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CM is reversible. 26% CM patient’s remission in 2
years.
Chronic migraine diagnostic criteria:
-
3+ months
-
15+ headache days
-
8+ migraine
attacks
Risk factors for chronic migraine?
-
High frequency
migraine to begin with (frequent episodic)
-
Overuse of acute
meds (common trap!)
-
Anxiety/Depression
-
Life stressors
Chronic migraine attacks:
-
Longer and more
severe
-
Never really goes
away completely (lingering on)
-
Noise and light
sensitive all of the time (not just during attack)
-
Migraine never
completely turns off
Chronic migraine patients imaging: we can see areas of
the brain are “hyperexcitable”. The threshold for triggering an attack
becomes lower and more frequent over time.
Observe abnormalities in CM brain between attacks too
but when patients go from chronic to episodic these brain changes go away.
Discussed difficulty with CM diagnosis vs high
frequent episodic patients. Some patients transition in and out of CM (15 day
cut off isn’t always that helpful). Similar levels of disability are found in
CM patients and high frequent episodic patients.
What are the common traps of Chronic migraine?
- Not realising
they have it. Patients tend to remember the worst headaches and report those
and underreport mild ones and daily “background pain”. So important to keep a
headache diary in order to truly get the correct diagnosis and know how many
headache free days do you have?
-
MOH – People who
take pain meds for other conditions seem to be fine. It only seems to be an
issue for headache patients. Days of month is important not the tablets.
(Paracetamol & NSAID’s: 15 days a month, Opioids: 10 days although some
people could be at risk who take 6-8.
-
Not getting a
good acute response (finding an effective treatment that stops a migraine in
its tracks is really important).
-
Not taking a
preventative treatment (side effects, not taking it for long enough or
unrealistic expectations).
-
Too much caffeine
-
Wrong diagnosis?
Hemicrania continua (always one side of head) – use a completely different
treatment from migraine. Low spinal fluid pressure (difficult to diagnose –
woke up with a headache one day that never went away).
Help! Need more than 9 acute meds a month?!
-
Increase dose of
preventative
-
Add in another
preventative
-
Change preventative
medication
-
Botox,
topiramate, anti CGRP meds for CM.
Complimentary? Lifestyle factors are SO important too.
-
Exercise
-
Hydration
-
Eat well
-
Sleep routine
(check sleep apnea)
-
Caffeine intake
-
Triggers (easy to
blame yourself)
-
Natural
supplements (Magnesium, B2 and CoQ10)
CM comorbidities?
-
Sleep problems
-
Anxiety
-
Depression
Doing everything right but not getting better? Is it
the wrong diagnosis?
-
Sometimes it’s
necessary to hospitalize people and use IV meds to break the cycle (lidocaine
can be used and ketamine can be useful for people who have been overusing pain
meds).
Does acute med work?
Benchmark for this – clinical trials: pain
free/significant relief within 2 hours.
Take meds early! Interrupt the attack process before
central sensitization occurs (1hr after attack started).
Look at the dose of your triptans and the different
formulations available.
How to intervene early to prevent CM? (if you are high
frequent episodic)
-
Awareness of
where you are on the scale (episodic – chronic)
-
Lifestyle measures
-
Keep an eye on
number of medication days
-
See a doctor!
Its much easier to treat episodic migraine than
chronic migraine so important to treat and get a hold of before it progresses.
Hope for those with CM? – nothings worked
Have you got the correct diagnosis?
-
Hypnic headache
(usually in older patients) alarm clock headache wakes people in sleep most
night for a few hours.
-
MOH – wake up and
brain needs meds again.
-
New daily
persistent headache (NDPH)- underlying causes (50% of time) such as POTs.
Intractable attack that does
not stop:
-
Status migraine
(prior history of migraine)
-
Prolonged attack
(72hrs +)
Central sensitization – the brain learns to stay in
pain
Also referred to as refractory or intractable
migraine.
Issues with diagnosis? Labs normal. Normal MRI. Issue with stigma with
patients turning up at the emergency room or at doctor’s office because there
isn’t a clear test.
How common?
Research is missing on the exact numbers and occurrence rates but is usually
found within the chronic migraine population.
Chronic daily migraine? Usually something else going on such as low
pressure/high pressure headaches.
NDPH vs Status Migraine?
New daily persistent headache characteristics:
-
Stubborn and
difficult to treat
-
Clear start of
headache
-
Remember that day
-
A different type/
new headache from what they have experienced before
Low pressure headache (spontaneous type – not after
surgery):
-
Like finding a
needle in a haystack
-
Good idea to pull
people back who haven’t got better and check for leaks.
-
Patient profile
-tall, EDS, joint
-
Positional (worse
being upright)
-
Good history
taking is important
Risk factors for status migraine?
-
Chronic migraine
-
Frequent
headaches
-
Treating
headaches twice a week
-
Severe illness/
stressful life event
-
Obesity
-
Lower social
economic status
-
Lack of access to
education
-
Psychiatric
comorbidities
-
GI issues –
gastric shuts down during an attack
How to treat?
Dopamine receptor antagonist:
-
Infusion
-
Nerve blocks
-
Steroids can be
used but not great side effects
-
DHE (IV week inpatient
stay)
Acute treatment plan at home: 3 drug approach
1. NSAID (ibuprofen): works on central sensitisation in
brain
2. Triptan (sumatriptan): works on CGRP and vasodilation
3. Dopamine receptor antagonist (domperidone): works
directly on dopamine receptor and gastric stasis.
Pain provides no benefit to those who live with
chronic migraine. For the general population, pain serves a purpose. If you
have no pain, you will probably die.
Migraine helps you “too much” to survive.
Pain > alert > tell body something is wrong
Chronic pain > creating networks
Not always real migraine. Probably something else
going on too as brain can’t reset itself.
An example of this is seen in patients with phantom
limb syndrome. Chronic pain – patient continues to feel pain in limb that’s not
there after surgery.
CM- pain sometimes starts before the “trigger” itself.
Pain will start before you go to do something you don’t want to do.
This is a complex problem! Multi-disciplinary – not
just one drug.
Chronic pain syndromes:
-
Much higher
percentage of women than men.
Research study: when they put CGRP on the dura of rats
ONLY the female rats developed pain related behaviours. WOW!
How does pain change the brain?
Dynamic
FMRI: acute pain and chronic pain (CM)
Chronic migraine patients?
-
Might be dynamic
aka reversible changes with patient
-
FMRI study shows
permanent lesions
-
There appears to
be a threshold: after a certain amount of time, the changes are not reversible.
Pain cycle?
Acute moment > there is no cycle.
Migraine:
-
Inflammation in
the dura
-
Lingering attacks
-
One attack after
the other
-
Psychological
fear of the next attack
The fear of the next attack probably lowers the
threshold for the next attack creating a big problem.
Repetition: the body learns quickly. Brain does not
need much to go into attack and it becomes a vicious cycle. Sooner you stop
this cycle the better.
Research in Spain: Botox
-
After 1 year of
CM your response to preventative treatment is worse.
-
It takes longer
to respond to treatments so you need to stick with them
-
New antibodies
(CGRP) looks like people are responding a bit quicker with these
Severe chronic patients tend to be stable at around
20+ headache days and not much movement from there. Some patients seem to go in cycles. 20 attacks one
month and then 3 the next. Perhaps this is their system trying to correct
itself and not go into chronic.
How to break pain cycle?
-
Education
-
Choose the right
medication for that patient
-
Timing of acute
med
-
Avoid opioids
-
Take into account
comorbidities such as mood and sleep disorders (sleep is SO important)
What about cannabis?
-
“sexy receptor”
-
Doesn’t seem to
help CM patients
-
For some it helps
with anxiety
CM> Chronic pain conditions tend to develop other
chronic conditions. Inflammation – balance is lost in the body.
Final thoughts?
-
Make pain your
friend. Don’t fight it.
-
Don’t create
energy around migraine pain.
-
Get the right
help and follow your instinct. If you’re not happy with Dr, find another one.
- Chronic pain
usually starts after a big life stress – explore the psychological issues –
therapy etc.
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