Migraine: much more than a headache
As part of Migraine Awareness Week, let us take a closer look at this common neurological condition, which can sometimes be highly disabling, but for which treatment options have evolved considerably in recent years.
What is a migraine?
A migraine is not simply a “bad headache”. It is a neurological disease characterised by attacks that can last from a few hours to several days. The pain is often pulsating, sometimes located on one side of the head, and may be aggravated by physical activity. It is frequently accompanied by nausea and increased sensitivity to light, noise or smells. In some people, the attack is preceded or accompanied by an aura: visual disturbances, tingling, difficulty finding words or other transient neurological symptoms. When headaches become very frequent, with at least 15 days of cephalalgia per month, including at least 8 with migraine characteristics, this is referred to as chronic migraine.
Treatments tailored to each patient
Management of migraine involves two main aspects. Acute treatment aims to stop or reduce an attack when it occurs. Depending on the patient, this may include paracetamol, anti-inflammatory drugs or triptans. When attacks are frequent or particularly disabling, preventive treatment, also known as prophylactic treatment, may be offered. Taken regularly, its aim is to reduce the frequency and intensity of attacks. Several medicines traditionally used in Belgium can fulfil this role, including certain beta-blockers, topiramate, amitriptyline and candesartan.
What if the usual treatments are not enough?
In some patients, several appropriately administered treatments unfortunately do not provide sufficient control of the disease. Depending on specific criteria, this may be referred to as resistant or refractory migraine. In recent years, the therapeutic options available to these patients have changed significantly.
Treatments targeting CGRP, a molecule that plays an important role in the mechanisms of migraine, represent one of the major advances. There are now antibodies directed against CGRP or its receptor, administered by injection, as well as oral treatments called gepants. For some patients with chronic migraine, injections of botulinum toxin (Botox®) administered according to a specific protocol into different muscles of the head and neck are also a preventive option.
In Belgium, access to and reimbursement of these treatments are subject to specific criteria and are assessed by the neurologist according to each patient’s medical history.
Aquipta®: now also for treating an attack
Atogepant (Aquipta®) is an oral medicine that blocks the CGRP receptor. Until now, it was used as a preventive treatment for migraine. A new indication has broadened its use: Aquipta® can now also be used to treat an ongoing migraine attack in adults, with or without aura. This development is particularly relevant for some patients for whom the usual acute treatments, especially triptans, are not sufficiently effective, are poorly tolerated or cannot be used.
What about tomorrow? A new avenue from interventional neuroradiology
Research is also continuing for patients suffering from the most difficult-to-treat forms. One particularly innovative approach is currently being studied: middle meningeal artery embolisation. This artery supplies, among other structures, the meninges—the membranes surrounding the brain—which are richly innervated and contribute to the mechanisms underlying headaches. The procedure involves using a small catheter inserted into an artery to reach and then occlude certain branches of the middle meningeal artery.
The first small studies conducted in patients with refractory chronic headaches have reported encouraging results, with some patients experiencing a substantial reduction in the number of headache days. However, these results must be interpreted with caution: this approach is still under evaluation, and its efficacy and safety now need to be confirmed in larger studies.
At H.U.B, the collaboration between our team specialising in headaches and the team of interventional neuroradiologists (Dr Guenego, Dr Bonnet, Dr Boustia, Dr Docquier and Prof. Lubicz), will enable us to explore this new approach and assess, in an appropriate setting and in carefully selected patients, the role it could play in the management of refractory chronic headaches.
A message to rememberMigraine is a neurological disease in its own right and can have a considerable impact on family, social and professional life. However, suffering from frequent migraines does not mean that no solution remains. From conventional treatments to CGRP-targeted therapies, including botulinum toxin and the new approaches currently being studied, therapeutic options are now more numerous than ever. The objective remains the same: to find, for each patient, the strategy that reduces the impact of migraine on their daily life as much as possible. |
