Recapping Headache and Migraine Research at Neurology Week

In this video, Migraine Section Editor and Neurology Week steering committee member Stephanie Nahas, MD, highlights some of the headache and migraine presentations given virtually during Neurology Week, including the state of science in headache and migraine, translating research into clinical practice, challenging headache cases, and more. 

Read the Transcript:

Dr Stephanie Nahas: Hi. My name is Dr Stephanie J Nahas. I'm an associate professor of neurology at Thomas Jefferson University, where I direct the Headache Medicine Fellowship program as a headache specialist at the Jefferson Headache Center.

I'm also honored to have been on the steering committee for this inaugural neurology week virtual conference, first of its kind. I am very excited to know that we're going to be having this as a recurring conference, because wow, was it fantastic.

Of course, I'm biased towards much of the headache content, where we had a great review of the state of the science, as well as how to translate that science into practice.

A review of some challenging cases complemented by bonus material on even more challenging cases in super refractory migraine. A closer look at some of the newer treatments, such as the monoclonal antibodies for migraine prevention, and newer acute treatments for migraine attacks. We also have, in the bonus sessions, a talk on neuromodulation.

One of my favorite talks on migraine plus, incorporating migraine with overlap of hypermobility syndrome, centralized pain, and the spectrum of mast cell disorders. In addition to this, we also had a couple of sessions outside of headache that I was very much looking forward to. I'd actually seen these talks before, but I'm always happy to see them again.

Dr Martin Samuels presented on the interface of medicine and neurology on a topic called “Voodoo” death. Interesting little fact, I was actually a first-year medical student back in 1996 when I first saw Dr Samuels deliver this lecture. It was eye-opening and groundbreaking for me. I even saved the handout from it.

I had already had a great interest in neurology, but that was one of the things that sealed it for me. He's somebody that I've looked up to ever since then and have been hoping to emulate, although he's inimitable.

Then the other talk I was very much looking forward to is on functional neurologic disorders from Dr John Stone, who I first saw lecture on the topic at an American Academy of Neurology meeting many years ago. I'm glad to see that there's a lot more interest in functional neurologic disorders ever since that time.

Some of the highlights from the science included the first talk by Dr Amynah Pradhan, where she covered 3 new topics in emerging science on the delta opioid receptor, on microtubules, and how their function or dysfunction may play into migraine, and then something called HDAC6.

This was very high-level stuff. Highly encourage you to take a deep dive into it. You might need to rewind the talk a few times to really digest it. It's groundbreaking material. I think it's going to lead to a lot of fantastic new treatments for migraine. There's been a lot coming out in the last few years, but we're very, very hungry for more. We need as much as we can get.

Perhaps the most exciting subtopic within that talk was indeed about the delta opioid receptor, which a lot of us have had our eye on for quite a while. There's evidence to suggest that this delta opioid receptor, when it is activated highly specifically, it doesn't engage mechanisms that may lead to addiction, dependence, and abuse of opioids. This is of critical importance.

Moreover, it may have positive effects on the affective system. Reversing anxiety and depression, or at least not aggravating them, like some other opioids can. Let's pause there so that I can wrap my head around what Dr Charles had to say.

Also highlighting science and translating science into clinical practice, we had Dr Andrew Charles give us a broad overview on several topics, including further debunking the vascular hypothesis of migraine, migraine as a brain state, which is something that appeals to me. I've often conceptualized migraine attacks as a shift in brain state and we have more evidence from functional neuroimaging, as well as theoretical neuroscience to support this notion that indeed, the brain can shift into different states. Different modules of the brain can lead to brain dysfunction that manifests in specific symptoms, especially with the interconnectedness of the nervous system with the rest of the body.

In particular, highlighted the role of neck pain in migraine, and how it is a two-way street. When migraine mechanisms in the brain are activated, they can further engage the interconnectedness of the trigeminal cervical system, thus leading to the sensation of neck pain and discomfort.

In addition, a migraine attack might start there in that circuitry, and then further connect up to the trigeminal vascular system and trigeminal autonomic systems. This speaks to this notion that migraine doesn't necessarily come from neck pathology.

I know I've got patients just about every day are asking me to scan their necks because they think that must be where the problem is. That's where their pain starts or that's where they've got a lot of pain during a migraine attack.

Of course, in a vast majority of cases, we don't find anything on imaging that explains that degree of neck pain and dysfunction. Indeed, in between the text, the neck is just fine.

It lends credence to this notion that the neck pain of migraine, much like the sinus symptoms that can occur in migraine, are not because of neck pathology or sinus pathology per se, or for sure, but they're more reflective of the way the nervous system can bring out these symptoms for an individual to experience pain in those areas.

I found that incredibly fascinating and also validating to our theoretical neuroscience. He also touched on the evolving understanding of the interplay of patent foramen ovale or PFO and migraine, particularly migraine with aura, and how this is still an open question that needs further scrutiny and further investigation to determine what is the link there.

For many years, it's been postulated that closing a patent foramen ovale could help certain subtypes of migraine. We're starting to get a little bit closer to finding that perfect niche of who may benefit from such a procedure. Finally, he gave us a review on our evolving knowledge of the calcitonin gene-related peptide system and where else we need to go.

One of my former fellows at the Jefferson Headache Center, Dr Jessica Ailani, who runs her own headache fellowship program at Georgetown these days, gave us 2 talks. One in the main agenda on challenging headache cases, which were fantastic. I highly encourage you to take a look at those.

I think that you'll see that a lot of the elements are relevant to your own clinical practice in managing patients who have tough headache disease.

This was complemented in the bonus sessions by even more cases of super refractory migraine and other headaches, for those of you who aren't afraid to dig deep into extremely challenging cases where complex treatment plans and management plans are what's necessary in order to give those patients relief.

Another one of my former fellows, Dr Larry Charleston IV, who is at Michigan, gave us an update on the monoclonal antibodies that are used for migraine prevention targeting that darling calcitonin gene-related peptide pathway, CGRP.

It was a tremendous review complemented by a case and a real patient experience with these medications in this class, and giving us more inspiration to seek out how these treatments and similar treatments that may come out in the future and beyond may be of benefit to our patients who need them the most.

Also, in the bonus sessions, we had Dr Stewart Tepper from Dartmouth, giving us a fantastic review on the spectrum of neuromodulation in migraine and other headache. If you want a succinct and meaty data-driven review of where these devices can fit into the management of headache disorders, I highly recommend that you take a look at that lecture.

Then finally, one of my favorite topics in headache is overlap syndromes. Dr Wade Cooper, also from Michigan, gave us a terrific talk about migraine plus. In this case, the plusses were centralized pain, such as we might see in fibromyalgia, complex regional pain syndrome, or other pain states.

Hypermobility syndrome, which is something that we've been recognizing more and more over the years as a major contributor and comorbidity to migraine, which can be associated with other risks, such as the risk for a spinal CSF leak, cervix spinal fluid leak, and low-pressure headaches.

Finally, he gave a detailed discussion on the spectrum of mast cell disorders and mast cell dysfunction, which is a topic of ongoing and increasing interest over the past few years. A very difficult entity to diagnose. This spans a spectrum of different presentations. Different ways to diagnose it, different ways to manage it, but it can be very, very tricky and very, very challenging.

This may be one of the reasons that a patient with migraine is in a super refractory state. It's a reminder that there are these other entities that we need to look for that can complicate the migraine picture. If they're not addressed and not managed, you're just going to be spinning your wheels in managing your patient's migraine.

I highly recommend you take a look at that lecture. In addition, in Neurology Week, we had sessions on an array of other topics, including sleep, dementia, epilepsy, stroke, movement disorders. I might be forgetting 1 or 2. There were 2 highlighted talks of major interest that I mentioned before.

I'm big fans of these guys, Dr John Stone, who gave us a talk on functional neurologic diseases. There's always a little something new to learn from Dr Stone's lecture. Even though I've seen him talk several times, I always pick up a cool little nuance. Definitely check out that talk, especially if you've never seen him talk before, but even if you've seen him talk before.

Of course, a legend and a giant in the field, Dr Martin Samuels from Harvard, gave us a lecture on the interface of medicine and neurology. He talks about a number of different topics in this realm. For our particular meeting, near and dear to my heart, he spoke on the topic of “Voodoo” death.

This is a lecture that I saw for the very first time when I was a first-year medical student. It was great to have this come full circle. One of the original legends who inspired me when I was a youngster, now here is at a meeting that I helped to create and to steer. It just gave me so much gratification and pleasure.