Detoxification From Medication Overuse Headache
Restoration to the episodic migraine pattern requires withdrawing the offending medication. Although withdrawal may be the most important step, it is imperative to address all migraine progression risk factors. Failure to do so will likely influence or unnecessarily complicate treatment.
Improvement may take weeks to months, and the goal is to return the attacks to an episodic pattern. Headache diaries provide important clues, as change may be slow and not noticed. A reduction in headache intensity and duration may be noticed before a reduction in headache days.
Effective treatment plans require addressing patient expectations, and encouraging patience and vigilance. Patients must be prepared for prolonged treatment, as therapy requires the commitment of physician and patient resources. The patient should prepare for a short-term increase in their headache pain, which will undoubtedly affect their productivity and quality of life for a while.6 Some physicians will consider short-term disability for the patient to allow a greater focus towards recovery.
Behavioral management techniques should be actively engaged during recovery. This requires preparation prior to the withdrawal date. These techniques are more effective when they are used regularly. Behavioral treatments consistently improve preventive and abortive medication effectiveness.6,52
Tzu-Hsien Lai, Tzu-Chou Huang, in, 2020
What Is A Migraine Again
To repeat: A migraine is more than a headache. Its a neurological disorder, usually inherited, that makes your brain more hypersensitive to certain triggers, those in the outside world and those inside your body. When something sets off an attacknot enough sleep, a glass of wine, a drop in estrogenthe neural pathways in your brain get activated in abnormal ways and release chemicals that set off the cascade of symptoms associated with an attack.
Even without the head pain , these attacks can totally derail your day or at least keep you from driving for a couple of hours. So its no wonder that migraines are the sixth most debilitating condition in the world, according to the Migraine Research Foundation. And theyre very commonin the U.S., about one in four households has a person who suffers from migraines living in it. Because theres a strong family history for the condition, children of any age can get them, possibly even babies. Among adults, three times as many women have migraines than men, and, yes, hormones have something to do with it, at least as triggers.
The Challenge Of Taking Acute Medication Early Enough But Not Too Often
Many people with migraine are prescribed triptans to stop a migraine attack in its early stages. But if you have chronic migraine, it can be difficult to know when to take them, says Dougherty.
People are told, Dont treat too often, but in order for the triptan to be effective, you need to treat really early, Dougherty says. If youre a rule follower trying to heed both of those things, that can be a real challenge, she adds.
Dougherty tells her patients that triptans can be a double-edged sword, in the sense that they can effectively relieve a migraine attack, but if taken more frequently than recommended, their use can lead to medication-overuse headache and raise the risk for chronic migraine.
Medication-overuse headache, also called rebound headache, is a chronic daily headache that happens when acute medications for headache or migraine are used more than two or three days per week, according to the American Migraine Foundation.
In addition to triptans, these headaches are linked with ergotamines, opioids, and over-the-counter pain relievers such as Tylenol , nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen, and combination pain relievers that contain aspirin and caffeine, according to the American Migraine Foundation.
Because of these concerns, there are people who have angst every time they take a triptan, says Dougherty, adding that they may feel guilty and think they are contributing to their disease process.
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Chronic Migraine Vs Episodic Migraine
Measuring the frequency of a patients migraine attacks allows medical professionals to determine whether they have a chronic or episodic migraine. According to Dr. Hindiyeh, Episodic migraine occurs when you have less than 15 headache days a month, and chronic migraine occurs when you have 15 or more headache days a month. For accurate tracking, Dr. Hindiyeh recommends that patients keep a headache diary or use a smartphone to log the frequency of their attacks.
When patients notice an increase in headache frequency or an elevated need for rescue medications, their migraine attacks may be progressing from episodic to chronic. Keeping an accurate log becomes even more important because symptoms dont always tell the full story. With chronic migraine, you may not have all of the same features you had before. That can be a typical pattern of chronic migraine, and it often happens if people are taking medications that may mask some of those symptoms, said Dr. Hindiyeh.
How Do I Know If I Have Chronic Or Episodic Migraine
A person with migraine would count the days in which they are having headache and migraine attacks and then also describe the features of the attack. A migraine attack is defined by associated nausea and/or light and sound sensitivity with certain features of pain: one-sided pain throbbing in quality, moderate in severity, and aggravated by physical activity at least eight of the 15 days of headache or migraine attacks should have those features.
Episodic migraine would then be fewer than 15 days of pain and/or associated symptoms. It is a fairly arbitrary number and some individuals have what we would call high-frequency episodic migraine, meaning eight to 14 days of migraine per month. Headache specialists think about high-frequency migraine as having similar issues as someone with chronic migraine.
But for purposes of classification, that 15-day cutoff is what has been assigned and is used as a qualification for some medications or treatments that are used specifically for chronic migraine.
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Structural Brain Alterations In Chronic Migraine
Coupled to changes in brain function, a number of studies have detailed structural changes in individuals with episodic and chronic migraine . Gray matter volumetric changes in several brain regions involved in pain processing including increased gray matter volumes in the amygdala, putamen, PAG and dorsolateral prefrontal cortex as well as decreased volumes in the anterior cingulate cortex, temporal and occipital lobes, precuneus, cerebellum and brainstem have been reported in chronic migraineurs . A recent study also found that both chronic and episodic migraine were associated with significantly decreased hypothalamic volumes compared to controls and the reduction in chronic migraineurs was positively correlated with headache frequency . These findings are consistent with the idea that the hypothalamus plays a role in migraine chronification potentially through its multiple ascending and descending connections. Furthermore, chronic migraineurs display increased iron accumulation in the PAG and red nucleus , which may also result from progressive changes during migraine chronification .
Figure 3. Brain regions involved in underlying mechanisms of migraine and reported alterations. Modulation of incoming noxious inputs: spinal trigeminal nucleus , periaqueductal gray matter , rostral ventromedial medulla and dorsal pons. Higher order processing: hypothalamus, thalamus, anterior cingulate cortex , insula and primary somatosensory cortex .
Early Sustained Pattern Reversal
Results showed patients achieved the primary outcome of pattern reversal from chronic to episodic migraine at all time-points of 1, 3, 6, 9, 12, and 13 months compared with baseline .
Table. Patients with a pattern reversal from chronic to episodic migraine.
As we can see during the period of observation, there is a growing percentage of the responders, Vaghi reported. It is worth noting that our data show a higher percentage of a response compared to a previous clinical trial.
After the first monthly dose, 10.2% of the patients experienced a 75% or greater reduction in monthly migraine days. By end of trial at 13 months, the figure had increased to 36.2% of patients.
Roughly a quarter of patients had a 50% to 74% reduction in migraine days after 1 month and this increased to 38.4% at 13 months.
Combining the 13-month data, three quarters of the participants were experiencing a 50% or greater reduction in monthly migraine days at that timepoint.
Concomitant with the reduction in number of migraine days was a precipitous drop in medication use. Monthly acute medication doses dropped from 31.9 doses at baseline to 12.3 doses at month 1 and to 8.1 doses at month 13.
Similarly, days of drug intake fell from 20.3 days at baseline to 9 days at month 1 and to 6.8 days at month 13 .
Patients also experienced reduced disability, as measured on the MIDAS and HIT-6 scales , and they showed reductions in allodynia at months 6, 9, and 12 vs baseline .
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How Do You Know If You Have Chronic Migraines
Between 3-5% of Americans have chronic migraine, though some estimates put that percentage a bit lower. Chronic migraine is a diagnosis for a person who experiences migraine symptoms at least 15 days per month. In other words, someone with chronic migraine has as many migraine days or more than days they go without migraine symptoms. These are the most severe instances of migraines and often involve migraines that last longer in addition to their increased frequency.
While all migraine cases can interfere with a person’s professional and personal life, chronic migraine can be especially debilitating because of their frequency. Chronic migraine treatment options are more likely to focus on prevention compared to treatment plans for less frequent migraines.
Migraine With Or Without Aura
First, we can classify migraines into two major categories with and without aura. You may have also heard these categories referred to as classic, or complicated, migraines and common migraines. To understand the difference between migraine with aura and migraine without, we have to understand what aura is.
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What Causes Episodic Migraine
Fundamentally, headache specialists don’t have a clear understanding of that. There’s clearly a genetic predisposition to episodic migraine. A parallel question is: What predisposes a person to chronic migraine vs episodic migraine? Researchers are constantly trying to identify whether or not there are modifiable factors that can prevent the transition from episodic migraine to chronic migraine.
Difference Between Episodic Migraine And Chronic Migraines
The difference between episodic migraine and chronic migraine is how oftentimes the headache happens. Long-winded headache victims have less than 14 migraines each month for 90 days. Persistent headache victims experience migraines 15 days or more each month. In the two cases, the cerebral pains dont need to be serious migraines or headache cerebral pains to check.
Episodic migraines can increment throughout months or years to become persistent headaches. Its anything but clear how episodic migraines increase and become chronic. A few scientists presume that irritation causes veins in the cerebrum to grow and pack close by nerves, causing migraines. Rehashed scenes of aggravation may add to the movement of episodic migraine to chronic migraine. Its conceivable that rehashed scenes of irritation cause some nerve cells in the cerebrum to get delicate and bound to cause headache torment.
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What Causes Chronic Headaches
The most common trigger of chronic headaches is stress, and stress can come from just about anything including: Chronic stress can lead to other chronic conditions such as anxiety or depression, both of which can cause chronic daily headaches. Chronic stress can also cause tension in the muscles of the neck which can cause tension-type headaches.
What Are The Different Types Of Migraines
Migraines are divided into several main types:
Episodic migraines, which means you have fewer than 15 attacks per month
Chronic migraines, which means you have 15 or more attacks a month
Migraines with auras, which are the neurological disturbances that involve lights, sounds, and sometimes speech
Migraines without auras, which are much more common than those with
Plus, there are a few subtypes within these categories. The main differences are in some of the symptoms and the frequency of attacks, not in what happens in your brain. Except for Botox shots, which are reserved for people with chronic migraines, the treatment all types of migraines is the samedrugs, non-drug devices, and lifestyle changes that can stop an attack or prevent one.
To get diagnosed with episodic and chronic migraines without auras, which always include headache pain, a doctor follows the criteria set out by the International Headache Society. Your attack must have at least two of these four features:
The pain is moderate to severe.
It usually occurs on one side.
Your head throbs or pulses.
The pain gets worse with physical activity.
It also needs to have one of these features:
You cant tolerate light or noise.
You feel nauseous and/or you actually vomit.
Finally, you have to have had at least five attacks in your lifetime that included these criteria and the doctor must have ruled out any reason for the migraines , either with an exam or an imaging test.
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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 .
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.
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 .
How Is Chronic Migraine Treated
Treatment of chronic migraine is focused on managing lifestyle choices and headache triggers, managing migraine attacks and providing preventive treatments to reduce migraine attacks.
Lifestyle changes include:
- Beginning treatment for any existing mood disorder or sleep problem.
The typical treatment plan for managing migraine attacks includes:
- Treating migraine attacks early when pain in mild begin with a simple pain killer and slowly increase the dose as needed to the max tolerated dose, unless the headache is severe at the start or will become severe. In such cases add a triptan to the above medication to improve efficacy. Avoid use of opiates if possible. Your doctor will devise a treatment plan to avoid worsening chronic headache by overusing medications.
- Treat associated side effects, such as nausea.
- Consider other treatment techniques, including transcranial magnetic stimulation and transcutaneous supraorbital nerve stimulation.
Preventive treatment is aimed at reducing the number of headaches. Preventive treatments include:
- Beta blockers, such as propranolol , atenolol and metoprolol
- Angiotensin blockers, such as candesartan
- Tricyclic antidepressants, such as nortriptyline , amitriptyline
- Anticonvulsants, such as topiramate , sodium valproate
- Calcitonin gene-related peptide , such as galcanezumab , fremanezumab , erenumab
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Current Guidelines For Episodic Migraine Prevention
The joint American Academy of Neurology/American Headache Society guideline on episodic migraine prevention has been updated, and it is interesting to see how European and American guidelines have converged . In both guidelines, first line drugs for migraine prevention include the beta-blockers propranolol and metoprolol and the antiepileptics valproate and topiramate. Flunarizine features as a first-line treatment in the European guideline but is not available in the USA. Second line treatments are also remarkably similar and include the antidepressants venlafaxine and amitriptyline.
Table 1. Current migraine prevention guidelines
AAN, American Academy of Neurology AHS, American Headache Society EFNS, European Federation of Neurological Sciences.
- Flunarizine is not available in the USA.
Patient Disposition And Baseline Characteristics
A total of 1773 patients were included in the ITT population, with 597 in the LFEM group and 1176 in the HFEM group. Overall, the patient population was largely female , white , and North American , and had a mean time since migraine diagnosis of 20.3years. The mean age of the patients was 41.3 years, and there was no significant difference in age between the LFEM and HFEM groups. At baseline, patients with HFEM had significantly more MHDs, and MHDs with acute medication use, with nausea and/or vomiting, with photophobia and phonophobia, with aura, and with prodromal symptoms than did patients with LFEM. Patient baseline characteristics are summarized in Table .
Table 1 Baseline characteristics
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What Are The Symptoms Of Chronic Migraine
Symptoms of episodic migraine and chronic migraine are the same. The difference is simply the increase in frequency of the number of headaches. Typical migraine symptoms include:
- Head pain that is moderate to severe in intensity, worsened by physical activity/movement
- Pain on one or both sides of the head
- Throbbing pain or pressure-like pain
- Sensitivity to light, sound, smells
Signs an episodic migraine is transforming to a chronic migraine include:
- Having a growing number of migraine attacks
- Taking more medication because of the growing number of attacks
Reversion From Chronic To Episodic Migraine
Reversion from chronic to episodic migraine occurs in 2570% of chronic migraineurs within 2 years. A 3-year longitudinal study of chronic migraineurs found that one-third of them had persistent chronic migraine, one-quarter remitted to fewer than 10 headache days per month, and the remainder of the migraineurs fluctuated between episodic and chronic migraine patterns. Factors associated with reversion from chronic to episodic migraine include lower baseline headache frequency, complete withdrawal of overused migraine-abortive medications, adherence to prophylactic therapy, absence of allodynia, and regular physical exercise.
Duren Michael Ready, in, 2015