Interview with Dr. Peter Goadsby

If you knew that a health condition affected one in seven people worldwide, both children and adults, would you consider it to be serious? If you discovered that this same affliction is the third-most prevalent on earth and also one of the world’s most disabling disorders, would you be concerned? If you knew that it usually strikes with little or no warning, would you feel for those who endure it?

These are just a few facts about migraine. This often-overlooked chronic condition (which, for clarity’s sake, is spoken as singular, much like asthma) has been studied by physicians since ancient times, and yet true progress toward a solution has only happened in recent years.

Dr. Peter Goadsby, a professor of neurology at UCLA, discusses the causes, effects, and impact of migraine and shares why hope is on the horizon.

Why do people get migraine? What can trigger them?

The underlying reason is genetics. That’s what you bring to the party. Then you can excite the party—with alcohol, nitrates, various physiological changes, altering your sleeping or eating patterns, etc.—and trigger an attack. So I make the distinction between cause, because you can’t get new genes, and things that are within your control.

Who is affected by migraine?

The best data shows that about 6 percent of boys and girls under the age of twelve will get migraine. It starts to affect more people in their late teens and twenties in particular. The peak prevalence is around age forty in the United States. Women get migraines three times as often as men, and they tend to go away as they reach menopause.

How long has migraine been studied? How has research advanced in recent years?

Migraine is an old condition. You can find it in antiquities. In the 1660s, physician Thomas Willis left a nice description of the features you would associate with migraine.

The scientific study of the problem is relatively modern, however, dating back to around the 1950s. And, like most things in science, there have been big therapeutic breakthroughs. The first was triptans in the early 1990s, which were the first designer treatments for a migraine attack. Then, in the mid-1990s, genes were identified for a rare form of migraine called familial hemiplegic migraine, where, instead of having visual auras, people get weakness down one side of the body.

How does science treat something it can’t see or measure?

This is an overall problem of what are considered primary headache disorders, where the head pain is part of the syndrome and not caused by something else. Migraine is particularly complex because of its nature, which is very frustrating for patients because very often it’s not the structure that’s the problem but how the brain functions. Brain disorders often involve degeneration, such as lesions in the brain with MS and loss of nerve cells with Parkinson’s disease. You can take an Alzheimer’s brain or a Parkinson’s brain and find pathology, whereas if you look at a brain with migraine, there’s nothing like that—the brain just doesn’t work properly often resulting in profound short-term disability. With migraine, it’s all about the history and discussing what the patient perceives and experiences.

What else is challenging about migraine?

One of the big problems is the unpredictable element of it. For example, if someone averages one attack a week, but doesn’t know which day it will happen, how severe it will be, or what treatments will work, and has plans tomorrow, that’s problematic. Then, of course, you have the headache and other things associated with it like the aura.

Would you elaborate on migraine auras?

Between 20 and 30 percent of people, depending on age, will have an aura. Most of them, 95 percent, will have visual aura: a bright, jagged, angulated light that starts small in the periphery of the vision and then grows and often results in a scotoma, which makes things disappear in their vision. Thirty to sixty minutes later, it’ll be gone and their headache will start. There’s nothing else like it in neurology.

Are there any myths associated with migraine?

Some people believe it’s necessary to have the aura to have migraine. That’s wrong 80 percent of the time. Another belief is that migraine is somehow a result of stress and lifestyle and everything could be managed if you behaved better; essentially, that it’s your fault. That’s rubbish. You don’t pick your parents, and you can’t control the entirety of your environment.

Is migraine a more frequent occurrence today, or is it just better understood?

Migraine is much better recognized today. In the past, if you grew up in a family where Mum got headaches from time to time and just took painkiller, when family members would get the same headache as her, they’d consider that a normal headache. Why would they ever question it? So one of the things that brings that out of the cupboard is social media, which allows you to discuss your experience with others. That shared realization of having the same condition but experiencing it differently is where some significant recognition has happened.

Has research and funding lagged for migraine?

If you look at NIH data, by impact and disability, migraine is the least-funded condition of everything in proportion to its impact on the community. They spend less than a dollar per migraine person per year, a ridiculously low amount of money.

Fortunately, the American Headache Society is now working with the NIH/NINDS, recognizing that we need to set goals and make progress on this. Because when people ask, “Why me?” or “What drug should I take?” I want to be able to give them an answer. So the opportunity now is to not just do research for the sake of understanding the problem but also to make it sensible and useful for anyone who gets migraine.

So, yes, it’s been underfunded, but I don’t winge about that. I look at the current situation and see the positive opportunity to really redress that in a way that’s constructive for everybody.

Have migraine treatments improved in recent years?

Migraine treatments have changed dramatically. Even two years ago, we had no preventive designed to stop migraine attacks; we only had the choice of one migraine-specific acute treatment drug, triptan. Now we’ve got three. The new medicines are called ditans, and the other is the small-molecule CGRP receptor antagonist called gepants. Combined with the various neuromodulation approaches—such as directly stimulating the nervous system—and it’s a whole different ball game today.

Up to now, the choice of preventives worked OK, but they were very side-effect prone. A huge difference with these CGRP drugs is they are incredibly better tolerated. Most patients benefit from the efficacy without paying a price; the majority are quite happy with them. So it’s optimistic at all levels.

What else gives you hope for future migraine treatment?

What’s exciting are oral small-molecule gepant drugs, two of which are licensed in the US. Some data shows that giving rimegepant every second day and another one, atogepant, every day would have a preventive effect. And giving a tablet instead of an injection is going to be simpler for both patient and doctor, so the evolution of an oral medicine is incredibly important for broadening the impact of the drug.

Also, when the drug patents go away, generic-drug manufacturers can make these medicines for pennies. And if you can genericize them, you’re not just developing first-world drugs—you start to develop all-world drugs. Because migraine doesn’t know any barriers. The prevalence rates are more or less the same in India, China, and Brazil, for example, as they are in America.

It’s exciting to me that eventually there will be no real obstacle to these treatments getting used much more broadly. Migraine affects a billion people, so even if you help only 10 percent, you’re well on your way to kicking the goal. We’re at a place in time with migraine that people can look back on and see as really transformative.


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