Migraine with aura from pathophysiology to treatment: therapeutic strategies

Alleviative effects of Cannabis flower on migraine and headache

OBJECTIVE

Few studies to date have measured the real-time effects of consumption of common and commercially available Cannabis products for the treatment of headache and migraine under naturalistic conditions. This study examines, for the first time, the effectiveness of using dried Cannabis flower, the most widely used type of Cannabis product in the United States, in actual time for treatment of headache- and migraine-related pain and the associations between different product characteristics and changes in symptom intensity following Cannabis use.

METHODS

Between 06/10/2016 and 02/12/2019, 699 people used the Releaf Application to record real-time details of their Cannabis use, including product characteristics and symptom intensity levels prior to and following self-administration; data included 1910 session-level attempts to treat headache- (1328 sessions) or migraine-related pain (582 sessions). Changes in headache- or migraine-related pain intensity were measured on a 0-10 scale prior to, and immediately, following Cannabis consumption.

RESULTS

Ninety-four percent of users experienced symptom relief within a two-hour observation window. The average symptom intensity reduction was 3.3 points on a 0-10 scale (standard deviation = 2.28, Cohen's d = 1.58), with males experiencing greater relief than females (P < 0.001) and a trend that younger users (< 35 years) experience greater relief than older users (P = 0.08). Mixed effects regression models showed that, among the known (i.e., labeled) product characteristics, tetrahydrocannabinol levels 10% and higher are the strongest independent predictors of symptom relief, and this effect is particularly prominent in headache rather than migraine sufferers (P < 0.05), females (P < 0.05) and younger users (P < 0.001). Females and younger users also appear to gain greater symptom relief from flower labeled as "C. indica" rather than "C. sativa" or other hybrid strains.

CONCLUSION

These results suggest that whole dried Cannabis flower may be an effective medication for treatment of migraine- and headache-related pain, but the effectiveness differs according to characteristics of the Cannabis plant, the combustion methods, and the age and gender of the patient.

Stroke and migraine

Young patients with migraine are at increased risk for stroke, particularly patients with an aura of focal neurologic deficits. Other causes of ischemia are often identified in patients with migraine, including patent foramen ovale, lupus anticoagulant, cervical carotid dissection, arteriovenous malformation, and hyperactivity of the clotting system. Migrainous stroke is only diagnosed when all other possible causes of stroke have been eliminated and the patient has irreversibility of the usual aura, associated with an ischemic infarct in the appropriate brain territory. Prophylactic therapy of migraine with aura may be beneficial in preventing migrainous stroke.

Interactions between migraine and stroke

When a patient with migraine has a stroke, all other causes of stroke should be ruled out before the stroke is attributed to migraine. Migraine mimics that present with headaches and stroke, including arteriovenous malformation and cervical carotid artery dissection, should be considered. Patent foramen ovale is a risk factor for both migraine and stroke and should be ruled out with transesophageal echocardiography. A patient with migraine with aura with persistent focal neurologic deficits in the distribution of the typical aura can be diagnosed with migrainous stroke. Patients with migraine with aura with persistent focal neurologic deficits can be treated pharmacologically with intravenous verapamil or magnesium sulfate to relieve the symptoms in familial hemiplegic migraine and sporadic hemiplegic migraine. Prophylactic treatment should be administered to patients with frequent attacks of migraine with aura to prevent recurrence. Oral verapamil is recommended for patients with familial hemiplegic migraine and may be effective in patients with sporadic hemiplegic migraine. Endovascular closure of patent foramen ovale has been reported to prevent recurrence of migraine with aura. The role of patent foramen ovale closure remains controversial pending completion of controlled randomized trials.

Preventive treatment of migraine

Migraine is a common episodic pain disorder, the treatment of which can be acute to stop an attack or preventive to reduce the frequency, duration or severity of attacks. Preventive treatment is used when attacks are frequent or disabling. Many different medication groups are used for preventive treatment, including beta-blockers, antidepressants and antiepileptic drugs. Their mechanisms of action include raising the threshold to migraine activation, enhancing antinociception, inhibiting cortical spreading depression, inhibiting peripheral and central sensitization, blocking neurogenic inflammation and modulating sympathetic, parasympathetic or 5-HT tone. In this article, I review evidence of the effectiveness of migraine preventive drugs. I also discuss the setting of treatment priorities.