New Therapies—New Promise for Patients With Migraine

Peter L. Salgo, MD: We’re evolving into the future. What does the future look like for the treatment and prevention of migraines?

Jill Dehlin, RN: The future is brighter than it has ever been. As we’ve been talking about, the different kinds of treatment plans for prevention have been borrowed from other disease states—from heart disease, high blood pressure, and depression. To have devices and medications that are created specifically for our disease, it’s amazing to hold on to that hope. Many people with migraine have a sense of learned helplessness because nothing has worked for them. To have this come out is really promising.

Peter L. Salgo, MD: Let’s talk about some of these emerging treatments and consider what their place might be going forward. Let’s talk about glutamate receptor antagonist therapy.

Peter Goadsby, MD, PhD: Glutamate is the major excitatory turning-on nerve transmitter in the brain, and there are 2 classes of the receptor. One class includes the ionotropics, or ions going through it, and there’s one that’s called metabotropic, where it changes second messenger systems. There’s quite reasonable controlled trial data that demonstrate that you can manipulate either of these, particularly the metabotropic one, to have an antimigraine effect. So far the problem has been developing something that doesn’t have troublesome side effects, or off-target effects. But there’s a light.

Peter L. Salgo, MD: What about neuromodulation? First of all, what is it?

Peter Goadsby, MD, PhD: Neuromodulation is sort of what it says. It changes the brain, usually through electrical or magnetic pulses. We talked about one of these earlier on, the noninvasive vagus nerve stimulator. The other one, which has been licensed by the FDA [Food and Drug Administration], is the single-pulse transcranial magnetic stimulator [sTMS].

The device is about this big. It’s held at the back, like this, and you push the little button and it gives a magnetic pulse that, with induction, produces a small electrical current in a deep part of the brain called the thalamus. There’s good acute randomized controlled evidence that suggest that it’s effective in acute migraine. There’s open-label evidence for its use in prevention. The combination of this led the FDA to approve it for acute and preventive therapy.

Peter L. Salgo, MD: Have you tried it?

Peter Goadsby, MD, PhD: Oh yes, I have. I’ve prescribed it for quite a few patients. Its big advantage is there are no side effects, virtually. It’s very, very well tolerated. For people who don’t handle medicines well, who have side effects and other things, it’s a useful thing to have in the armamentarium.

Peter L. Salgo, MD: Let me just ask a crazy question that occurred to me while you were speaking. Do we have any data on people with migraines who get MRIs of the head and feel better after?

Peter Goadsby, MD, PhD: No, there’s no data that I know of.

Peter L. Salgo, MD: Because it’s a highly powerful magnetic field.

Peter Goadsby, MD, PhD: It’s not focused, however, because it’s all over.

Peter L. Salgo, MD: That’s right.

Peter Goadsby, MD, PhD: What this device delivers is a nominal 0.9 Tesla, which is focused over a couple of centimeters. An MRI scan is not focused that way.

Peter L. Salgo, MD: And we’re convinced this isn’t doing some irreparable harm to the brain?

Peter Goadsby, MD, PhD: Yes.

Peter L. Salgo, MD: OK.

Jill Dehlin, RN: I have something to add. There have been studies that show very good efficacy with the sTMS in pediatric patients.

Peter L. Salgo, MD: Really?

Jill Dehlin, RN: Because it’s very easy for them to use and there really are no side effects. I, myself, have used it for migraine treatment.

Peter L. Salgo, MD: Did it work?

Jill Dehlin, RN: Yes, it did work. At first, I felt a little weird afterward. I was a little dizzy. But I got used to the pulses, and after a while, I didn’t notice that effect anymore.

Peter L. Salgo, MD: What percent of people get some relief from this?

Peter Goadsby, MD, PhD: The response rate, if you look at pain-free cases, is about 40%.

Peter L. Salgo, MD: How much does the machine cost?

Jill Dehlin, RN: You rent the machine and they send you a SIM card. You pay for the SIM card. Hopefully your insurance will pay for it. I quit using the device because my insurance did not pay for the SIM card. The other issue with this device is that traveling with it is difficult because it looks like a bomb under x-ray.