If you suffer from migraine, you’re not alone. According to a January 2021 study published in the journal Headache, almost 16 percent of adults in the United States had migraine and severe headaches in 2018. The condition affects 21 percent of women and nearly 11 percent of men. The study also found that migraine accounted for about 4 million emergency department (ED) visits, making it the fifth-most common reason for an ED visit overall, as well as 4.3 million office visits. But migraine treatment is not one-size-fits-all.
Despite its prevalence, migraine is often misunderstood. “I think many people who don’t have a migraine don’t understand how debilitating it is,” says Kumeren Govender, MD, Ph.D., Chief Medical Officer of Mable and a founding member of the company. “Many people might think, ‘Oh, it’s just a headache. Just take a tablet, you’ll get over it.’”
The reality for people with moderate or severe migraine is rarely that simple.
The same Headache study found that in 2018, roughly 40 percent of U.S. adults with migraine were unemployed. There were also tremendous socioeconomic disadvantages that could go along with this, including not having health insurance, having a high school education or less, and being classified as poor or near-poor.
The researchers concluded migraine is a severe public health issue in the U.S. According to the American Migraine Foundation, lost productivity and healthcare costs because of migraine are estimated to be as much as $36 billion each year in the U.S.
Although migraine is a type of headache, it’s very different from a tension headache, which people often think of when talking about headaches. A tension headache usually feels like a tight band around the head, and the pain is often mild to moderate. Stress often triggers it.
In contrast, migraine pain tends to be moderate to severe. “Migraine is a headache that’s generally on one side of the head—the name comes from the Greek word hemicrania, which means ‘half skull,’” Dr. Govender says. Nausea, vomiting, or sensitivity to light can also accompany this head pain known as photophobia. “Generally, people with migraine also go to a quiet, dark room where it’s less noisy,” he adds. Although migraine can be triggered by stress or other factors, they can also come on unpredictably.
The significant pain of migraine and the need to retreat from the world when it strikes is why the condition can make it difficult for people to perform consistently at work. The impact of migraine can spill into other areas of their lives, including relationships with family and friends, hobbies, and more.
You might think that such a debilitating condition would have a few go-to medications that help people find relief. After all, there are a handful of over-the-counter options often used to treat tension headaches, such as Tylenol, Motrin, and Excedrin. But unfortunately, treatment is another aspect of living with migraine that is rarely simple. “There is a long list of medications used to treat people with migraine, but up until now, clinicians have not had a way to help them choose the right one,” says Roman Rothaermel, who has a Ph.D. in Neuroscience and is the co-founder and Chief Executive Officer of Mable.
In the U.S., there are seven types of triptans available, which are the primary drugs used to treat migraine in the acute phase, meaning when you’re in the throes of one. They may also prescribe preventative medications to people with moderate or severe migraine to cut down on the number of migraine daysthey experience and the severity of symptoms when they get one. And currently, there are over 15 different drugs used on or off-label to prevent migraine.
There’s a system failure to educate [primary care] doctors about migraine, and as a result, migraine is often not diagnosed correctly
Another major issue with migraine treatment is getting diagnosed correctly. “About 80 percent of migraine patients are currently handled in primary care,” says Dr. Rothaermel, “And there’s a system failure to educate [primary care] doctors about migraine, and as a result, migraine is often not diagnosed correctly. This is a huge pain point because how do you treat undiagnosed people living with migraine?”
Although headache specialists treat migraine, there aren’t nearly enough of them for all people who have the condition. There are only about 580 migraine specialists in the United States, according to Carolyn Bernstein, MD, FAHS, a neurologist who specializes in headache medicine at Osher Center for Integrative Medicine at Harvard Medical School and Brigham and Women’s Hospital in Boston, even though there are 39 million people who have the condition.
According to the Migraine Research Foundation, most people with migraine do not seek medical treatment for their pain. Nearly all people living with migraine would benefit from the appropriate acute medication to stop the pain once it begins. Even though 25 percent of those with migraine would benefit from preventive treatment, only 12 percent are actually on one — but with no guarantee that it is the right one for them.
Even for people with migraine who are correctly diagnosed, finding the proper treatment can take a lot of work. When prescribing you a particular migraine treatment, the average doctor may simply guess, based on what has worked for other migraine patients they have, or on the limited amount about migraine that they gleaned in medical school, where migraine was just one of the hundreds of conditions they learned about.
Migraine treatment has to be individualized, and the treatment people receive is often not right for them
“Migraine treatment has to be individualized, and the treatment people receive is often not right for them,” says Dr. Rothaermel. Mable conducted a research study in 2021 in the United Kingdom on the effectiveness of migraine treatment for people with the condition. When looking at 700 people with migraine, “What we found is that 70 percent of migraine sufferers are on the wrong drug,” he says. “This means a drug causes either side effects or it does not actually help much with their pain.”
According to the American Migraine Foundation, headache specialists consider several factors when deciding what kind of migraine treatment to prescribe you. This includes migraine frequency, how severe they are, and how much they impact your life, such as your ability to work. A doctor will also consider any other medical conditions you have. For example, if you have vascular disease (blood vessel disease), this will limit your migraine drug options.
Why is it that most people diagnosed with migraine aren’t on the right drug? As mentioned, PCPs are often not given enough training to treat the condition properly. But even among highly knowledgeable headache specialists, prescribing treatment involves some guesswork. “We practice medicine, and we make recommendations as doctors based on the scientific information that we have,” says Dr. Bernstein. “But to date, there have not been good predictors of who is going to respond to what drug.”
But to date, there have not been good predictors of who is going to respond to what drug.
Bernstein says that the number one problem headache specialists face in effectively treating migraine is the lack of biomarkers for the condition. Biomarkers are measures that show what is happening in an organism or cell at a particular time. They are used to measure the presence of a disease and the effects of treatment. Biomarkers have been used to predict, diagnose, and create far more targeted therapies for different types of cancer, as well as other conditions.
Genomic research has made tremendous progress in understanding how genes affect a person’s response to medications. Since the response to different drugs can be so variable and ineffective, migraine is a condition that needs more tailored treatment. Of the work at Mable, Rothaermel says, “That’s why we are bringing in the genomic component—we are combining the latest clinical evidence on drug effectiveness and then fill the remaining knowledge gaps with genetics.”
For people who experience migraine once a month or less or experience only mild disruption to their routine, doctors first recommend trying over-the-counter options like acetaminophen. Others are ibuprofen, aspirin, and naproxen, a class called non-steroidal anti-inflammatory drugs (NSAIDs). Common NSAID side effects are digestive issues such as nausea, diarrhea, and upset stomach. Taken at high doses, NSAIDs may also increase the risk for ulcers. The more considerable challenge with NSAIDs is that most people with migraine experience only partial or ineffective relief from their migraine.
If NSAIDs don’t help, or if you get migraine more often, doctors move on to prescription drugs. The side effects of these will depend on the drug class and your particular genetic predisposition. “Some people will clear a particular drug out of their system quickly before it can start working because of the person’s genetic makeup,” says Rothaermel. “Others will accumulate the drug in their body, so they get side effects.” Some of these drug classes include antidepressants, antihypertensives, anticonvulsants, barbiturates, ergotamines, narcotics, and calcitonin-gene related peptide (CGRP) antagonists. Side effects can be considerable, so they have to be weighed against the amount of migraine relief a drug provides you. The side effects can include fatigue, dizziness, mental slowness, insomnia, drowsiness, and dry mouth.
Another part of the challenge is that people with migraine often need to try a drug for months to see if it will work for them before trying a different medication that may or may not work for them. This problem is often exacerbated by the long waiting times to see a specialist.
The goals of migraine treatment are for you to have few or no migraine. The symptoms are mild and easily treated with acute medication when you have a migraine. And the larger goal is to have a vastly improved quality of life—to perform fully at work or school and to participate in activities with family and friends without fear of being struck down by a migraine. But this isn’t currently the case for most people with the condition.
In Mable’s study of people with migraine in the United Kingdom, when the patients followed the company’s recommendations, they reported 80 percent high treatment effectiveness—showing a 55 percent reduction in pain, versus 35 percent for people who were on the wrong drug. “For a migraine treatment to be classified as clinically effective, it needs to cross the 50 percent threshold,” Rothaermel explains.
We help match people with the right medication and push their treatment into the effective zone
“So the average of the population is actually not getting effective pain reduction in their current treatment. But we help match people with the right medication and push their treatment into the effective zone.” This can have a tremendous impact on your quality of life. “In our study population, we found it reduces the frequency of migraine as well, and the patients gained one extra day per week of normal life,” he adds.
To help find the best treatment for you, Mable sends you an online questionnaire to fill out, along with mailing a DNA test to your home. Once you’ve sent the test back, the company provides a personalized medication plan based on the latest clinical advances, as well as genetic insights. Mable will continue to send you the medication and follow up to see how well it’s working and allow you to log your symptoms and lifestyle practices or medical changes over time to enable continuously optimized care. “We maintain a long-term relationship with our members—we want to help people to be on the best possible treatment as their life or physiology changes, science advances, and new treatments emerge,” Rothaermel says.
While there are different companies now that deliver virtual care, others that offer personalized medicine via genetic reports, and still more who are online pharmacies, there are not currently any other companies like Mable that combine all three of them for people who have migraine. “We specialize in remote personalized medicine and deliver the treatment to you straight away. We tailor the solution to your genes and to your clinical presentation—effective treatment from the convenience of your home.”
Mable’s questionnaire can help you get some clarity if you’re unsure if you suffer from migraine. Or, if someone has already diagnosed you with migraine, but you’re not on a medication that’s helping enough, Mable can help you find a more effective treatment. Either way, get started today by taking Mable's quiz.
Photo by Paul Hanaoka on Unsplash.
1. Burch R, Rizzoli P, Loder E. The prevalence and impact of migraine and severe headache in the United States: Updated age, sex, and socioeconomic-specific estimates from government health surveys. Headache. 2021Jan;61(1):60-68. https://pubmed.ncbi.nlm.nih.gov/33349955/
2. Video interview with Dr. Kumeren Govender, CMO, Mable
3. American Migraine Foundation, “The Facts About Migraine.” https://americanmigrainefoundation.org/resource-library/migraine-facts/
4. Video interview with Dr. Roman Rothaermel, CEO, Mable
5. Lippincott Nursing Center, "What is a Biomarker?" https://www.nursingcenter.com/ncblog/november-2019/biomarker
6. University of Michigan Medicine, "Headaches: Should I Take Medicine to Prevent Migraines?" https://www.uofmhealth.org/health-library/ty7032
7. Healthline, "Over-the-counter medications for migraine attacks." https://www.healthline.com/health/over-the-counter-migraine-medication#otc-relief-options
8. RxList, "Migraine Medications." https://www.rxlist.com/migraine_medications/drugs-condition.htm