Common disease migraine: The forgotten epidemic

Nearly 15 percent of Germans suffer from migraines. Professor Hartmut Göbel explains what patients should pay attention to and what can help them. Research offers hope. Migraines are among the most common illnesses affecting people in Germany. One person who knows a great deal about them is Professor Hartmut Göbel. He is the founder, medical director, and managing director of the pain clinic in Kiel. The recipient of the Federal Cross of Merit also established a migraine degree program at Kiel University. In conversation with editor Matthias Jansen, Göbel discusses the illness, who is affected, what can be done about it, and current research topics.

Are the figures accurate that up to 15 percent of Germans suffer from migraines?

Within a single year, the figure is accurate. Frequency must always be considered over a period of time. Looking at a lifetime, approximately 40 percent of the population suffers from migraine attacks. Migraine is the third most common human illness after tooth decay and tension headaches. It is also the leading cause of disability in people under 50.

Are headaches becoming more common in our fast-paced world?

Studies show that headaches have become significantly more common in recent decades, particularly among children and adolescents. Headaches have always been a major problem for adults as well. Primary headaches, migraines, and tension headaches are among the most common neurological disorders. While many patients used to give up and rely on alternative treatments, many of these sufferers are now specifically diagnosed and can receive effective medical therapy. However, stress, irregular daily routines, and family pressures can also exacerbate headaches. Therefore, current psychosocial factors also contribute to the increased frequency and severity of headaches in our time.

Is it true that more and more children are affected? Why is this happening and how can they be helped?

Studies from recent decades show a significant increase in headaches among children. Long-term studies indicate that headache frequency has increased by more than 300 percent, particularly among young children. Children today live in a fast-paced world, and frequent family moves play a role. Parents' work-related stress can also negatively impact children's headaches. Media consumption, especially digital applications, can also place considerable strain on children's nervous systems and contribute to more frequent headaches. A consistent routine and regular daily schedule are especially important for children. Time for relaxation and rest should be provided. A regular, carbohydrate-rich diet is essential for ensuring adequate energy supply to the nervous system. A regular sleep schedule should also be maintained. Precise diagnosis and an effective treatment plan are crucial for children to prevent headaches from becoming chronic and more frequent at a young age.

At what point do headaches become chronic?

If headaches occur on more than 15 days a month for more than three months, they are considered chronic. It is therefore particularly important that treatment reduces the frequency of headaches. The more frequently headaches occur and the more headache days there are per month, the more difficult the treatment and the greater the effort required to achieve effective therapy.

Who is most affected by the disease and why do people get migraines?

It particularly affects women because they have a more active, faster nervous system. They can perceive and process stimuli and emotions more intensely. This is why the female nervous system requires a higher energy expenditure, and therefore energy deficits are more pronounced. In addition, there are more significant changes in metabolism and energy supply during the menstrual cycle. Migraine is therefore not an age-related disease. Migraine requires an active, reactive brain. Migraine sufferers are capable of very rapid and highly active mental activity. This high level of neural activity demands a high energy expenditure in the nerve cells. However, if an energy deficit occurs, the nerve cells are temporarily unable to function adequately. Nerve function is disrupted or collapses. This then leads to the typical symptoms of a migraine attack.

What are the consequences?

In some patients, neurological symptoms such as visual disturbances like zigzag lines with flashing lights before the eyes, speech difficulties, dizziness, tingling sensations, or even paralysis occur as an initial symptom. These are followed by headaches. The pain lasts between four and 72 hours. The pain can be unilateral. It is characterized by a throbbing, pulsating pain. Physical activity can intensify the pain, necessitating bed rest. Nausea, vomiting, and sensitivity to noise and light may accompany the pain.

Why, then, is migraine not really present as a disease?

Migraine sufferers usually suffer in isolation. They live behind closed curtains, are confined to their homes for three days, stop eating and drinking, are ignored by the world around them, and are incapacitated. Migraine is the forgotten epidemic. Although so many people suffer from it for a lifetime, awareness of the significance of migraine is still low. Fortunately, there has been a marked improvement in recent years. The need for society to advocate for this group has only recently begun to be increasingly recognized.

How do you proceed when trying to diagnose migraine?

Headache diagnosis consists of several steps. First, the exact course of the headache must be recorded and analyzed. Since there are now over 367 main types of headaches, this is a very complex and time-consuming process. The affected patients must describe the course of their headaches very precisely. Headache questionnaires, headache diaries, and migraine apps can be very helpful. People can also experience several types of headaches simultaneously or at different times. Therefore, all these different types must be identified and differentiated.

What happens next?

The next step involves a very thorough neurological and general medical examination. Taken together, these examinations reveal that most patients exhibit the symptoms of a so-called primary headache disorder. This means that the headaches are the primary condition and not a symptom of something else.

And if not?

However, if doubts arise, these must be confirmed or ruled out, and further targeted diagnostic measures must be taken. The underlying conditions causing the headache must be addressed therapeutically. For example, a headache caused by high blood pressure cannot be effectively treated with painkillers. The high blood pressure must be treated. The headache will then subside.

Is it true that migraines begin in puberty?

Migraines often begin around the time a child starts school. This is the period when the brain is mature enough to learn and react quickly. Typically, migraines start with a higher incidence in boys. However, girls quickly overtake them, and from puberty onwards, the frequency is roughly 1:3 in boys compared to girls.

Those affected say that only medication helps with migraines. What should be considered when doing so?

With 367 main types of headaches, it's understandable that there are many different ways to treat them. Every headache treatment should begin with information and education about the diagnosis and the underlying concept of the condition. This is followed by behavioral measures to manage headaches through lifestyle changes, diet, relaxation, exercise, or structuring daily routines. The next step for headaches that occur in attacks is to determine the appropriate treatment. Pain relievers also play an important role in treating headache attacks. However, specific headache prevention is particularly crucial. This is because simply administering triptans or other pain relievers is insufficient to effectively treat headache disorders, especially when headaches occur very frequently. Taking acute migraine medication on ten or more days a month can lead to medication-overuse headache. This means that headaches become more frequent, respond less well to acute medications, and can eventually develop into chronic headaches. Therefore, finding effective headache prevention strategies is of paramount importance. The goal is to reduce the frequency of headaches and to make the frequency of headaches as low as possible.

They mentioned behavioral measures. What can migraine patients do to feel well even without medication?

Modern pain therapy doesn't differentiate between "either/or" approaches. Instead, it aims to provide patients with everything that has proven effective in scientific studies. Nutrition, exercise therapy, relaxation, knowledge, information, and other non-pharmacological methods are essential components of modern and effective pain therapy. The nervous system requires complex carbohydrates for healthy function. Due to genetic factors, the nerve cells of migraine sufferers are particularly active. During a migraine attack, energy consumption increases, leading to an energy deficit. The nerve cells can no longer function adequately, resulting in a migraine attack.

How can patients contribute through their diet?

It is important that those affected consume sufficient complex carbohydrates, such as potatoes, rice, or whole-grain products. A regular eating schedule should be maintained, and meal intervals should be consistently observed. Omega-3 fatty acids have also proven effective in preventative measures in scientific studies. They reduce inflammatory processes in the nervous system. Therefore, it is important to ensure an adequate intake of omega-3 fatty acids in the diet. For preventative measures through behavior, relaxation techniques, biofeedback, and exercise therapy have proven particularly effective. Behavioral therapy can also be highly effective for severely affected patients.

Is migraine a barrier to professional career advancement?

In fact, people with migraines are particularly high-achieving. They have very active, creative brains. Their genetic makeup enables them to implement innovative ideas, quickly perceive problems, and find solutions. Furthermore, migraine sufferers often experience attacks after an active period, typically on Saturdays and Sundays. By Monday, they are back to work and can once again contribute their skills to society. Smart employers are therefore best advised to hire migraine sufferers. In many fields, there are well-known migraine sufferers who excel. From this perspective, the notion that migraines impair one's performance is completely inadequate and does not reflect the current state of scientific knowledge.

Which patients come to your clinic?

The Kiel Pain Clinic admits severely affected patients from across Germany with chronic pain conditions. A key characteristic is that, despite numerous therapeutic attempts, these patients have not responded effectively to treatment. The pain causes significant suffering, severely impacting their quality of life. Many patients are unable to work or face the threat of early retirement. Due to persistent pain or a high frequency of attacks, medication must be taken very frequently. This can lead to medication overuse, paradoxically exacerbating the pain. The pain medication becomes less effective. Simultaneously, the frequency and intensity of the pain increase. The severe impairment caused by the pain leads to anxiety, loss of confidence, hopelessness, depressive thoughts, social withdrawal, sleep disorders, and complex psychosocial consequences. Many patients also suffer from complicated physical comorbidities, which further complicate pain management. For example, diseases of the stomach, intestines, and liver can preclude the use of certain medications. Overall, "pain" is not an isolated symptom, but rather a complex condition with diverse consequences.

At what point should I seek help for a headache?

Headaches can be very complex conditions and should be medically diagnosed. If other, previously unknown types of headaches occur, if headaches become more frequent, cause significant distress, and interfere with professional, social, and family life, medical treatment should be sought. The same applies to headaches accompanied by unclear physical symptoms. Examples include fever, chills, stiff neck, joint pain, muscle pain, and increasing neurological and psychological symptoms.

What changes have occurred in the treatment of different types of headaches in recent years? What research is being conducted?

In recent years, the introduction of antibodies against CGRP, the calcitonin gene-related peptide, has led to a significant improvement in migraine prevention. CGRP is an important messenger substance that plays a central role in migraines. It causes the blood vessels in the meninges to dilate and become inflamed, resulting in the characteristic throbbing, pounding, and pulsating headaches. Decades of research have now made it possible to develop specific substances that inhibit the effects of CGRP in migraines. Four so-called monoclonal antibodies are approved for treatment. In practical application, they demonstrate high efficacy and are generally well-tolerated. They are also effective in patients who do not respond to existing medications approved for migraine prevention. Other substances, such as ditane and gepante, are under development for the treatment of attacks; some are already approved, while others are nearing market availability.

What exactly is immunotherapy for the prevention of migraines?

During a migraine attack, the neurotransmitter CGRP is elevated. With effective treatment using a triptan, this level can be reduced. In patients with chronic migraine, this substance is generally elevated. Administering CGRP to migraine patients can also trigger a migraine attack. Antibodies developed in recent years block either the substance itself or the CGRP receptor. These medications are administered to the patient via autoinjector or infusion at four-week or three-month intervals. They do not lead to lasting immunity but must be administered repeatedly to block the neurotransmitter. This can therefore be described as passive immunization or immunotherapy against migraine. Treatment with monoclonal antibodies has significantly improved migraine therapy. Patients who previously could not be helped can now experience a marked reduction in their migraine attacks and a completely new quality of life. However, not all patients respond to this therapy. Drug treatment should never be the sole component of a modern migraine therapy.