NeuroVoices: Emad Estemalik, MD, on Pioneering a New Age of Migraine Care

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The director of the headache section at Cleveland Clinic’s Neurological Institute provided thoughts on how recent advances have propelled migraine care, treatment possibilities behind prevention, and emerging research targets.

Emad Estamalik, MD

Emad Estamalik, MD

Headaches disorders, characterized by recurrent headache, are among the most common disorders of the nervous system and pose a challenge to the greater medical community. Despite regional variations, headache disorders are a global issue, affecting all ages, races, incomes, and geographical levels. These burdensome diseases can have significant impacts on an individual’s economic situation, family relationships, as well as work and school activities. Globally, migraine was the second last contributor to the disability-adjusted life-years (DALYs) lost due to neurological disorders in 2016, accounting for 16.3% of the attributable DALYs.

Migraine treatment consists of nonpharmacologic and pharmacologic options. For the acute phase, there are specific, non-specific, and adjuvant treatments that are aimed to stopping the attack moments after it occurs. Clinicians have a number of prophylactic therapies as well, including anti-convulsant, antidepressants, and blood pressure medications. Above all, the most notable innovation to the care paradigm has been monoclonal antibodies directed against calcitonin gene-related peptide or its receptor. These agents, which have been around for a few years, are considered highly efficacious with a low risk profile for adverse events.

Keeping up-to-date on the latest innovations in migraine can be challenging for clinicians considering how quickly the field as evolved, says Emad Estamalik, MD. As part of a new iteration of NeuroVoices, Estamalik, director of the headache section at Cleveland Clinic’s Neurological Institute, sat down to discuss some prominent topics regarding migraine care amid the American Headache Society’s (AHS) Scottsdale Symposium. He spoke specifically about the introduction of CGRP-targeting medications and why there is room for additional research, as well as some of the nonpharmacological approaches that are key to patient’s wellbeing. Furthermore, he spoke on the areas of need among this patient population, including a greater understanding for why migraine impacts women more and the origins of this disease.

NeurologyLive®: What aspects of this year’s AHS Scottsdale Symposium excite you?

Firstly, the AHS meeting in Scottsdale, Arizona, is an annual conference that occurs around the same time each year at the same place in Scottsdale. We love being there, and it is one of several important headache conferences held within the United States each year. The other ones include the scientific meeting in June and, of course, the American Academy of Neurology meeting. The November Scottsdale meeting is unique as it brings together a diverse community of headache specialists, neurologists, and internal medicine specialists who treat headache patients from around the world. Despite being a United States conference, it attracts a significant number of attendees from abroad. During this meeting, a wide range of topics is covered, with a focus on migraine as well as other types of headaches, including less common ones such as secondary headaches and cluster headaches.

In recent years, there has also been a notable emphasis on addressing COVID-related symptoms, particularly those related to headaches. The scientific community discusses clinical experiences, real-world evidence, and highlights new data on novel treatments that have emerged in the past few years. The migraine world, in particular, has seen significant advancements in treatments since 2018 when the first preventive monoclonal antibody was introduced. The conference provides updates on new therapies, open-label trials, and the long-term efficacy of treatments. It's a great opportunity for networking, and as someone from overseas running a Headache Center, it's especially rewarding to see the success of the fellows we train each year as they contribute to headache care throughout the United States.

What are some of the current greatest unmet needs of patients that need greater attention?

Despite significant progress in managing the disorder and minimizing the suffering of individuals, there is still a long way to go in finding a cure for migraine. Migraine predominantly affects women, and they often endure symptoms from the onset of their menstrual cycle to menopause, covering the childbearing age period. While understanding of the disease has improved over the years, including recognizing its genetic elements, the exact position of migraine on an individual's DNA map is yet to be pinpointed. Beyond migraine, there are other headache disorders and facial neuralgias that still pose challenges and require ongoing research. Trigeminal neuralgia, for instance, is one of the conditions that demand attention. The field has made strides in comprehending migraine, but there remains a need for further research to ultimately find a cure and address the broader spectrum of headache disorders.

From an administrative perspective, how have the efficiencies of diagnosing and treating patients with migraine improved?

There has been a significant modification of the treatment algorithm for managing migraine patients. The introduction of preventive monoclonal antibodies, small molecule CGRP antagonists, neuromodulation, and onabotulinumtoxin has transformed the approach to treatment. The treatment landscape has evolved from relying on traditional therapies, such as seizure meds, blood pressure meds, and antidepressants, which were last updated in guidelines in 2012. With the continuous introduction of new therapies, the treatment algorithm has become more dynamic. These novel therapies offer more treatment options with fewer side effects compared to traditional medications. Moreover, the use of advanced imaging technologies, such as 3T MRIs, has enhanced diagnostic capabilities, aiding in the identification of secondary headaches and contributing to early detection and intervention in non-migraine-related disorders. The continuous evolution of treatment algorithms and the adoption of sophisticated imaging tools represent an exciting time in the neurology field.

What types of nonpharmacological approaches to migraine have you seen incorporated?

Nonpharmacological interventions and lifestyle modifications play a crucial role in migraine management. While there's no magic formula, many patients have realized the importance of achieving a better work-life balance, particularly in the post-COVID era. Virtual or hybrid work models have reduced stress related to commuting, and technology use is being optimized to minimize eyestrain. Sleep hygiene practices have gained importance, and the impact of nutrition and maintaining a healthy weight is emphasized, especially considering the obesity epidemic. These nonpharmacological interventions, combined with lifestyle modifications, contribute significantly to improving overall health for migraine patients. The holistic approach recognizes that addressing mental health, stress reduction, and adopting a biopsychosocial perspective are integral aspects of managing neurologic illnesses effectively.

Over the coming years, where should research be focused towards?

While current research has made substantial strides, there is still much to explore in the migraine field. Potential areas of focus include investigating PACAP, a peptide that shows promise but is still in preliminary stages without FDA-approved medications. The understanding of migraine has evolved beyond the vascular perspective, and with various targets and receptors involved, research is expected to continue exploring new avenues. The role of CGRPs, especially the small molecule CGRP antagonist, may see more data emerging, leading to the development of new drugs. The continuous evolution of treatment options and the expanding understanding of migraine's complexity suggest that research in the next five years will likely focus on further refining existing treatments, exploring new targets, and addressing unmet needs in the diverse landscape of migraine disorders.

Click here for more iterations of NeuroVoices.

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