For this month’s ANA Q&A, the ANA spoke with Nina Riggins, MD, PhD, a neurologist and associate professor at UCSF Health who specializes in headache medicine. Dr. Riggins discusses the public’s misunderstanding of headaches, how treatments have greatly improved over the years, and more.
What does the public need to understand about headaches that it often doesn’t?
Perhaps the most misunderstood notion is that a headache is a singular malady. In fact, there are excellent International Classification of Headache Disorders (ICHD-3), with several hundred headache possibilities, including headache due to stroke, tension headache, cluster headache, and migraine, to name a few.
Migraine is probably the most widely known type of “primary” headache and second leading cause of global disability. With that said, migraine is possibly the most misunderstood type of headache. Migraine is not just a headache. It is a genetic neurologic disease. Multiple brain networks are involved.
Brain sensations can be affected by migraine. For example, turning on cochlear implants, which increase auditory sensory input, possibly can impact headaches. We published our research on this topic in 2020 in “Cephalalgia Reports.”
While people living with migraine have episodes of migraine attacks, there is a growing understanding that the interictal (in between attacks) stage of the disease is a significant burden for many.
In identifying migraine, we have learned to avoid the use of the plural “migraines” because a person with migraine always has it (genetic disease). In treating migraine, we have learned the importance of lifestyle modifications and behavioral therapy.
Migraine patients describe the many symptoms they experience. In addition to headache, other frequent symptoms cited as the most bothersome are sensitivity to light, sound, smell, cognitive symptoms, and dizziness. We also take into consideration comorbidities which increase the burden of migraine including anxiety, depression, and complications during pregnancy.
People living with migraine can have cranial autonomic symptoms and other associated symptoms. We continue to research on how such symptoms can help our understanding on the best therapeutic approach to each patient individually.
There are other important Conditions in International Classification of Headache Disorders that need more research. For example, cluster headache is widely reputed to be the most severe pain that humans can experience.
I am a dedicated advocate for my patients and my chosen profession of headache neurologist. Patients, clinicians, researchers had a huge win in July 2021 when it was announced that CMS.gov will cover oxygen treatment for cluster headache.
In sum, while there is room for increasing knowledge about headache and migraine, I believe that education, research, and advocacy will lead to providing patients with migraine and other headache disorders with treatments they need.
How are headache treatments different today from 10 years ago?
On May 27, 2021, rimegepant was approved by the FDA for the preventive treatment of episodic migraine in adults. This is one of the gepants already FDA approved for “as needed” migraine treatment.
Calcitonin gene-related peptide (CGRP) blocking antibodies and small molecules are changed the field of headache medicine. It is groundbreaking to have targeted therapy for migraine management.
CGRP blocking agents, ditans are new classes of medications which, in conjunction with external neuromodulation devices, create additional opportunities for migraine improvement. New medications have much better side effect profile than opioids. Science helps us to fight opioid epidemic.
I was a principal investigator for a gammacore trial. Gammacore is a vagal nerve stimulator that is FDA approved for the treatment of migraine and cluster headache.
We are researching new, non-invasive procedures (no needles!) for treating headache disorders. For example, we are looking at the use of anesthetics to block sphenopalatine ganglion (SPG) for different types of headache. We hope to publish our work shortly on this exciting new front in the treatment of headache.
While it is well-established that migraine generally affects women more than men at a 3:1 ratio, specific treatments for women are still not always sufficient. It is critical that we provide women who have migraine with treatment options that are safe and effective during pregnancy and lactation. As such, we are publishing our review on the use of behavioral modalities for headache during pregnancy and breastfeeding in “Current Pain and Headache Reports.” Based on our research, behavioral modifications, at home SPG blocks and some other modalities have a high degree of efficacy and safety for this population of migraine patients.
What promising research is poised to change headache medicine?
We are learning more about pathophysiology of migraine and other headache disorders. It creates new opportunities for targeted therapies.
Another example of recent advances in the field of headache are developing understanding of effects of hormones on headache. Working with patients with migraine, using a headache diary to figure out patterns together, we are able to improve functioning by addressing endocrine changes, including pituitary pathology, hypo- and hyperthyroid and at multiple times change in exogenous hormonal medications leads to changes in headache.
Every new day gives us more knowledge, we are using technology to help us, starting with good history taking and physical exam, making sure that secondary headache is not there or addressed, reaching out to high resolution MRI when appropriate are all components of comprehensive collaborative approach which can be offered at the Comprehensive headache center.
What work is your lab undertaking to move the understanding of headaches forward?
My clinical experience and research in the field of headache and has led me towards a vision of building a world-class Center for the Treatment of Headache and Traumatic Brain Injury.
At our Center we will provide clinical outpatient services, an in-patient program for intractable cases, and perform cutting-edge research in migraine and other primary and secondary headache disorders. In addition, because headache is one of the most prominent symptoms of even mild traumatic brain injury, we will dedicate special attention to helping patients with post-traumatic headache.
While patients may have normal routine CT and MRI imaging, advanced technics and serum biomarkers need to be developed to help diagnose and treat headache resulting from traumatic brain injury (TBI). We need answers to the underlying causes of post-TBI headache, including exploring the possibility of cortical spreading depression, the role of tau protein deposition, and more. I envision our goal in this direction as finding best therapy and providing best known treatment for post traumatic headache and TBI.
My personal mission is to create less pain in this life for headache patients. I am grateful for our amazing Neurology team which makes it possible. I am inspired by my mentors in the field of Headache Medicine, including Dr. Goadsby, Dr. Dawn Buse, and Dr. Loder. I am thankful for the outstanding work of Dr. Brewer, Chair of Neurology at UCSD, on sharing my vision and getting approval for the multidisciplinary comprehensive Center for Headache and Traumatic Brain Injury at UCSD.
Want to learn about more of the groundbreaking research being conducted by ANA members? Read past editions of The ANA Q&A.