(Also Called 'Headache (Migraine)', 'Headache - Migraine')
What really happened to Serene Branson full interview
Stanford Hospital's Meredith Barad, MD, Discusses Migraine Headaches
(Also Called 'Headache (Migraine)', 'Headache - Migraine')
What is a migraine headache?
A migraine headache is a primary headache disorder that effects approximately 12% of the population. It is a headache that tends to recur in an individual and is moderate to severe if left untreated. It can be one sided, throbbing and aggravated by routine physical activity. It can be associated with light and sound and even smell sensitivity and many patients will become nauseated with it.. In a minority of patients there can be visual or sensory changes before, during or after the headache, known as auras.
Who is affected by migraines?
The National Headache Foundation estimates that nearly 30 million Americans suffer from migraines. Migraines occur about three times more frequently in women than in men. Each migraine can last from four hours to three days. Occasionally, it will last longer.
What causes a migraine?
The exact causes of migraines are unknown, although they are related to changes in the brain as well as to genetic causes. People with migraines may inherit the tendency to be affected by certain migraine triggers, such as fatigue, bright lights, weather changes and others.
For many years, scientists believed that migraines were linked to the expanding (dilation) and constriction (narrowing) of blood vessels on the brain’s surface. However, it is now believed that migraine is caused by inherited abnormalities in certain areas of the brain.
There is a migraine "pain center" or generator in the mid-brain area. A migraine begins when hyperactive nerve cells send out impulses to the blood vessels leading to the dilation of these vessels and the release of prostaglandins, serotonin and other inflammatory substances that cause the pulsation to be painful.
Certain brain cells that use serotonin as a messenger are involved in controlling mood, attention, sleep, and pain. Therefore, chronic changes in serotonin can lead to anxiety, panic disorder, and depression.
What triggers a migraine?
Many migraines seem to be triggered by external factors. Migraine sufferers can help the physician identify these triggers. Possible triggers include:
- Emotional stress is one of the most common triggers of migraine headache. Migraine sufferers generally are highly affected by stressful events. During stressful events, certain chemicals in the brain are released to combat the situation (know as the "flight or fight" response). The release of these chemicals can provoke migraine. Repressed emotions surrounding stress, such as anxiety, worry, excitement and fatigue can increase muscle tension and dilated blood vessels can intensify the severity of migraine.
- Sensitivity to specific chemicals and preservatives in foods. Certain foods and beverages, such as aged cheese, alcoholic beverages, and food additives such as nitrates (in pepperoni, hot dogs, luncheon meats) and monosodium glutamate (MSG, commonly found in Chinese food) may be responsible for triggering up to 30% of migraines.
- Caffeine. Excessive caffeine consumption or withdrawal from caffeine can cause headaches when the caffeine level abruptly drops. The blood vessels seem to become sensitized to caffeine, and when caffeine is not ingested, a headache may occur. Caffeine itself is often helpful in treating acute migraine attacks.
- Changing weather conditions such as storm fronts, barometric pressure changes, strong winds or changes in altitude
- Menstrual periods
- Excessive fatigue
- Missing meals
- Changes in normal sleep pattern
Are migraines hereditary?
Yes, migraines have a tendency to run in families. Four out of 5 migraine sufferers have a family history of migraines. If one parent has a history of migraines, the child has a 50% chance of developing migraines, and if both parents have a history of migraines, the risk jumps to 75%.
What are the symptoms of migraines?
The symptoms of migraine headaches can occur in various combinations and include:
Type of pain
The pain of a migraine can be described as a pounding or throbbing. The headache often begins as a dull ache and develops into throbbing pain. The pain is usually aggravated by physical activity.
Severity/intensity of pain
The pain of a migraine can be described as mild, moderate, or severe. Untreated the headache will become moderate to severe
Location of pain
The pain can shift from one side of the head to the other, or it can affect the front of the head or feel like it’s affecting the whole head.
Duration of pain
Most migraines last about 4 hours, although severe ones can last up to a week.
Frequency of headachesRead More...
|Classification and external resources|
The pain of a migraine headache can be debilitating.
|DiseasesDB||8207 (Migraine) |
|eMedicine||neuro/218 neuro/517 emerg/230 neuro/529|
Migraine is a chronic disorder characterized by recurrent moderate to severe headaches. It is believed to be a neurovascular disorder. The word derives from the Greek ἡμικρανία (hemikrania), "pain on one side of the head", from ἡμι- (hemi-), "half", and κρανίον (kranion), "skull".
A typical migraine headache is unilateral (affecting one half of the head) and pulsating in nature, lasting from 2 to 72 hours. Symptoms include nausea, vomiting, photophobia (increased sensitivity to light) and phonophobia (increased sensitivity to sound); the symptoms are generally aggravated by routine activity. Approximately one-third of people who suffer from migraine headaches perceive an aura: transient visual, sensory, language, or motor disturbance which signal that the migraine will occur soon.
Migraines are related to a mix of environmental and genetic factors. About two-thirds of cases run in families. Fluctuating hormone levels may also play a role: migraine affects approximately equal numbers of girls and boys before puberty, but about two to three times more women than men. Propensity to migraine headache sometimes disappears during pregnancy, but in some women, migraines may become more frequent. The underlying mechanisms of migraines are unknown. The most supported theory is that migraine is related to hyperexcitability of the cerebral cortex and/or abnormal control of pain neurons in the trigeminal nucleus of the brainstem.
Initial recommended management is with analgesics for the headache, an antiemetic for the nausea, and the avoidance of triggers. Specific agents such as triptans or ergotamines may be used by those for whom simple analgesics are not effective. Globally, more than 10% of the population is affected by migraine at some point in life.
Signs and symptoms
Migraines typically present with self–limited, recurrent severe headache associated with autonomic symptoms. About 15-30% of people experience migraines with an aura and those who have migraines with aura also frequently have migraines without aura. The severity of the pain, duration of the headache, and frequency of attacks is variable. A migraine lasting longer than 72 hours is termed status migrainosus. There are four possible phases to a migraine, although not all the phases are necessarily experienced:
- The prodrome, which occurs hours or days before the headache
- The aura, which immediately precedes the headache
- The pain phase, also known as headache phase
- The postdrome
Prodromal or premonitory symptoms occur in ~60% of those with migraines with an onset of two hours to two days before the start of pain or the aura  These symptoms may include a wide variety of phenomena including: altered mood, irritability, depression or euphoria, fatigue, craving for certain food, stiff muscles (especially in the neck), constipation or diarrhea, and sensitivity to smells or noise. This may occur in those with either migraine with aura or migraine without aura.
An aura is a transient focal neurological phenomena that occurs before or during the headache. They appear gradually over a number of minutes and generally last fewer than 60 minutes. Symptoms can be visual, sensory or motor in nature and many people experience more than one. Visual effects are the most common, occurring in up to 99% of cases and exclusively in more than half. Vision disturbances often consists of a scintillating scotoma (an area of partial alteration in the field of vision which flickers.) These typically start near the center of vision and than spread out to the sides with zigzaging lines which have been described to look like fortifications or walls of a castle. Usually the lines are in black and white but some people also see colored lines. Some people loss part of their field of vision known as hemianopsia while other experience blurring.
Sensory aura are the second most common occurring in 30-40% of people with auras. Often a feeling of pins-and-needles begins on one side in the hand and arm and spreads to the nose-mouth area on the same side. Numbness usually occurs after the tingling has passed with a loss of position sense. Other symptoms of the aura phase can include: speech or language disturbances, world spinning, and less commonly motor problems. Motor symptoms indicate that this is a hemiplegic migraine and weakness often last longer than one hour unlike other auras. Rarely an aura may occur without a subsequent headache, known as a silent migraine.
Classicly the headache is unilateral, throbbing, and moderate to severe in intensity. It usually comes on gradually and is aggravated by physical activity. In more than 40% of cases however the pain may be bilateral and neck pain is commonly associated. Bilateral pain is particularly common in those who have migraines without an aura. Less commonly pain may occur primarily in the back or top of the head. The pain usually lasts 4 to 72 hours in adults however in young children frequently lasts less than 1 hour. The frequency of attacks is variable, from a few in a lifetime to several a week, with the average being about one a month.
The pain is frequently accompanied by nausea, vomiting, sensitivity to light, sensitivity to sound, sensitivity to smells, fatigue and irritability. In a basilar migraine common effects include: a sense of the world spinning, lightheadedness, and confusion. Nausea occurs in almost 90 percent of people and vomiting occurs in about one-third. Many thus seek a dark and quiet room. Other symptoms may include: blurred vision, nasal stuffiness, diarrhea, frequent urination, pallor, or sweating. Swelling or tenderness of the scalp may occur as can neck stiffness. Associated symptoms are less common in the elderly.
The effects of migraine may persist for some days after the main headache has ended; this is called the migraine postdrome. Many report a sore feeling in the area where the migraine was, and some report impaired thinking for a few days after the headache has passed. The patient may feel tired or "hungover" and have head pain, cognitive difficulties, gastrointestinal symptoms, mood changes, and weakness. According to one summary, "Some people feel unusually refreshed or euphoric after an attack, whereas others note depression and malaise."
The diagnosis of abdominal migraines is controversial. Some evidence indicates that recurrent episodes of abdominal pain in the absence of a headache may be a type of migraine. Or are at least a precursor to migraines. These episodes of pain may or may not follow a migraine like prodrome and typically last minutes to hours. They often occur in those with either a personal or family history of typical migraines. Other syndromes that are believed to be precursors include: cyclical vomiting syndrome and benign paroxysmal vertigo of childhood.
The underlying cause of migraines is unknown however they are believed to be related to a mix of environmental and genetics factors. They do run in families in about two-thirds of cases and rarely occur due to a single gene defect. A number of psychological conditions are associated including: depression, anxiety, and bipolar disorder as are many biological events or triggers.
Studies of twins indicate a 34 to 51 percent genetic influence of likelihood to develop migraine headaches. This genetic relationship is stronger for migraines with aura than for migraines without aura. A number of specific variants of genes increase the risk by a small to moderate amount.
Single gene disorders that result in migraines are rare. One of these is known as familial hemiplegic migraine, a type of migraine with aura, which is inherited in a autosomal dominant fashion. It is related to disorders of gene coding for proteins involved in ion transport. Another is CADASIL syndrome or cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.
Migraines may be induced by triggers, with some reporting it as an influence in a minority of cases and others the majority. Many things have been labeled as triggers, however the strength and significance of these relationships are uncertain. A trigger may occur up to 24 hours prior to the onset of symptoms.
Common triggers quoted are stress, hunger, and fatigue (these equally contribute to tension headaches). Migraines are more likely to occur around menstruation. Other hormonal influences, such as menarche, oral contraceptive use, pregnancy, perimenopause, and menopause, also play a role. These hormonal influences seem to play a greater role in migraine without aura. Migraines typically do not occur during the second and third trimesters or following menopause.
Reviews of dietary triggers have found that evidence, mostly relying on subjective assessments and is not rigorous enough to prove or disprove any particular triggers. Regarding specific agents there does not appear to be evidence for an effect of tyramine on migraine and while monosodium glutamate (MSG) is frequently reported as a dietary trigger evidence does not consistently support this.
Potential triggers in the indoor and outdoor environment concluded the overall evidence was of poor quality, but nevertheless suggested people with migraines take some preventative measures related to indoor air quality and lighting. While once believed to be more common in those of high intelligence this does not appear to be true.
Migraines are believed to be a neurovascular disorder.
The phenomenon known as cortical spreading depression, which is associated with the aura of migraine, has been theorized as a possible cause of migraines. In cortical spreading depression, neurological activity is initially activated, then depressed over an area of the cerebral cortex. This situation has been suggested to result in the release of inflammatory mediators leading to irritation of cranial nerve roots, most particularly the trigeminal nerve, which conveys the sensory information for the face and much of the head. This theory is, however, speculative, without any supporting evidence, and there are indeed cogent arguments against it.
Migraines were once thought initiated exclusively by problems with blood vessels, but some believe the vascular changes of migraines are secondary to brain dysfunction though, so far, evidence does not support this idea. Dodick summed it up: "There is no disputing the role of the central nervous system in the susceptibility, modulation and expression of migraine headache and the associated affective, cognitive, sensory, and neurological symptoms and signs. However, to presume that migraine is always generated from within the central nervous system, based on the available evidence, is naïve at best and unscientific at worst.The emerging evidence would suggest that just as alterations in neuronal activity can lead to downstream effects on the cerebral blood vessel, so too can changes within endothelial cells or vascular smooth muscle lead to downstream alterations in neuronal activity. Therefore, there are likely patients, and/or at least attacks in certain patients, where primarily vascular mechanisms predominate." Some have even attempted to show that vascular changes are of no importance in migraine, but this claim is unsubstantiated and has not been supported by scientific evidence. 'If we swing between vascular and neurogenic views of migraine, it is probably because both vascular and neurogenic mechanisms for migraine exist and are important'- J Edmeads
The exact cause of the head pain which occurs during a migraine is subject to debate. Some evidence supports a role for the sensory nerves that surround blood vessels. The potential candidates vessels include: dural arteries, pial arteries and extracranial arteries such as those of the scalp. The role of vasodilatation of the extracranial arteries, in particular, is believed to be signficant.
The diagnosis of a migraine is based on signs and symptom. Imaging test are occasionally performed to exclude other causes of headaches. It is believed that a substantial number of people with the condition have not been diagnosed.
- Five or more attacks — for migraine with aura, two attacks are sufficient for diagnosis.
- Four hours to three days in duration
- Two or more of the following:
- Unilateral (affecting half the head);
- "Moderate or severe pain intensity";
- "Aggravation by or causing avoidance of routine physical activity"
- One or more of the following:
If someone has two of the following: photophobia, nausea, or unable to work / study for a day the diagnosis is more likely. In those with four out of five of the following: pulsating headache, duration of 4–72 hours, pain on one side of the head, nausea, or symptoms that interfere with the persons life, the probability that this is a migraine is 92%. In those with less than three of these symptoms the probability is 17%.
Migraines where first comprehensively classified in 1988. The International Headache Society most recently updated their classification of headaches in 2004. According to this classification migraines are primary headaches along with tension-type headaches and cluster headaches, among others.
Migraines are divided into seven subclasses (some of which include further subdivisions):
- Migraine without aura, or "common migraine", involves migraine headaches that are not accompanied by an aura
- Migraine with aura, or "classic migraine", usually involves migraine headaches accompanied by an aura. Less commonly, an aura can occur without a headache, or with a nonmigraine headache. Two other varieties are familial hemiplegic migraine and sporadic hemiplegic migraine, in which a person has migraines with aura and with accompanying motor weakness. If a close relative has had the same condition, it is called "familial", otherwise it is called "sporadic". Another variety is basilar-type migraine, where a headache and aura are accompanied by difficulty speaking, vertigo, ringing in ears, or a number of other brainstem-related symptoms, but not motor weakness.
- Childhood periodic syndromes that are commonly precursors of migraine include cyclical vomiting (occasional intense periods of vomiting), abdominal migraine (abdominal pain, usually accompanied by nausea), and benign paroxysmal vertigo of childhood (occasional attacks of vertigo).
- Retinal migraine involves migraine headaches accompanied by visual disturbances or even temporary blindness in one eye.
- Complications of migraine describe migraine headaches and/or auras that are unusually long or unusually frequent, or associated with a seizure or brain lesion.
- Probable migraine describes conditions that have some characteristics of migraines, but where there is not enough evidence to diagnose it as a migraine with certainty (in the presence of concurrent medication overuse).
- Chronic migraine is a complication of migraines, and is a headache that fulfills diagnostic criteria for migraine headache and occurs for a greater time interval. Specifically, greater or equal to 15 days/month for longer than 3 months.
Other conditions that can cause similar symptoms to a migraine headache include: temporal arteritis, cluster headaches, acute glaucoma, meningitis and subarachnoid hemorrhage. Temporal arteritis is typically in people over 50 years old and presents with tenderness over the temple, cluster headaches presents with one sided nose stuffiness, tears and severe pain around the orbits, acute glaucoma is associated with vision problems, menigitis with fevers, and subaracchnoid hemorrhage with a very fast onset. Tension headaches typically occur on both sides, are not pounding, and are less disabling.
Preventive treatments of migraines include: medications, nutritional supplements, lifestyle alterations, and surgery. Prevention is recommended in those who have headaches more the two days a week, cannot tolerate the medications used to treat acute attacks, or those with severe attacks that are not easily controlled.
The goals is to reduce the frequency, painfulness, and/or duration of migraines, and to increase the effectiveness of abortive therapy. Another reason prevention is to avoid medication overuse headache. This is a common problem and can result in chronic daily headache.
Preventive migraine medications are considered effective if they reduce the frequency or severity of migraine attacks by at least 50%. Guidelines are fairly consistent in rating topiramate, divalproex/sodium valproate, propranolol, and metoprolol as having the highest level of evidence for first-line use. Their recommendations varied substantially however for gabapentin. Timolol is also effective for migraine prevention and in reducing migraine attack frequency and severity, while frovatriptan is effective for prevention of menstrual migraine. Botox has been found to be useful in those with chronic migraines but not those with episodic ones.
Acupuncture is effective in the treatment of migraines. The use of "true" acupuncture is not more efficient than sham acupuncture, however, both "true" and sham acupuncture appear more effective than routine care, with fewer adverse effects than prophylactic drug treatment. Chiropractic manipulation, physiotherapy, massage and relaxation might be as effective as propranolol or topiramate in the prevention of migraine headaches; however, the research had some problems with methodology. There is some tentative evidence of benefit for: magnesium, coenzyme Q(10), riboflavin, vitamin B(12), fever-few, and butterbur, although better quality trials must be done to confirm these preliminary results.
Devices and surgery
Medical devices, such as biofeedback and neurostimulators, have some advantages in the migraine prevention, mainly when common antimigraine medications are contraindicated or in case of medication over use. Biofeedback helps people be conscious of some physiologic parameters to control them and try to relax and may be efficient for migraine treatment. Neurostimulation uses implantable neurostimulators similar to pacemakers for the treatment of intractable chronic migraines with encouraging results for severe cases. Migraine surgery, which involves decompression of certain nerves around the head and neck, may be an option in certain people who do not improve with medications.
There are three main aspects of treatment: trigger avoidance, acute symptomatic control, and pharmacological prevention. Medications are more effective if used earlier in an attack. The frequent use of medications may result in medication overuse headache, in which the headaches become more severe and more frequent. This may occur with triptans, ergotamines, and analgesics, especially narcotic analgesics.
Recommended initial treatment for those with mild to moderate symptoms are simple analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) or the combination of acetaminophen, acetylsalicylic acid, and caffeine. A number of NSAIDs have evidence to support their use. Ibuprofen has been found to provide effective pain relief in about half of people. Diclofenac has been found effective.
Aspirin can relieve moderate to severe migraine pain, with similar effectiveness to sumatriptan. Ketorolac is available in an intravenous formulation. Paracetamol (also known as acetaminophen), either alone or in combination with metoclopramide, is another effective treatment with a low risk of adverse effects. In pregnancy acetaminophen and metoclopramide are deemed safe as are NSAIDs until the third trimester.
Triptans such as sumatriptan are effective for both pain and nausea in up to 75% of people. They are the initially recommended treatment for those with moderate to severe pain or those with milder symptoms who do not respond to simple analgesics. The different forms available include oral, injectable, nasal spray, and oral dissolving tablets. In general, all the triptans appear equally effective, with similar side effects. However, individuals may respond better to specific ones. Most side effects are mild, such as flushing; however, rare cases of myocardial ischemia have occurred. They are thus not recommended for people with cardiovascular disease. They are not addictive, but may cause medication overuse headaches if used more than 10 days per month.
Ergotamine and dihydroergotamine are older medications still prescribed for migraines, the latter in nasal spray and injectable forms. They appear equally effective to the triptans, are less expensive, and experience adverse effects that typically are benign. In the most debilitating cases, such as those with status migrainosus, they appear to be the most effective treatment option.
Intravenous metoclopramide or intranasal lidocaine are other potential options. Metoclopramide is the recommended treatment for those who present to the emergency department. A single dose of intravenous dexamethasone, when added to standard treatment of a migraine attack, is associated with a 26% decrease in headache recurrence in the following 72 hours. Spinal manipulation for treating an ongoing migraine headache is not supported by evidence. It is recommended that opioids and barbiturates not be used.
Long term prognosis in people with migraines is variable. Most people with migraines have periods of lost productivity due to their disease however typically the condition is fairly benign and is not associated with an increased risk of death. There are four main patterns to the disease: symptoms can resolve completely, symptoms can continue but become gradually less with time, symptoms may continue at the same frequency and severity, or attacks may become worse and more frequent.
Migraines with aura appears to be a risk factor for ischemic stroke doubling the risk. Being a young adult, being female, using hormonal contraception, and smoking further increases this risk. There also appears to be an association with cervical artery dissection. Migraines without aura do not appear to be a factor. The relationship with heart problems is inconclusive with a single study supporting an association. Overall however migraines do not appear to increase the risk of death from stroke or heart disease. Preventative therapy of migraines in those with migraines with auras may prevent associated strokes.
Worldwide, migraines affect more than 10% of people. In the United States, about 6% of men and 18% of women get a migraine in a given year, with a lifetime risk of about 18% and 43% respectively. In Europe, migraines affect 12–28% of people at some point in their lives with about 6–15% of adult men and 14–35% of adult women getting at least one yearly. Rates of migraines are slightly lower in Asia and Africa than in Western countries. Chronic migraines occur in approximately 1.4 to 2.2% of the population.
These figures vary substantially with age: migraines most commonly start between 15 and 24 years of age and occur most frequently in those 35 to 45 years of age. In children, about 1.7% of 7 year olds and 3.9% of those between 7 and 15 years have migraines, with the condition being slightly more common in boys before puberty. During adolescence migraines becomes more common among women and this persists for the rest of the lifespan being two times more common among elderly females than males. In women migraines without aura or is more common than migraines with aura, however in men the two types occir with similar frequency.
An early written description consistent with migraines is contained in the Ebers papyrus, written around 1200 BC in ancient Egypt. In 400 BC, Hippocrates described the visual aura that can precede the migraine headache, and the relief that can occur through vomiting. Aretaeus of Cappadocia is credited as the "discoverer" of migraines because of his second-century description of the symptoms of a unilateral headache associated with vomiting, with headache-free intervals in between attacks.
Galenus of Pergamon used the term "hemicrania" (half-head), from which the word "migraine" derives. He thought there was a connection between the stomach and the brain because of the nausea and vomiting that often accompany an attack. For relief of migraine, Andalusian-born physician Abulcasis, also known as Abu El Qasim, suggested application of a hot iron to the head or insertion of garlic into an incision made in the temple.
Ebn Sina (Avicenna) described migraine in his textbook "El Qanoon fel teb" as "... small movements, drinking and eating, and sounds provoke the pain... the patient cannot tolerate the sound of speaking and light. He would like to rest in darkness alone."
Abu Bakr Mohamed Ibn Zakariya Râzi noted the association of headache with different events in the lives of women, "...And such a headache may be observed after delivery and abortion or during menopause and dysmenorrhea."
In Bibliotheca Anatomica, Medic, Chirurgica, published in London in 1712, five major types of headaches are described, including the "Megrim", recognizable as classic migraine. The term "classic migraine" is no longer used, and has been replaced by the term "migraine with aura" Graham and Wolff (1938) published their paper advocating ergotamine tartrate for relieving migraine. Later in the 20th century, Harold Wolff (1950) developed the experimental approach to the study of headache and elaborated the vascular theory of migraine, which has come under attack as the pendulum again swings to the neurogenic theory. Recently, there has been renewed interest in Wolff's vascular theory of migraine led by Elliot Shevel, a South African headache specialist, who has published a number of articles providing compelling evidence that Wolff was correct.
Trepanation, the deliberate and (usually) nonfatal drilling of holes into a skull, was practiced 9,000 years ago and earlier. Some scholars have (controversially) speculated this drastic procedure might have been a migraine treatment, based on cave paintings and on the fact that trepanation was a historical migraine treatment in 17th-century Europe.
Society and culture
Migraines are a significant source of both medical costs and lost productivity. It has been estimated that they are the most costly neurological disorder in the European Community, costing more than €27 billion per year. In the United States direct costs have been estimated at 17 billion USD. Nearly of tenth of this cost is due to the cost of triptans. Indirect costs are around 15 Billion USD of which missed work makes up the greatest component. In those who do attend work with a migraine effectiveness is decreased by around a third. Negative impacts also frequently occur for a persons family.
Calcitonin gene related peptides (CGRPs) have been found to play a role in the pathogenesis of the pain associated with migraine. CGRP receptor antagonists, such as olcegepant and telcagepant, have been investigated both in vitro and in clinical studies for the treatment of migraine. In 2011, Merck stopped phase III clinical trials for their investigational drug telcagepant. Transcranial magnetic stimulation also shows promise.
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