While common, headaches present a significant challenge in the medical community due to their complex nature and the considerable disability they cause many patients. Dr. Anthony Davis, a board-certified neurologist at UAMS specializing in dementia and headaches, recently appeared on AFMC TV to share his insights on the difficulties of treating headaches and the latest advancements in headache medication.
In this blog:
1. What are the key challenges and latest advancements in treating headaches?
Due to their diverse types and symptoms, headaches present a significant challenge in healthcare. According to Dr. Anthony Davis, identifying effective treatments for each type can be complex. However, recent advancements have introduced a new class of medications targeting the calcitonin gene-related peptide (CGRP), including pants for acute treatment and preventative purposes and monoclonal antibodies for longer-term prevention. These developments offer new hope for individuals suffering from severe and frequent headaches.
2. How crucial is a detailed headache history in diagnosis and treatment?
A comprehensive headache history is not just a formality, but a vital tool for diagnosing the specific type of headache and determining the most effective treatment plan. Dr. Davis emphasizes that understanding the headache's duration, frequency, onset, and triggers can empower patients to actively participate in their treatment, leading to a choice between abortive therapy or a prophylactic approach, which significantly improves the chances of treatment success.
3. What distinguishes gepants from monoclonal antibodies, and how do insurance limitations affect medication choices?
Gepants and monoclonal antibodies are at the forefront of headache treatment, providing acute relief and long-term prevention, respectively. Dr. Davis's team navigates insurance limitations by keeping detailed records of covered medications, ensuring patients receive the best possible care within their insurance plan. This strategic approach helps combine clinical decisions with insurance realities, offering effective care despite financial and bureaucratic hurdles.
4. When is it advisable for primary care providers to refer headache patients to a neurologist?
Dr. Davis suggests that primary care providers play a crucial role in patient care, not just in complex cases but whenever a patient's headaches are not adequately controlled by first-line treatments or if they experience adverse medication effects. Their early referral can facilitate a more tailored and effective treatment strategy, potentially enhancing patient outcomes, making them an integral part of the healthcare system.
Headaches are Tough to Get Through…And Tough to Treat
Headaches are often difficult to treat due to the different types of headaches that exist. “There are several different types of headaches, which changes how you approach both treatment and prevention,” Dr. Davis said. The variety not only poses a challenge for providers but also for patients, as different headaches could cause a variety of different symptoms.
People commonly talk about migraines, which is a word many use to describe a bad headache. In reality, all headaches have a different semiology, or set of characteristics and symptoms, that go with them. “A migraine headache is, of course, the most common. Migraines have classic characteristics, including unilateral (or one-sided) throbbing pain, sensitivity to light and sound, and vomiting,” Dr. Davis said.
Another very common type of headache is tension headache, which usually occurs on both sides of the head. Tension headaches are often band-like. I hear people describe them as if they’re wearing a hat that’s too tight.” There are some types of headaches, however, that are far less frequent and may be very severe, such as autonomic trigeminal cephalgia or cluster headaches.
“Cluster headaches are mediated by the trigeminal nerve and, while usually shorter in duration, they have a higher frequency over time,” Dr. Davis explained. Cluster headaches have special symptoms alongside the traditional headache symptoms. These special symptoms include wateriness and redness in the eyes, drooping and swollen eyelids, and skin color on the side of the face that hurts.
Advancements in Treatment
For decades, doctors have used the same treatment methods for headaches. “I have described to my patients that, when it comes to headache treatment, we try to bake a cake that pleases every palate, but we only have so many ingredients,” Dr. Davis explained.
Patients have traditionally used anti-seizure, antihypertensive, and anti-depressive medications to treat headaches. “Then the triptans came out 20–30 years ago, which were used to treat acute headaches,” Dr. Davis explained. “However, the most recent change has been a new class of medications that affect a protein called calcitonin gene-related peptide, or CGRP, which has been found in the spinal fluid of patients with migraine headaches in particular.” CGRP levels increased when the headaches became more severe and decreased when the headache became milder. This opened up new medication options for patients.
Headache History Helps with Diagnosis
Due to the different types and symptoms of headaches, Dr. Davis explained that a detailed headache history is key to determining the right approach for each patient. “Headache history will tell you things like how long the headaches last, how frequently they occur, at what age the patient first started having headaches, and if there are any precipitating factors that may have brought on the headache.”
This information helps in deciding whether to pursue abortive therapy or a more prophylactic approach, depending on the patient’s situation. “For example, if you have a patient who only gets one headache per month, you can probably just get by with treating that single headache,” Dr. Davis explains. “But if you have a patient who has 2, 3, or daily headaches per week, then I’ll generally go for an abort or more of a prophylactic measure where the patient takes something on a regular schedule with the goal of reducing or removing the number of headaches per month.”
Gepants vs. Monoclonal Antibodies
CGRP (calcitonin gene-related peptide) type drugs have emerged as a revolutionary approach to headache treatment. CGRP-type drugs are categorized into two main types: gepants and monoclonal antibodies. Gepants, oral medications primarily introduced as abortives for acute migraine attacks, include popular brands like Ubrelvy™ and Nurtec®. Notably, Nurtec later received FDA approval for preventive use on an every-other-day basis, joining Qulipta®, another gepant designated for daily prophylactic intake.
Monoclonal antibodies, on the other hand, represent a different approach. These are administered through injections or infusions, focusing on long-term CGRP blockade. Aimovig®, Ajovy®, and Emgality® are monthly subcutaneous injections utilized for prophylaxis. Additionally, Vyepti®, an infusion likened to a chemotherapy drug but within the same family, extends the arsenal for migraine prevention.
“A lot of my patients have had few side effects with both of these treatment approaches,” Dr. Davis says. “Of course, there are side effects with any drug, but generally, my patients tolerate them fairly well.”
Challenges and Setbacks
Despite the few symptoms his patients experience, Dr. Davis faces challenges that make it difficult to get patients the right treatment. “One of the biggest problems I run into with these medications is, of course, insurance payments. These treatments can cost $700 to $1,000 per month, and often, I don’t get to pick the drug based on what I think would be best for the patient. I have to look at the patient’s insurance and see which one the insurance company prefers. That makes it hard for patients to get the right treatment.”
There are ways to overcome this challenge. Dr. Davis’s team made special notes about which insurance companies covered which drugs. “Unfortunately, that brought insurance into the clinical space. I don’t think there’s a doctor alive that went into medicine to handle those kinds of issues,” he says.
When Are Referrals Appropriate?
Primary care providers are the tip of the spear for patients. A provider’s connection to their patient helps with adherence to the complex treatment plans that headaches may require. “I will say that, as a neurologist, providers don’t have to only send us the hard ones,” Dr. Davis jokes. “I’m certainly happy to get the easy ones as well.”
“I would recommend that the doctor talks through the headache with the patient, trying to get an idea of the symptoms, which will help identify a headache type. That will guide them to the medication or treatment to try first,” he adds. If the patient has adverse effects or does not respond to a medication, a referral to a neurologist is appropriate.
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