Migraine: what’s new in care?

Migraine is a debilitating pathology, causing headaches of varying intensity several times a month and often accompanied by other symptoms. It affects 12% of adults in Canada, with a higher proportion of women (18% against 6% of men).

In France, they would be around 6 million adults concerned, in total. How is migraine defined and how should it be managed during an acute attack?

Different Types of Migraines

Migraine is characterized by neuronal hyperexcitability. “Migraine attacks can be broken down into 5 phases: prodrome, aura, headache, postdrome and interictal.

However, not all migraine attacks go through all phases (for example, only one-third of migraine sufferers will experience an aura) and the phases do not necessarily follow each other (for example, aura and headache can occur simultaneously)” Firstly recalls the Canadian Medical Association.

Characteristics of migraine with aura

Additionally, in migraine with aura, the aura symptoms must meet at least 3 of the 6 aura characteristics:

• At least 1 aura symptom gradually increases over 5 minutes or more;
• Two or more aura symptoms follow each other;
• Each aura symptom lasts 5-60 min;
• At least 1 aura symptom is unilateral;
• At least 1 aura symptom is present;
• The aura is accompanied – or followed within 60 min – by headache.

The objective is to better distinguish the migraine aura from the symptoms of a transient ischemic attack.

No systematic imaging

According to the recommendations of the Journal of the Canadian Medical Association, “routine imaging is not recommended in patients with migraine who do not have red flags, atypical symptoms, or abnormal findings on neurological examination“.

This recommendation is based on those of the American College of Radiology and the American Headache Society, which strongly advise against routine neuroimaging for patients with stable headaches who meet the criteria for migraine and have a normal neurological examination. . “It’s the same thing in France, but it’s difficult to convince a patient worried about his headaches that there’s no point in doing imaging, but we sometimes manage to do it” admits Dr. Wilfrid Casseron, neurologist in Aix-en-Provence. “I rather advise patients to write down their attacks and the treatments taken in a calendar as well as the cycles for women, because migraines are sometimes of hormonal origin in order to better target the attacks.“.

Detect “red flags” or “red flags” that require an MRI

In some cases, however, imaging is necessary. ” I always ask for an MRI for older patients, often over 50, who have other symptoms: weight loss, fever, pain that increases with changes in position… So many little red flags that are indicators for imaging” adds the specialist.

Other recommendations from the Canadian Medical Association

Regarding treatments, the Canadian Medical Association recommends “a layered approach to the treatment of acute migraine (which) allows patients to choose from different treatment options based on symptoms and severity of the attack and encourages patients to combine drugs from different classes“.

She also recalls that theeffective treatment for acute migraine includes acetaminophen, nonsteroidal anti-inflammatory drugs, and triptans” and that “ubrogepant and rimegepant – two drugs that have just been approved in the United States by the FDA – are new effective treatments for migraine, suitable for patients with cardiovascular diseases in whom triptans are contraindicated. indicated“. According to Dr. Casseron, these two molecules “induce vasoconstriction, which is contraindicated in patients with cardiac history“.

The neurologist also wishes to recall that there are other effective drugs in France, the CGRP monoclonal antibodies, which are not currently reimbursed by Social Security. “It is scandalous because on the one hand, it creates a two-speed medicine, with the patient who can afford to pay for his treatment at 350 euros per month and the one who cannot “ specifies on the one hand the doctor.

“And in addition, if we quantify the overall cost (consultations, treatments, absenteeism at work, etc.) of the management of these refractory migraine sufferers – these are those who have escaped at least two disease-modifying treatments – who are 60,000 at the very least in France, I think that the reimbursement of this type of treatment is largely justified” concludes the specialist.