Recent Advances in the Understanding and Treatment of Migraine

Abstract

Migraine is a disorder that afflicts more than 23 million individuals in the United States alone. The disorder is characterized by paroxysmally recurring attacks, which are moderately to severely disabling. The migraine attack is typified by a severe, usually unilateral headache, which is pulsatile in quality, and by one or more concomitant symptoms, such as nausea, vomiting, photophobia, and/or phonophobia. Because of its debilitating nature, migraine causes significant morbidity among sufferers, including lost time from work or school, and inability to perform other normal daily activities during attacks. The precise pathogenesis of migraine remains to be elucidated. However, the attack may be initiated and perpetuated by both neural and vascular mechanisms. The trigeminovascular system appears to be particularly involved. Treatment of migraine consists of avoidance of trigger factors, acute or abortive pharmacotherapy, and prophylactic pharmacotherapy. A plethora of endogenous and exogenous migraine triggers have been identified, some of which can be avoided or controlled in order to reduce attack frequency. The ergots represent the accepted standard for the treatment of the acute attack, though significant toxicity and the potential for rebound headache with overuse limit the usefulness of these agents. Simple and combination analgesics are also limited by their inherent propensity to cause a rebound phenomenon when overused. Sumatriptan is a selective serotonin receptor agonist that is now available for abortive treatment of migraine. It has been shown to be highly effective in treating the acute attack. Beta-blocking drugs are the agents of choice for migraine prophylaxis, though anti-depressant compounds, calcium channel antagonists, non-steroidal anti-inflammatory drugs, cyproheptadine, and methysergide are also used. Non-pharmacological therapy may be tried, but is rarely effective by itself.