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Are Migraines Considered Chronic Pain

Vascular Changes In Migraine

The 4 Phases of a Migraine Headache

While it may be reasonable at this point to discard vasodilation as a direct cause of migraine, more studies are needed before eliminating blood vessels from the list of factors contributing to the pathophysiology of migraine. Both normal and pathological events occurring within and between vascular cells could mediate bi-directional communication between vessels and the nervous system, without the need for changes in vascular tone . Blood vessels consist of a variety of cell types that both release and respond to numerous mediators including growth factors, cytokines, adenosine triphosphate , and nitric oxide , many of which can sensitize trigeminal neurons. In addition, the majority of genomic loci identified in GWAS to be associated with migraine without aura are involved in pathways associated with vascular function . Hence, it could still be possible that blood vessels play a role in migraine pathophysiology in the absence of vasodilation.

The postdrome phase

About 80% of migraine patients report at least one non-headache symptom following the end of their headache, while the disability scores remain high . The migraine postdrome is the least studied and least understood phase of migraine. Only recently, functional imaging showed widespread reduction in brain-blood flow in the postdrome, but at least some persistent blood flow increase in the occipital cortex .

Brain Changes In The Migraineur: Is It A Brain Evolutive Process

Beyond functional changes, differences in the structural brain integrity, involving both the white and gray matter, which evolve over time, have been reported by several studies between migraine patients and controls.

A number of studies showed cortical structural changes in migraine patients (detail reviews can be found here . To this end there are conflicting results to whether there is cortical thinning or cortical thickening in the migraineurs brain. Such changes include, increased thickening in the somatosensory cortex of patients with migraine that does not differ between patients with and without aura, decreased grey matter in cingulate cortex and reduced volume of the medial prefrontal cortex, atypical age-related cortical thinning in episodic migraine, increased thickness of the left middle frontal sulcus and the left temporo-occipital incisure, as well as, reduced thickness of the left superior frontal sulcus and the left precentral sulcus . A more recent multi-centre 3T MRI study utilising a large number of migraine patients demonstrated significant clusters of thinner cortex in the patients with migraine compared with control subjects .

How Are Migraines Treated

Migraines that are severe, frequent or accompanied by neurological symptoms are best treated preventively, usually with a combination of dietary modification, lifestyle changes, vitamins and daily prescription medications. Most of our best preventive medications are often used for other medical purposes as well the majority are blood pressure drugs, antidepressants or epilepsy medications. Individual headache attacks are best treated early, often with one or more of the following types of medications: triptans, nonsteroidal anti-inflammatory drugs , anti-emetics , and sometimes narcotics or steroids.

Migraines typically last a few hours to a couple of days and respond well to specific treatments. However, in some patients, the migraine is particularly severe and long-lasting and may even become chronic, occurring continuously for weeks, months or even years. If improperly managed or left untreated, intermittent migraines may essentially transform into a chronic daily headache, with continuous and smoldering symptoms that periodically erupt into a “full-blown” migraine. This condition is extremely difficult to treat.

At the Johns Hopkins Headache Center, located at the Johns Hopkins Bayview Medical center, we have expert physical therapists, nutritionists and psychologists who work closely with our neurologists to help manage patients with frequent migraines. Biofeedback and relaxation techniques are available to complement our standard medical treatments.

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Economic Impact Of Migraine

The economic cost resulting from migraine-related loss of productive time in the US workforce is more than $13 billion per year, most of which is in the form of reduced work productivity. In the American Migraine Study, more than 85% of women and 82% of men with severe migraine had some headache-related disability. Migraineur men required 3.8 bed-rest days per year, whereas women required 5.6 bed-rest days per year.

How Common Are The Two Conditions

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Episodic migraine is more common than chronic migraine. According to the American Migraine Foundation, about 12 percent of Americans have migraine. The Migraine Research Foundation adds that migraine has a higher prevalence in women than in men . Studies have found that chronic migraine affects between 3 and 5 percent of Americans.

Prevalence can also vary by race and ethnicity, but this may be due to socioeconomic factors, health inequities, and other variables that may affect stress and anxiety.

For example, a 2021 study noted that unadjusted analyses in earlier research showed that the prevalence of chronic migraine was highest among Black and African American people, Latinx people, and people with low household incomes.

However, after adjusting for multiple variables, the same research found that only household income was linked with higher rates of chronic migraine. This may be because of cost concerns around care.

Women in their 40s appear most likely to experience chronic migraine. This points to a hormonal factor in migraine development. In fact, the National Headache Foundation says that 60 percent of women have migraine attacks around their menstrual cycle.

Other factors related to a higher prevalence of chronic migraine include:

  • obesity

third leading cause of disability in people under the age of 50, and its the second most common cause of lost work days.

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What Is Chronic Migraine

Chronic migraine is defined as having headache on at least 15 days per month, with eight of these having migraine symptoms, for at least three months. People who have fewer headache days with migraine symptoms have episodic migraine.

If you have chronic migraine your symptoms may include:

  • frequent headache
  • increased sensitivity to light, sound or smells
  • nausea
  • vomiting .

Other symptoms include aura , dizziness and vertigo .

Proving Your Migraines Are Disabling

There are no laboratory tests to prove a headache is a migraine or so severe that it’s disabling, and a physical examination probably won’t be able to uncover anything wrong with you. The SSA will need to rely on your statements about the severity of your migraines and your doctors’ reports documenting your symptoms. The SSA, however, does not have to believe your claims of how severe your migraines are. That’s why medical documentation is so important in migraine cases.

In order for SSA medical consultants to determine whether the severity and frequency of your migraines are sufficient to create a disability, they will want to see the following documentation.

  • Reports by the doctor who primarily treats your condition, such as a neurologist, pain management specialist, or headache specialist
  • Specific documentation of your daily symptoms and migraines, so as to measure the frequency of occurrence, duration, location, and intensity of your migraines as well as their effects on your daily living activities, and
  • Documentation of medications taken and treatments tried, whether successful or unsuccessful, and any side effects you experienced from them.

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An Adolescent Rating Scale

I continue to use the adult scale today and now proposes an adolescent chronic migraine refractory scale. Points for the adolescent patient would be tallied as follows:

  • Refractory to preventives = 1 point
  • Refractory to abortives = 1 point
  • Headache occurrence greater than one year = 1 point
  • Number of headaches per month if 25 or more days, on average = 1 point
  • Significant comorbidities if at least one are present = 1 point
  • Psychiatric comorbidities: severe Axis I, or a strong indication that Axis II may be present = 1 point.
  • Disability defined as an inability to go to school for at least 2 months due to headache , or a significant decrease in functioning = 1 point
  • Severe family dysfunction, which may include a personality disorder pathology in the primary parent = 1 point

With this scale, a total of 8 points would be possible, ranking as such:

  • 2 to 4 points = mild RCM
  • 5 to 6 points = moderate RCM
  • 7 to 8 points = severe RCM.

Migraine And Vascular Disorders

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Migraine and ischemic strokes reportedly occur in 1.4-3.3 per 100,000 population and account for 0.8% of total strokes. Milhaud et al showed that in young patients with active migraine who had suffered ischemic stroke, risk factors such as patent foramen ovale, female gender, and oral contraceptive use were much more likely to be present posterior circulation stroke was characteristic. Surprisingly, older patients characteristically lacked vascular risk factors .

Even in patients older than 45 years, women with migraine are more likely to suffer from ischemic stroke.

Migraineurs, male and female, have a 2.5-fold increased risk of subclinical cerebellar stroke and those with migraines with aura and increased headache frequency are at the highest risk.

Migraineurs also have a higher incidence of adverse cardiovascular profiles , and they are more likely to be smokers, have a family history of early heart attacks, and have an unfavorable cholesterol profile. The odds of an elevated Framingham risk score of coronary artery disease are doubled with migraine with aura, and women who have migraine with aura are more likely to be using oral contraceptives.

These findings have been confirmed in a population-based study by Bigal et al. Similarly, a study by Gudmundsson et al found that men and women who have migraine with aura are at a higher risk for cardiovascular and all-cause mortality than are those without headache.

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What Medicines Help Relieve Migraine Pain

For mild to moderate migraines, over-the-counter medicines that may help relieve migraine pain include:

  • Aspirin
  • Acetaminophen
  • An acetaminophen, aspirin, and caffeine combination
  • Ibuprofen
  • Naproxen
  • Ketoprofen

People who have more severe migraines may need to try abortive prescription medicines. A medicine called ergotamine can be effective alone or combined with other medicines. Dihydroergotamine is related to ergotamine and can be helpful. Other prescription medicines for migraines include sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan, and frovatriptan.

If the pain wont go away, stronger pain medicine may be needed, such as a narcotic, or medicines that contain a barbiturate . These medicines can be habit-forming and should be used cautiously. Your doctor may prescribe these only if they are needed and only for a short period of time.

Functional Brain Alterations In Chronic Migraine

In addition to central sensitization, it is likely that the activation and sensitization of the trigeminal pathway and related pain circuits within the brain become persistent with disease chronification. This may further contribute to the structural and functional reorganization of pain-related circuits in chronic migraineurs, increasing susceptibility to the development of more frequent attacks, thus bypassing the interictal phase in most instances .

Brainstem

While existing evidence from episodic migraine studies indicates that the PAG may play a distinctive role in migraine pathogenesis , further investigations are necessary to delineate whether the PAG is involved specifically in migraine or more generally in pain conditions. Nonetheless, these progressive episodic migraine studies have paved the way for chronic migraine research by delineating the potential role of the PAG in underlying mechanisms of chronic migraine.

Hypothalamus

Cerebral Cortex

These observations in functional changes suggest that chronic migraineurs exhibit aberrant pain processing due to altered descending pain modulation . Determining if underlying neural alterations are analogous to both episodic and chronic migraineurs or specifically involved in migraine chronification remains elusive and requires further research .

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Migraine In Other Inherited Disorders

Migraine occurs with increased frequency in patients with mitochondrial disorders, such as MELAS . CADASIL is a genetic disorder that causes migraine with aura, strokes before the age of 60, progressive cognitive dysfunction, and behavioral changes.

CADASIL is inherited in an autosomal dominant fashion, and most patients with the disorder have an affected parent. Approximately 90% of cases result from mutations of the < INOTCH3< I> gene, located on chromosome 19. Patients with CADASIL have significant morbidity from their ailment, and life expectancy is approximately 68 years.

Migraine is also a common symptom in other genetic vasculopathies, including 2 autosomal dominant disorders: RVCL , which is caused by mutations in the TREX1 gene, and HIHRATL , which is suggested to be caused by mutations in the COL4A1 gene. The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear.

The Evolutive Process Of Migraine Chronification

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Chronic migraine is a disabling, underdiagnosed and undertreated disorder, affecting ~12% of the general population . Progression from episodic to chronic migraine is a clinical reality . Studies show that each year 2.5% of episodic migraine patients progress into chronic migraine which appears as a distinct entity in the classification of the International Headache Society . The nosology of CM has several clinical implications, including the elimination of modifiable risk factors and the therapeutic preventive options for CM patients.

Patients with chronic migraine, have a significantly higher incidence of positive family history of migraine, menstrual aggravation of migraine, identifiable trigger factors, associated symptoms, and early morning awakening with headache . A number of risk factors have been identified to double the risk for migraine chronification , including de novo increased migraine attack frequency and overuse of acute migraine medications , ineffective acute treatment that could lead to medication overuse , depression , which is a common comorbidity of migraine, and lifestyle factors such as stress, high caffeine intake and obesity .

Inflammation and central sensitization in the pathophysiology of migraine chronification

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Accommodating Employees With Migraines

People with migraines may develop some of the limitations discussed below, but seldom develop all of them. Also, the degree of limitation will vary among individuals. Be aware that not all people with migraines will need accommodations to perform their jobs and many others may only need a few accommodations. The following is only a sample of the possibilities available. Numerous other accommodation solutions may exist.

Pathophysiology Of Chronic Migraine

Figure 1. Central vs. peripheral mechanism of migraine. The prevailing theories of migraine initiation include the existence of a peripheral trigger and/or central nervous system changes including oscillations in the sensitivity of descending pain modulatory pathways across the migraine cycle. Such changes in brainstem tone are proposed to either prevent or allow an external trigger or basal brainstem activity from evoking activity changes in ascending pathways which are ultimately responsible for the presence of a migraine event.

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What Are Some Migraine Risk Factors And Triggers

Some risk factors make you more likely to get migraine headaches. Other things may trigger a migraine.

Common migraine risk factors include the following:

  • Family history: You are much more likely to have migraines if one or both of your parents had migraines.
  • Sex: Women are more likely than men to have migraines.
  • Age: Most people have their first migraine during adolescence, but migraines can start at any age, usually before age 40.

Common migraine triggers include the following:

  • Food and drink: Certain food and drink may cause migraines. Dehydration and dieting or skipping meals may also trigger migraines.
  • Hormone changes: Women may experience migraines related to their menstrual cycles, to menopause, or to using hormonal birth control or hormone replacement therapy.
  • Stress: Stress may trigger migraines. Stress includes feeling overwhelmed at home or work. But you can also become stressed by exercising too much or not getting enough sleep.
  • Senses: Loud sounds, bright lights , or strong smells may trigger migraines.
  • Medicines: Certain medicines may trigger migraines. If you think your migraines might be related to your medicine, talk to your doctor. Your doctor may be able to prescribe a different medicine.
  • Illness: Infections, such as the cold or the flu, may trigger migraines, especially in children.

Foods that may trigger migraines:

  • Aged, canned, cured, or processed meat
  • Aged cheese
  • Soy sauce

Coping With Chronic Headache Pain

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Daily life with chronic headaches can be tough. Sometimes, medications and complementary treatments aren’t enough to help you cope. When you have chronic headaches, seeking support may help you get through the hard times.

Support groups and online pain forums are great coping resources. Make sure you have a good relationship with your healthcare provider and that he or she is evaluating the effectiveness of your treatment plan often.

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Vasoactive Substances And Neurotransmitters

Perivascular nerve activity also results in release of substances such as substance P, neurokinin A, calcitonin gene-related peptide, and nitric oxide, which interact with the blood vessel wall to produce dilation, protein extravasation, and sterile inflammation. This stimulates the trigeminocervical complex, as shown by induction of c-fos antigen by PET scan. Information then is relayed to the thalamus and cortex for registering of pain. Involvement of other centers may explain the associated autonomic symptoms and affective aspects of this pain.

Neurogenically induced plasma extravasation may play a role in the expression of pain in migraine, but it may not be sufficient by itself to cause pain. The presence of other stimulators may be required.

Although some drugs that are effective for migraine inhibit neurogenic plasma extravasation, substance P antagonists and the endothelin antagonist bosentan inhibit neurogenic plasma extravasation but are ineffective as antimigraine drugs. Also, the pain process requires not only the activation of nociceptors of pain-producing intracranial structures but also reduction in the normal functioning of endogenous pain-control pathways that gate the pain.

Dealing With Chronic Headache Pain

Did you know that headaches are one of the leading types of chronic pain, along with back pain and arthritis? A headache may sound like a fairly minor ailment, but if you’re in pain every day, you know that chronic headaches can be very debilitating.

Getting a migraine or a cluster headache under control is a bit more complicated than taking two aspirin and calling your healthcare provider in the morning. Here’s what you should know about the various types of chronic headaches and your treatment options.

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