Burden of migraine

After demonstrating that the language we use to talk about migraine can sometimes be stigmatizing for patients and is an essential part of advocacy, Dr. Kingston and Ms. Kelly presented results from the OVERCOME study. This study showed that, among nearly 12,000 respondents without migraine, more than one third of them had some stigmatizing attitudes, such as believing that patients with migraine should be able to easily treat their condition or that they have migraine as a result of their own unhealthy behavior.¹ 

Conversely, among more than 13,000 US respondents with migraine in the CAMEO study, 32.7% reported ≥1 negative career impact.² In the global My Migraine Voice survey, in which 11,266 respondents from 31 countries participated, 85% of migraine patients reported feeling anxious, depressed, or not understood.³ 

Additionally, there are significant costs associated with 1) absenteeism due to migraine and 2) the presentation of chronic migraine (CM) patients in headache clinics, representing annual costs of $980 million and $2 billion respectively in Canada.^4,5

Altogether, migraine poses significant societal, psychological, and financial burden to individuals living with migraine and society as a whole

Factors that contribute to the chronification of migraine

After demonstrating that many environmental and genetic factors can contribute to migraine from childhood to young adulthood, Dr. Kingston and Ms. Kelly advocated for early prevention of migraine before it leads to chronification later in life. However, preventive methods are often underused in general practice potentially due to: misdiagnosis, access to care, patient preference, inadequate education, provider discomfort, and suboptimal first-line treatment efficacy. Among risk factors for chronification, some are modifiable, such as caffeine consumption, obesity, and sleep disorders, while others are non-modifiable, such as genetics, a high number of monthly migraine days at baseline, and a lower level of education.⁶ 

Multiple signs of chronification can be easily recognized, such as the interictal burden, absenteeism/presenteeism, medication use, the subjective worsening of mood/anxiety disorder symptoms, and the increasing allodynia or somatic symptoms

The different purposes of acute and preventive migraine treatments

Acute and preventive migraine treatments have different treatment goals. Indeed, the goal of an acute migraine treatment is to provide rapid relief from pain and from the most bothersome symptom after 2 hours, to improve function and quality of life, and to gain control over headaches. Acute migraine treatments should be administered early during a migraine attack, from 30 minutes to 1 hour after the headache onset. 

As for preventive migraine treatments, an important treatment goal is the 50% reduction in migraine frequency

However, according to Dr. Kingston and Ms. Kelly, patients who experience frequent and long-lasting migraine attacks, significant disability, diminished quality of life, psychosocial impairment, who fail acute therapies, have a contraindication to acute therapies, a risk of medication overuse headache, or menstrual migraine might also benefit from a preventive therapy.

Management of special populations

Given the high prevalence of migraine in the general population, it is not surprising to observe that migraine is particularly common in pregnancy. However, Dr. Kingston and Ms. Kelly highlighted that pregnancy also has effects on migraine and aura. Indeed, higher estrogen levels may potentiate glutamatergic activity, which might in turn lead to cortical spreading depression, a process implicated in aura. As for older adults, multiple variables such as cardiovascular risk factors or events, medical comorbidities, polypharmacy, and change in headache presentation underlined the importance of choosing the right acute and preventive medications for the right population at the right time.

Throughout their presentation, Dr. Kingston and Ms. Kelly demonstrated that migraine is associated with high burden, disability, and stigmatization, that neurologists have a large armamentarium of acute medications and preventive therapies for migraine and that special populations with migraine can be adequately managed with appropriate caution. Moreover, by stressing the fact that untreated migraine can lead to chronification and is a huge burden on the Canadian healthcare system, both speakers highlighted the importance of prevention in the reduction of disability caused by migraine.