Migraine and Headache: Interventions and Updates

Headache and migraine are complex conditions with diverse etiologies. Treatment of these conditions must, therefore, encompass diverse mechanisms of action and routes of administration. I’m excited to present this month’s issue of Practical Neurology, which reviews innovations in the treatment of migraine and headache, including currently approved therapies as well as potential off-label therapeutics under investigation. The review articles in this issue are comprehensive, covering topics across the full scope of headache and migraine treatment, including prevention, diagnosis, and rehabilitation.

Dr. Zubair Ahmed begins this issue with an update on calcitonin gene-related peptide (CGRP) therapies, including monoclonal antibodies (mAbs) and gepants. Dr. Ahmed details findings related to CGRP therapies in various combinations (eg, gepant with mAb, mAb with onabotulinumtoxinA), as well as their potential efficacy beyond common migraine (eg, vestibular migraine, menstrual migraine, post-traumatic headache [PTH]).

Next, Dr. Aarushi Suneja, Dr. Meghan Piccinin, Dr. Emad Estemalik, Dr. MaryAnn Mays, and Dr. Payal Patel Soni discuss the growing body of evidence pointing to therapeutic applications of onabotulinumtoxinA in treating trigeminal neuralgia. The authors propose a novel protocol and identify potential injection sites for using this agent in clinical practice.

Intranasal therapeutics are a valuable alternative for patients with migraine who have needle phobia or are intolerant of injectable formulations. Dr. Victor S. Wang and Dr. Clinton G. Lauritsen review the various intranasal options, including several Food and Drug Administration (FDA)-approved (eg, sumatriptan, zolmitriptan, dihydroergotamine, zavegepant, ketorolac) and off-label agents (eg, ketamine, lidocaine, oxytocin) that are available for treating acute migraine. These medications provide rapid-onset relief, especially for people with nausea, vomiting, and gastroparesis.

Neuromodulation devices offer another option for noninvasive intervention for the management of headache. Dr. Stewart J. Tepper, Dr. Peter McAllister, and Dr. Teshamae Monteith provide an overview of 6 FDA-cleared neuromodulation devices, which have low risk and minimal adverse events, constituting a valuable addition to the neurologist’s toolset. However, patient access for these devices remains an issue.

Dr. Yevgeniya Sergeyenko and Dr. Miriam Segal outline a multimodal, comprehensive, individualized approach to treating PTH. They identify the lack of dedicated FDA-approved treatments, little high-quality evidence for pharmacological management, and the condition’s complex presentation as unique challenges for treating PTH.

Some people with refractory headache and migraine may turn towards alternative treatment using non-FDA–approved substances, such as cannabis, psilocybin, and ketamine. Dr. Michelle Sexton and Dr. Nathaniel Schuster review the existing studies that have explored the safety and efficacy/effectiveness of these potential therapeutics.

Nutraceuticals are another category of off-label substances sometimes used in the self-treatment of migraine. Dr. Lex Denysenko and Dr. Deena Kuruvilla provide an overview of recent updates regarding the use of butterbur (Petasites hybridus), coenzyme Q10 (CoQ10), vitamin D, and curcumin in the prevention and management of migraine.

Finally, Dr. Lea Saab, Dr. Nisha A. Malhotra, Dr. Fred Cohen, and Dr. Mia T. Minen explore the technological horizons of headache diagnosis and treatment, discussing the use of online diagnostic platform, telehealth, mobile health applications, wearable devices, and the potential of artificial intelligence in improving headache management.

Each review article provides an exciting look into the leading edge of headache and migraine treatment. I am thankful to all our authors for providing their insightful commentary. Please enjoy this new issue.