that can be broken down any which way you like. If you want to do 10 minutes in the morning and 10 minutes in the evening and exercise every day, great. If you’re 60 minutes one day, 90 minutes another, and then you’re pretty much finished for the week, great. If all you can do is walk, that’s good enough. It doesn’t mean that you’re not going to get better. It’s the regularity that’s important. 

And it’s also understanding that exercise will attack a couple of other important factors involved in migraine. It helps reduce your stress. It helps reduce and manage your anxiety. It’s really good for the heart, and it’s really good for long-term brain health.

So you’re kind of meeting a lot of different things just by moving and trying to move a little bit every day if you can. And so for some of my patients, that means five minutes of stretching in the morning, five minutes of stretching in the afternoon, five minutes of stretching at night. That’s all they can do because they’re really struggling with daily, severe attacks, and that is okay. Again, it’s not about the type in my mind. It’s just about the activity.

So a lot of people then, with lifestyle, really get hung up on food, saying, I know there’s certain things that might trigger my migraine, so I don’t eat them. But then, they’re not eating a lot of things, and that’s not so good for us. So my advice for eating and dietary is really focus on regular food timings and intake, having some protein in every meal because protein is fuel for the brain. Sugar is fuel for the brain too but not the best type of fuel. So protein will get you going a lot farther.

And then the rest of it, try not to get too stuck on what is a trigger when it comes to meals because we don’t have great evidence, and it’s really very variable. You might end up pulling out everything from your diet and then getting yourself stressed, thinking you ate something wrong when you have a migraine. And we don’t love the self-blame. It is not your fault. This is a disease. It’s going to happen, and sometimes there’s not a reason for it. So you want to eat at regular times.

You want to drink water as much as you’re going to drink something, choose water as much as you can. So there’s not a certain amount of water you should drink every day, but you should drink water when you’re thirsty as opposed to sodas or juices or other beverages that are artificial, and they’re not really adding much to us.

So these are the basic lifestyle things that we really focus on, and then we will talk about treatment, and when it comes to prevention, there’s lots of options. We might add a medication if your attacks are frequent and you’ve already tried a vitamin supplement. So vitamin supplements that have good evidence in migraine. Vitamin B2 and magnesium, those are two of my favorites. There’s some data on coenzyme Q10 and feverfew, and one called butterbur. But butterbur has to be the right type or the right brand, or it can cause liver toxicity. CoQ10 is expensive, and the data is kind of okay. So B2 and magnesium, they’re affordable. They’re easy to find and easy to use, and the dosage, you can easily find this online. 

If you try the supplements for a few months and they haven’t been helpful, usually that’s when we’re talking about mediations.  Or you have chronic migraine, in which case, supplements don’t have great data there, we really want to move to trying a medication option. 

Medication, we have the traditional medications, as I mentioned. These have been studied for over 30, 40 years. They are not initially meant for migraine but have data and FDA approval for migraine, like topiramate. But they tend to sometimes come with side effects. So, we might start one of those treatments, see how it’s tolerated, and make changes based on that.

We do now have more newer therapies, as talked about, these migraine-specific treatment options. These are targeting a protein called CGRP, or calcitonin gene-related peptide. It’s a protein that we know goes up when you’re having a migraine attack, comes down when a migraine attack is properly treated. And in someone who has migraine, this protein is a little bit higher than in someone who doesn’t have migraine kind of all the time. So if we’re able to suppress the amount of protein in your system, it’s not activating migraine as frequently, and it can cause that brain irritability that’s always ready for that next migraine attack to really calm down.

And so when it comes to targeting CGRP, we have some options that are injections you can do at home every month that are really blocking the protein specifically, or where the protein goes. And there are oral tablets available that you can take every day or every other day to prevent migraine. So the flexibility is wonderful. It really depends on what you think you can do at home and what you think is a better option for you.

And then there’s an infusion that can be done every three months in the office. So we have patients who find the injections work better but don’t like to do the injections at home themselves. Or the injection was working but not working as well anymore, and they need to make a switch. That’s when we can make a switch to something like the IV treatment in the office where the patient doesn’t have to do the injection. The treatment’s only 30 minutes, so it can be really convenient.

If you have chronic migraine, another treatment option is onabotulinumtoxin A, which is Botox, and these are injections done by your clinician every three months. They’re injected in very specific places where the nerve is communicating back to the brain and sending abnormal signals. So even though the nerve is normal, it looks normal, and the examination will look normal, it’s telling the brain, hey, there’s a knife in your head right here, and it’s all the time. And so Botox is trying to disconnect that signal and quiet it down. So the treatment can really stop that abnormal signaling and irritation that’s going on and can help reduce migraine frequency.

In addition to all this, we have behavioral treatments that can be added in, like biofeedback or cognitive behavioral therapy. Cognitive behavioral therapy is especially important in patients who are having pain most of the time. They’re starting to develop some anxiety around the pain, starting to take too much as-needed treatment, even when they’re not having pain. So there’s a lot of times we might pull something like that in. There’s also things like acupuncture that can be added in at any time for anyone with migraine. But sometimes these treatments aren’t covered by insurance, so they can get a little costly.

And then of course we have neuromodulation devices. Some of these devices can only be used as needed, but some of them can be used as needed and on a daily basis or every other day to help reduce migraine frequency. And devices are really interesting because we have studies that show they change the way the brain is working, even though the device is external. We have a device that goes on the arm, a device that goes on the forehead, one that’s at the forehead and the front, another that’s like a machine you pulse at the back of the head a few times a day, and then a vagal nerve stimulator. All of these things are working external. None of them are implanted in the brain, but repeated use tends to reduce the negative input from certain parts of the brain back to the rest of the system. So it is fascinating how using them can really change migraine.

But again, these aren’t always covered by insurance, so they can get a little bit costly for some patients. And so it might not be something that’s pulled up right away, unless you really feel like, I want to start a non-medication option right away, I’m really okay with the cost there. And then that’s a way to get started as well.

O’Brien: Okay, take a breath because that was a lot of talking [laughter] I’ll give you a minute to just…which is great because there are so many options and not necessarily all medication, not all shots if you don’t want to take a shot all the time. There’s just so many options. So I did want to just give you an opportunity to take a breath there before I pop into the next question.

Ailani: No problem. I have to say, I’ve been in practice, you know, 16 years now, and the amount of treatments we have available at this time are tremendous. We’re not done. We have so many things in trials. And I think that’s the most exciting is that if something isn’t working today, it doesn’t mean tomorrow there might not be something for you. And they’re so targeted to what is okay for the patient, going back to that goals of care. If it doesn’t make you feel better and it’s something you can do easily at home on your own, well, then we got something else for you. So don’t give up.

O’Brien: We talked about some of these newer migraine medication options. We talked about some of the CGRP-targeted medication, and you mentioned the ones that we can take at home, oral medication. We call them gepants. 

I want to talk a little bit about that when we’re doing prevention, without getting too much into the weeds, but they can act similarly, they can act a little differently. So when we’re talking about migraine prevention, can we switch things up within the classes when we’re talking about CGRP monoclonal antibodies and gepants? Can we combine treatments? And we’re starting to see some newer studies on this, which is hopeful. So can you just kind of walk us through that a bit?

Ailani: Yeah, sure. So say you’re on a preventive treatment of some type, and you’re 30% better. The reason I say 30% better, if you’re not better at all, it’s time to walk away from that treatment and try something different. That’s never the question. The question always comes up, well, I’m a little bit better. Do I just cut my losses here and keep going? Like, what do I do? If you’re 30% better, we have data with the injectable CGRP options that show if you change from one to another, you can actually gain more migraine-free days. You can do better. So that 30% is an indicator you’re responding, but it might not be the right one. So we can make a change.

If you’re no better, I would suggest usually we change the whole mechanism of how the treatment works. So say you’re on a CGRP monoclonal antibody, we might change you to a gepant. If you’re chronic migraine, this might be a good time to introduce Botox injections. We might go all the way back to old school, introduce some topiramate.

So you really need to be thoughtful about what’s working, what’s not working. Is there some improvement? Is there no improvement?

Now, why would I say there’s a difference between a gepants and the CGRP monoclonal antibodies when they’re both attacking CGRP? Well, there’s a lot of research and thought going into the gepants that perhaps they’re doing more than just blocking the CGRP receptor. And so I really think they’re slightly different in their mechanism of action.

And we’ve had a lot clinical experience and real-world data that shows changing from a CGRP monoclonal antibody to a gepant can actually gain you a good amount of improvement. So I think there’s a difference enough between those drugs that it kind of is a different class.

Now, if you’re 30% better, and you’re really satisfied with that drug you’re on, that’s making you 30% better, we might opt to layer a treatment in. So say you’re on a CGRP monoclonal antibody and you’re 30% better. This is the first time you’ve had a headache-free day in a long time. You don’t want to give up on this drug. What do you do? We might layer in, add on, a treatment like Botox, where we have data that suggests that combining an anti-CGRP treatment with Botox can reduce the number of days of migraine that you’re having per month. Four days less for a CGRP monoclonal antibody and Botox together, seven days less if we add atogepant, which is Qulipta, to Botox.

So we’re getting more and more studies that are giving us more and more information that make it so much easier for us to have that conversation about what would we add? When would we do it? What is the benefit that I might gain? What might I expect to see? And so I think that’s amazing that we have this kind of information.

Now, what if you’re on a CGRP monoclonal antibody, 30% better? Would I add something like atogepant, like Qulipta, or rimegepant (Nurtec) every other day as another prevention? I would not do that. Because we actually don’t have any data to support taking two CGRP preventives together is safe. To me, safety is number one. I’m pretty sure to many of our listeners it is too. If I don’t have safety data, I’m not going to take a risk of really blocking that area. 

And why is that? I mentioned that people with migraine have more CGRP, but we don’t know if every person with migraine has more CGRP available. We know that blocking CGRP with one agent is pretty safe, doesn’t really cause problems. We know that if you take a CGRP agent, one of them, and occasionally use a second…so say you’re on an injectable monthly, and you take an as-needed gepant like rimegepant every once in a while, it’s probably safe. We have some safety data there. But we don’t have data about consistent suppressing of both. And why is that important?

Well, we know that CGRP plays a really important role in maintaining your vascular function. So if you have a heart attack, it helps bring all the other blood to the heart so you don’t die. You have a stroke, it helps improve blood flow to the rest of the areas in the brain so you don’t have a higher area of damage. So if your blood pressure is not well controlled, you have diabetes, and you’re on two agents blocking CGRP at the same time, I think the risk is getting a little bit higher, and I don’t have enough safety data.

So I don’t recommend it. There are doctors out there, there are clinicians out there who are going to say that’s okay to do. They’re looking at the individual person and really making an individual evaluation. But as a whole, I don’t recommend that.

O’Brien: I’m wondering if you have anything, quickly, on what we know about migraine prevention for those who have menstrual migraine. Is there any evidence that any treatments help? What do you got for that?

Ailani: Yeah, so it’s extremely impressive how we have so little data on something that affects 60 to 70% of women with migraine, which is menstrual migraine. What do you do during that time period to improve your migraine attacks? There are lots of different ways of thinking about it. You could suppress your menstrual cycle so you don’t have a period. If you don’t have a period, you might not get an attack. That sometimes works. But sometimes women will break-through bleed their suppression of their cycle, and so then it doesn’t work so well.

There are short-term prevention strategies, something you take for a few days around your cycle to try to stop that menstrual migraine component. That works if your cycle is predictable, your migraine onset is predictable because you start the treatment before the onset of migraine, and I will tell you that’s true for women from 20 to about 32, 35.

But after that point, your cycle starts to become a little bit less predictable, especially once you hit your 40s where you’re in that perimenopausal time period where cycles become less consistent, migraine frequency tends to go up, and so just starting a general prevention at that time is usually what’s recommended.

When it looks at mini prevention, things that have been studied have been non-steroidal anti-inflammatories. They’ve looked at certain triptans, but then the migraine just comes back when you stop it. And right now, there’s a couple of studies that are ongoing looking at our gepants, particularly ubrogepant and rimegepant, so Ubrelvy and Nurtec, during that menstrual cycle time period where you’re taking it a very scheduled way to see if that will stop migraine from happening.

And I will tell you, from my personal experience in clinical practice, I think those are actually probably the best treatments out there. Because they don’t cause a rebound attack, if you can plan it properly, and even if you don’t, they can be very effective in getting rid of that attack during that time period. And sometimes that’s my way of introducing prevention is just that short-term prevention. A patient loves it and says, what about other times of the month? I’m, like, there you go. Now, we’re going to talk about prevention, and we can stick with the gepants. So I think it’s a nice way to kind of be introduced to a treatment option.

O’Brien: Excellent. That’s very exciting and thank you for touching base on that. Why do you think prevention is an important aspect for literally anyone with migraine? With that, is there anything else you think people should know about migraine prevention?

Ailani: I think prevention is really important in migraine because aren’t you tired of having to chase after the attacks? Usually, that’s the time to say, I don’t want to chase anymore. I want to stop these from happening as much as I can. It’s a really active way you can be involved in trying to reduce how often they’re happening. Really take that stand against the disease process itself.

I think anything else I would add for our audience out there who is dealing with migraine, I think that you can do this a lot on your own, which many of our patients do. But it’s not a bad thing to ask for help, either your healthcare providers, going online. There’s so many forums out there now where you can talk about how you’re feeling and how isolated you feel with this disease. Reading the information out there, there are so many great websites that, like I said, I’ve been doing this for a long time, they weren’t available for our patients even five to eight years ago. And I think getting involved, reading about it, learning about the disease state, and understanding treatment options, it’s a great thing to do even before you talk to a healthcare provider.

O’Brien: Dr. Ailani, thank you so much for sharing all of your knowledge with me and our audience today. What a great conversation, help us understand the basics, and then some about migraine prevention.

Ailani: Well, thank you so much. It’s been my pleasure to be with you all today.

O’Brien: And that wraps up this episode of Spotlight on Migraine. To our followers, thank you for listening. This podcast is made possible by supporters like you. You can make a tax-deductible donation today at migrainedisorders.org.

[music]

If you missed it, hope you’ll check out the first episode in this two-part series all about migraine prevention. I’m Molly O’Brien. We’ll see you next time.