I’ve been in Italy this last week, for the EFIC Congress, which is the biggest international scientific meeting that pain types go to in a year when there is no official World Congress. On the first day of the meeting I went to a session about headache, and I came away both daunted and hopeful.
After the usual introductory hour or so of reviewing what is currently known about migraines and tension type headaches, things took a decidedly interesting turn. We were introduced to Prof Messoud Ashina from Copenhagen who makes a living luring migraine sufferers into his lab when they are well, and then infusing them with various things that he hopes will give them a migraine. The reason he is able to get away with this type of research is because there is no animal model for migraine which can predict whether drugs will work. As far as we can tell, it is a strictly human problem. It makes sense then to conclude that if we can reliably trigger migraines with known substances, we can have a human model to help us find targets for treating those headaches, since we know what the stuff does that we are giving them.
Migraine sufferers (who for reasons lost to time and tradition are known in the field as migraineurs) know that there are often definite environmental triggers for their attacks, which can include alcohol, overcast days, emotional stress and some types of food. What is different about what Ashina and his colleagues do is that they use small peptides that occur naturally in the body to produce the attacks experimentally.
The main 4 he has found that are best for his nefarious purpose include nitric oxide (given as nitroglycerine intravenously), Calctonin gene-related peptide (CGRP), Vasoactive Intestinal Peptide (VIP) and Pituitary Adenylate Cyclase Activating Peptide (PACAP38). Of these, the PACAP38 produces severe migraines in almost every subject after 4-6 hours. Whereas for the other peptides, the migraineurs mostly get headaches of moderate severity which are easily reversed by drugs which block their action, in the case of PACAP38 almost every subject had to use their rescue triptan drug, and the average severity of headache was double that of the others. There isn’t a currently available drug which blocks PACAP38, but you had better believe the pharma companies are now starting to hunt for it. Thanks to one slightly sadistic lab in Denmark and their selfless migraineurs, (to whom Ashina is touchingly proud and devoted) they know where to look for the next effective and non-toxic migraine drug.
The last speaker in the session was Prof Tim Steiner from London, who is the Chair of the Global Campaign Against Headache. He concentrated on the cost to society of chronic headaches. Would it surprise you to know that only 10% of the economic impact of migraines is the actual treatment cost? The direct cost of drugs and hospital admissions is dwarfed by the other economic losses. In the UK alone, 190,000 people get a severe enough migraine to ruin their day. Half of those can’t go to work or school. Imagine the benefit to society of returning hundreds of thousands of people to productivity.
Perhaps the most poignant part of the societal impact of migraines is the lives that people never live because of their headaches. Chronic migraineurs will never live up to their potential because their life choices are plagued by the unpredictability of the crippling attacks that leave them prostrated. Nobody dies from migraines, but the migraineurs I see regularly have lived most of their lives just dreading the hammer falling on them. Their choice of study, career and relationships would all be different without their headaches.
So the economic and humanitarian case for finding new treatments for migraines is overwhelming. It almost doesn’t matter what they cost. Beyond the obvious benefits of increased productivity, new treatments will change the life choices open to a tenth of the population who would otherwise by haunted and plagued by their invisible enemy.