Duren Michael Ready

What to Try When Nothing’s Working

When migraines fail to respond to the usual therapies, we can believe that we are either cursed or that we have missed something. Only one of these thoughts allows us to move forward. When we believe that we have missed something, we go back to the beginning. We repeat a history and physical looking for missed clues. We consider intervention previously tried and those untried. We adopt new approaches and mindsets that allow patients to become comfortable with being uncomfortable. When people say that they have done everything, it should be pointed out that it is unlikely that they have “done everything” because they have not found out what the next thing to do is. There are multiple interventions that have demonstrated benefit in refractory cases, and if these interventions fail to improve the condition, then it is always appropriate to adopt new perceptions and behaviors regarding pain. It is always too early to quit.

Sorting Through Headache Patterns

When headache is made a medical complaint, the headache is almost always migraine. However, the clinician should not be lulled into a sense of complacency. The first question rightly remains “Is this a primary (headache as disease) or secondary (headache as symptom)?” Red flags are helpful in identifying which headaches require further investigations and validated brief questionnaires have been developed for diagnosing migraine. Once a diagnosis is made, the patient should be told what is causing their headache and in the case of migraine that their headache is not the result of a serious threat to their life. It is important for the patient to accept that migraine alone is a sufficient explanation for their headache.

Looking for the Migraine Gene

There is a strong genetic component in developing migraine. Genetic markers have been identified for several rare autosomal dominant migraine types. Migraine with and without aura has been linked to various genetic variations.

The Migraine Team

The most productive approach to migraine management involves collaborative care. At its most fundamental form this collaboration recognizes the presence of two headache experts: the patient and the provider. The headache expert provider’s role is to insure that the headache expert patient is provided with sufficient guidance and feedback in order to facilitate successful management. Often other team members are involved (nurse, psychologist, dietician, and physical therapist). Family members can become important team members with proper education.

Changing Thoughts and Attitudes About Migraine

Patient’s thoughts regarding their migraines will greatly influence their capacity for action. When left alone to their own intuitive thoughts, patients will frequently catastrophize which ultimately facilitates migraine progression. Catastrophic thinking also exaggerates pain severity, impact, and patient helplessness. Adopting productive thoughts and attitudes will allow patients to reduce helplessness, symptom magnification, and negative ruminating. Cognitive restructuring allows for the more productive endeavor of changing the body’s response to stress rather than the often impossible goal of avoiding stress.

Migraine Is More Than “Just a Headache”

Migraine is always more than a headache. Migraine is comorbid with many common conditions including, depression, anxiety, bipolar disorder, insomnia, fibromyalgia, and epilepsy. Migraineurs have increased risk for cardiovascular disease. Migraine also creates difficulties with familial and social functioning when family, friends, and the workplace do not understand migraine.

When, How Much, and How Often

Medications have an important role in migraine management. It is important to understand the distinct role and limitations in migraine prevention, acute treatment, and rescue. Prevention should be started when migraine has an intolerable effect on functioning. Acute medication use should be focused on restoring function, but their use also needs to be limited because of the propensity to induce migraine progression. The frequent use of both acute and rescue medications indicate that prevention should have an increasingly prominent role. Successful migraine management will always include an acute treatment plan and a rescue plan, and frequently a preventive plan.

The Dos and Don’ts of Headache Diaries

Diaries are more than just haphazard markings in a record. They should be approached with specificity and intent. Daily recording should cover occurrences of interest, including but not limited to pain, sleep, diet, stress, activity, and potential triggers. Diaries can help fill in patient histories and allow for cultivation of a more effective treatment plan. Diaries can also have a role in assessing any change in a primary headache pattern that is suggestive of a condition that requires further investigation.

The Sensitive Migraine Brain

Continuous or frequent exposure to nociceptive input produces neuroplastic changes that allow pain perception with lower levels of stimulation. As the nervous system becomes more sensitized, receptive fields increase recruiting addition input that is perceived as pain. The allodynia (perception of pain with normal input) of an acute migraine attack is the result of a completely sensitized nervous system. Understanding central sensitization allows individuals to change their response to the input and take better control of their migraine pain.

Using Behavioral Therapy as a Treatment Foundation

As migraine transforms from episodic to chronic, there is a commensurate need for the incorporation of behavioral interventions. Behavioral intervention reduces reliance on passive interventions. Better outcomes are achieved when behavioral therapies are included with medications. Behavioral therapies include relaxation (biofeedback, guided imagery, meditation), exercise (yoga, aerobic), and schedule management (sleep, diet). Migraine patients should set aside time in their schedule for their daily behavioral treatment.