A podcast about an interesting new study that may begin to change the way we calculate the number of “migraine attacks” we get in a given period. Find out why this is important to future research, and to your current understanding of your personal migraine attacks.
[display_podcast]You can read the full study here: What constitutes a migraine attack? -A counting clinician’s perspective.
Migraine with aura actually refers to a whole set of clinically different types of migraine. It’s characterized by temporary symptoms such as seeing flashing lights or patterns (visual aura), or a feeling of “pins and needles”, numbness, or problems with speech. (Read more here – Migraine with aura)
So obviously experiencing or not experiencing aura means that the symptoms are somewhat different. But is migraine with aura actually a different disease? Should it be treated differently? Is it doing something different to your body than migraine without aura?
These are questions that doctors and researchers have been struggling with for many years. A new report in The Journal of Headache and Pain is helping to direct the discussion toward future research.
If you really want to delve into the details, you can read the report (and use all the footnotes!) here: Differences in treatment response between migraine with aura and migraine without aura: lessons from clinical practice and RCTs. But here are a few brief thoughts, based on the article, about migraine with aura.
There is a lot of discussion about whether or not we should call migraine a “disease”, but researchers use the word “etiology”. That means, does migraine with aura have a different basis, a different cause. We don’t know what causes migraine, but we have clues.
There are hints that migraine with aura may have a different etiology, but we don’t know for sure. As we’ll see below, it does sometimes respond differently to treatment, and it can affect the body in different ways. Is it just a variation of migraine? Or is it really different?
And this is complicated by the fact that many people experience both migraine with and without aura.
Generally speaking, there has not been a different treatment regimen for migraine with aura. And with good reason – most studies show similar results for both. However, there are some exceptions.
For example, magnesium may work better for those who have aura. Botox may be another example.
A rather interesting example was tonabersat. Don’t feel bad if you haven’t heard of it. It’s a “gap-junction modulator” that actually inhibits the cortical spreading depression in the brain which happens during a migraine attack – and which seems to directly influence aura. In trials, tonabersat at first didn’t seem very effective – until patients with migraine with aura were separated out. Then it was shown that it seems to help only patients with aura.
So if we target the cortical spreading depression (CSD), would that stop the attack in patients with this type of migraine? Well, the jury is still out. We often talk about migraine as a “chain reaction” here, but we’re still not sure if the CSD is just a link in the chain, or if it’s more part of a “web” of biological changes.
However, the study of tonabersat may give us new insights into how migraine should be treated.
Yes, it seems to. Although other types of migraine may raise your risk of cardiovascular problems (think heart attack, stroke, etc), migraine with aura does seem to uniquely increase your risk of ischemic stroke in particular. There may also be differences in blood flow and the effect on the brain itself.
In many trials, migraine with aura was also more difficult to treat – it simply didn’t respond as well to typical treatments.
Interestingly, one study showed that women with migraine with aura are more likely to suffer from anxiety and depression, compared to those with other types of migraine.
Researchers want to see more studies on targeting migraine aura itself. They also feel that it would be worth it to differentiate more between the two major types of migraine in studies, so that more information can be gathered.
At this point, very little is understood about the difference between types of migraine, other than the differing symptoms. However, it is clear that there are differences beyond symptoms – migraine with aura may be harder to treat, may respond better (or worse) to individual treatments, and does seem to change the brain and body in some different ways.
The American Academy of Neurology has some new and little known videos that are very helpful summaries of concussion and post-concussion syndrome. Made from a medical field perspective, they will also be helpful for anyone trying to understand the treatment of concussion today.
Concussion (a type of traumatic brain injury), because of its frequent connection to sport, is a highly controversial and often political issue. But whatever your personal point of view, it’s important to understand the terms that are being used today to even talk about the issue. The first video gives an overview of terms and the current understanding of the condition.
The second video gives a very brief overview of current treatment guidelines. A lot of of understanding of concussion has changed significantly in the last few years, as our understanding of the brain has improved, so you may be surprised by some of the recommendations.
One caution that might be needed – when we talk about a “gradual return to activities”, that may include 1-2 days of complete rest. That’s a component that is often missing from concussion treatment. When we talk about complete rest, that means no video games, no homework – very limited physical and mental activities. After that, a very gradual return to normal activities, with careful supervision, as you’ll see in the video below.
For more detailed recommendations, check out Coaches, Parents: Know the Sports Related Concussion Global Recommendations.
As is the case with many cluster or migraine treatments, reviews are mixed when it comes to cannabis. This isn’t really reason to ignore it or embrace it – uncertainty is not surprising in a treatment that has been studied as little as cannabis, for a condition that has been studied as little as cluster.
Back in 2010, the results of a questionnaire were published that gave us some early insight into just how effective cannabis was at the time. More than half of the cluster headache patients who had used cannabis felt that the results were “variable or uncertain”. But 22% said it was definitely un-useful or even made their symptoms worse. 25% felt that it was beneficial, providing at least a 50% improvement.
So that leaves us with a 75% fail, or in some cases variable effectiveness.
In a more recent European study, a THC-CBD combination was administered in a study to cluster patients as a preventative, with an extra dose administered as needed during an attack. This seemed to help, but only about as much as amitriptyline, an antidepressant often used for cluster.
An interesting side note was that the abortive dose helped some patients – and which ones? The patients who had had migraine as children. For patients who had not had childhood migraine, the extra dose did nothing at all.
Studies like these leave us with a multitude of questions – what dose is the right dose? How should it be administered? How does it compare to other more established treatments? There are so many options that successful treatment can’t be ruled out, but it will be a long time before there is solid evidence for a good treatment.
The caution comes in because, as with any new treatment, the long term effects of various versions of cannabis treatment are unknown. But more immediately, cluster headache patients should be aware that for many cannabis does make symptoms worse.
Being aware of the risks doesn’t mean you shouldn’t try the treatment. It just means that you are aware of the risks, and so can make wise decisions with your doctor about which treatment to try first.
And we hope that research continues.
For more information:
We know that migraine is a biological and genetic reality. We can even see much of the migraine chain-reaction taking place in the body, through modern technology.
But that doesn’t mean we know everything about migraine, and it doesn’t mean that we can explain simply what exactly is causing the pain. In fact, pain is incredibly complex.
For example, we also know that the way we think about pain influences how much pain we feel, and how persistent it is (see, for example, Pain Catastrophizing and Your Headache).
Recently TED-ed posted a little introduction to some of the complexities of pain. Take the time to watch it below. It’s critical that we start thinking about these things, so that we don’t over-simplify either our condition or our treatment.
The video is just 5 minutes long.
