Insights into headache 2022

KEYWORDS:

• Migraine
• COVID-19
• long-Covid headache
• CGRP(r) monoclonal antibodies
• gepants
• ditans
• education
• telemedicine

1. Introduction

The pandemic that began in late 2019 has shocked all Public Health structures, causing over 5,6 million total deaths, and has profoundly re-oriented clinical and basic research toward the knowledge of the mechanisms and multi-organ pathologies that derives from this devastating illness, producing in 24 months a surge in scientific production specifically oriented on COVID-19 of over 0.22 million published peer-reviewed papers. During this pandemic new issues have risen, regarding not only the value of headache in COVID-19 symptomatology but also the persistence of the so-called long-COVID headache and the rebound headache post-vaccination [1–3].

All these issues, combined with the still incomplete management of migraine globally, are here the motive for an analysis of the unmet needs and the existing barriers, and to promote action toward migraine patients.

2. Barriers

The pandemic has produced a slowdown in the spread of innovative migraine therapies and a temporary impoverishment of the availability of human resources dedicated to the treatment of headaches, due to the emergency reorganization of health facilities [4–6].

Now that we begin to look with reasonable certainty into the future of this multidisciplinary sub-specialty, that is headache medicine, we are rejoining a series of issues that are no longer new but still unresolved. Among them, the first is the access to care for patients eligible for treatment with monoclonal antibodies, being this the cornerstone in the control of this disabling and chronic painful pathology [7].

Headache research has been positively reinvigorated, after decades of stagnation, by the discovery of CGRP as a key pathophysiological target in migraine.

What can we see then in the year 2022 for the migraine area, having in our availability the monoclonal antibodies for CGRP or its receptor (CGRP (r)), the second and third generation of gepants as CGRP receptor antagonists and ditans, agonists of 5HT_1F? Research articles, post-hoc analyzes of Randomized Control Trials, Real World Evidences will be able to better clarify the mechanisms, drug-drug interactions, safety and long-term therapeutic adherence of these new drugs.

But among the unmet needs we still find an incomplete awareness on migraine, a growing but insufficient education of new human resources dedicated to it, a deeper perception in the general population of the awareness that migraines can and must be treated to avoid the chronicity risk, and the knowledge of the incomplete valorization of headaches as a data to be offered to stakeholders to improve efficiency and multiply the public health services dedicated to it [8–11].

Furthermore, Long-Covid Headache and the post-traumatic headache are clinical areas involving a large population still widely underestimated but with psycho-social implications and the need for long care still to be quantified, and are still to be subjected to rigorous studies on the mechanisms and on the clinical-therapeutic profile [1,12,13].

3. Solutions

Among the solutions that can be concretely hypothesized in 2022, the most important one is the involvement of general medicine in the management of the migraine population which presses beyond belief to the Public Health structures dedicated to them. The economic analysis of the costs of this painful pathology shows a pitiless picture considering the results obtained, other than the disability and the impact on labor productivity [14,15]. The unexpressed potential of the General Practitioners network could take charge of low-frequency episodic migraines, while local specialists not specifically dedicated to headaches could act as a filter, taking charge of high-frequency migraines in the first instance, thus reserving for hospitals and academic the management of chronic, resistant, refractory forms [16,17].

The cultural education to migraine also passes through the extension of the migraine culture especially through general medical journals, a reading ground for non-migraine specialists, in order not to leave this competence in the context of qualified but numerically insufficient experts.

Last but not least, an expansion of Schools dedicated to post-academic clinical training in headaches is already operational in the three international scientific societies dedicated to headaches, the European Headache Federation, the International Headache Society and the American Headache Society, but still quantitatively insufficient to adequately cover the demand for training in excellence in this subspecialty.

4. Projects

What we have been forced to do in the pandemic, the safe management of our patients remotely, will be the standard for the management of therapies and the progress of disease control in the primary headaches area. It is understood that with the appropriate and mandatory safety procedures, the first visits must be carried out in person, as the physical approach to the patient is essential for the completion of a correct medical history and physical examination. Teleconsultations will and should be conveniently used for the remote follow-up of therapies [18,19].

In conclusion, if we are able to seize the organizational opportunities that the pandemic has forced us to adopt, we will be able to improve the care performance toward patients with primary headaches, also helped by the new pharmacological classes that reduce medical intervention in hospitalized areas such as CGRP (r) MoAbs [20], considering that this is not a first-line treatment [17].

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The paper was not funded.