Saturday, 18 April 2020

The Migraine World Summit: Day 3

*This post is not sponsored by the Migraine World Summit but I am a participant in the Migraine World Summit affiliate program. This means I earn a commission from any qualifying purchases of the summit made through my link. http://www.migraineworldsummit.com/?afmc=1k

Chronic migraine patients – 1-2% population

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 hyper mobility
-        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?

A bit of everything:
-        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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