Doctor on Call
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Irma, a 37 year old mother of three who lives in Albuquerque writes:
I’ve been struggling with migraine for what seems like my entire life. For the last few years I’ve averaged about three attacks per month, with each attack lasting three or four days and leaving me useless for at least one or two of those days. When I got my second COVID vaccination last May, it gave me a migraine that lasted for a month. My doctor told me I’m now due for a booster, but I’m afraid if I get it I’ll have another terrible month of migraine…or worse.
I have a friend who has migraine which is practically identical to mine. Her doctor recently gave her medication for migraine that is supposed to help stop acute migraine attacks and also prevent attacks from occurring, and she says it has worked wonders. I asked my doctor to prescribe that same medication, and it has done absolutely nothing.
What is wrong with me? I’m worried that because I failed to respond to this supposedly wonderful medicine or to any other migraine treatment I’ve received in the past that I may have something besides migraine. Maybe a tumor brain tumor? I had a brain MRI scan several years ago and was told it was normal, but I asked my doctor to order another scan.
Help!
The Doctor’s Reply:
There’s a lot in Irma’s letter to unpack. To begin with, from simple clinical observation and from case series recently published in the medical literature it’s clear that a certain percentage of individuals who receive a COVID vaccine may experience headache as a side effect of vaccination. It also appears that if the individual has a pre-existing history of migraine, he/she may be more inclined to develop this complication. If you have a history of migraine, should you avoid vaccination? This deceptively simple question is not all that easy to answer. Given the evidence currently available, suffice it to say that even if you are young, healthy and therefore at a very low risk of a serious clinical outcome from COVID infection, and even allowing for the fact that the long-term safety of the COVID vaccinations has not been established, the risk: benefit ratio for you - and even more for the community as a whole - favors vaccination.
Why has Irma failed to respond to multiple “migraine-specific“ therapies, including this interesting new hybrid treatment that has been so effective for her friend? Any answer should begin with the emphatic reminder that absolutely no therapy is “migraine-specific“. Put another way, a failure to respond to a given migraine therapy does not exclude the diagnosis of migraine, and, conversely, responding to such a therapy does not exclude other conditions that may mimic migraine.
The newer migraine medications for acute headache treatment and headache prevention, from sumatriptan (Imitrex) on, are “designer drugs“ developed specifically to “fit“ various components of migraine’s biologic circuitry. They are not naturally occurring substances such as the ergotamines or medications developed for another purpose such as the beta blockers (e.g., propranolol/Inderal) developed for other purposes and serendipitously found to be effective for some migraine patients. Again, these “designer drugs“ are specifically targeted to activate or inactivate certain points along the way in the electrochemical circuit that conducts head pain signal…and none of these drugs is specifically intended to be magically specific to migraine alone. For example, patients suffering acute, severe headache from a ruptured brain aneurysm may experience significant headache relief from subcutaneous injection of sumatriptan.
There are many genetic permutations that may produce the symptom complex we know as “migraine“, and it stands to reason that there also exist a number of different variations on the biologic circuitry producing migraine. Not surprisingly, then, there is no existing migraine treatment that is universally effective for all migraineurs.
Keep trying, Irma. We are in the midst of a revolution involving migraine therapeutics, and “your” treatment is either out there waiting or just around the corner. If you have not done so already, consider consulting with a headache sub-specialist who is skilled in the use of these new therapies and, ideally, also involved in research intended to identify new therapies soon to arrive.
