Every year, headache experts from around the country (and even the world) meet in Scottsdale, Arizona to discuss updates on the optimal clinical management of headaches. The American Headache Society President and winner of the 2021 Brain Prize Dr. Goadsby opened this meeting acknowledging the current limitations in our knowledge and care for headache disorders. Despite all the advances, we are still not satisfied with our current management of headache diseases and understanding. We need more research. After engaging and passionate conversations, everyone went home more motivated than ever to keep working on trying to make things better for migraine warriors and people with headache diseases. 

Here are a few highlights from the lectures during the Symposium:

New Medications 

Dr. Ailani from Georgetown University and Dr. Armand from the Montefiore Headache Center discussed considerations regarding the relatively new migraine treatments and ways to best incorporate them into care. Acute treatment with gepant medications such as Ubrelvy and Nurtec is effective for people who take CGRP monoclonal antibody medications for prevention (such as aimovig, ajovy, emgality, and vyepti). However, patients and doctors need to discuss the risks and benefits of such a combination (gepant + CGRP monoclonal antibody) when patients have cardiovascular risks such as a history of large stroke, a recent stroke, or angina. From the research data we have so far, taking a triptan and a gepant together is not more effective than taking a triptan or a gepant alone. Hence, if one does not work, it is advised to save the other medication for another attack and layer a different treatment such as an NSAID or anti-nausea medication. Currently, there is no data regarding the safety and potential side effects of using triptans and ditans together. Since 2018, six new migraine-specific preventive medications came to the market: aimovig, ajovy, emgality, vyepti, nurtec, and atogepant. According to the recently published Consensus Statement from the American Headache Society, the new preventive medications are indicated in people with migraine who had insufficient help from and/or did not tolerate at least two older medications (such as topiramate, propranolol, amitriptyline, botox, etc) and have frequent and/or disabling migraine symptoms. Combining botox injections with monthly CGRP monoclonal antibody injections can provide additional efficacy without increasing the risk of side effects. However, it can still be challenging to get the combination treatment covered by insurance. 

Visual Snow

Dr. Robertson from the Mayo Clinic in Rochester reminded us that visual snow, which refers to seeing like TV statics, can have many potential causes including vitamin deficiencies, abnormalities in blood cell count, traumatic brain injury, starting a new medication, being sick from an infectious disease, changes in hormone levels. It is always important to notify your doctor of visual changes including symptoms that may appear like visual snow. You may need blood work and an eye exam by an Ophthalmologist too if you have visual snow. Sometimes, visual snow comes without identifiable causes. Visual snow is more common in people with migraine than people without migraine. Treatment of visual snow include medications, visual distraction, improvements in lighting, better sleep, stress reduction, and colored lenses such as FL-41 filtered lenses. Avoiding caffeine, stimulants, marijuana, and hallucinogens may help too. If you are wondering whether you have visual snow, check out the online visual snow stimulator at visionsimulations.com. 

Sleep 

Dr. Lipton from the Montefiore Headache Center and Dr. Terwindt from Leiden University Medical Center discussed the complex bidirectional relationship between migraine and sleep disturbances. Long-term insomnia increases the risk of developing migraine by 1.4-fold. Migraine also increases the risk of developing insomnia by 1.7-fold. Unfortunately, insomnia can add to the disability related to migraine for example by worsening the thinking and/or concentration difficulties. Sleep disturbances can trigger and worsen the frequency and severity of migraine symptoms. Sleep disturbances are the second most common headache trigger after stress; they are a trigger for 41% of people with migraine. Women with migraine are also twice as likely to develop cold feet than women without migraine, which may interfere with their ability to fall asleep at night. We still don’t know exactly why this is the case nor how to specifically address the issue of having cold feet.