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Monday
Feb232015

Episodic or chronic migraine? How, using scientific-based evidence, we can help our doctors improve our treatment outcomes

 

"We cannot direct the wind, but we can adjust the  sails." - Bertha Calloway

Migraine, a genetic neurological disease characterized by hyperexcitability and episodic events known as migraine attacks, is classified as a primary headache disorder (ICHD-3). For many of us with migraine, optimal management of our disease is a challenge.

In an important step toward improving our treatment outcomes, a recent study tested the hypothesis that ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine (Lipton, et al., 2015). In line with this approach, authors of a recent article, (Lipton and Silberstein, 2015), discuss how to breakdown barriers to optimal treatment and prevention for those of us with episodic migraine (EM) and chronic migraine (CM).

To help us have a better understanding of the challenges we face and offer suggestions on ways to assist our doctors in improving our treatment outcomes, using information from this study and journal article, this article focuses on our role as patients in:

  • Diagnosis of Migraine. 
  • Diagnostic criteria for Episodic migraine (EM) and chronic migraine (CM).
  • Risk factors for progression to CM.
  • Acute and preventive treatment. 
  • Electronic diaries. 

"The principle of Priority states (a) you must know the difference between what is urgent and what is important, and (b) you must do what's important first." -Steven Pressfield 

Diagnosis of Migraine: 

When we have a severe migraine attack, we want immediate treatment and relief from our headache and associated symptoms. But, to ensure we receive effective treatment, we must have an accurate diagnosis. 

Our diagnosis of migraine is based on a thorough history, including family history and onset of headache; physical examination; and, should they be necessary, diagnostic tests to rule out other headache disorders. To help our doctor make an accurate diagnosis, we need to be familiar with common characteristics of migraine: 

  • for migraine without aura, headache is usually unilateral location, pulsating in quality, of moderate to severe intensity, aggravated by physical activity (need to have at least 2 of the 4 preceding), lasts 4-72 hours without treatment and is associated with at least one of the following: nausea and/or vomiting, sensitivity to light (photophobia), and sensitivity to sound (phonophobia).
  • for migraine with aura, we may have transient focal neurological symptoms that usually precede or may accompany headache, including visual (most common), sensory, speech and/or language, motor, brainstem, or retinal symptoms. Subforms of migraine with aura include: migraine with typical aura (typical aura with headache and typical aura without headache), migraine with brainstem aura, hemiplegic migraine (familial hemiplegic migraine types 1, 2, 3, familial hemiplegic migraine other loci and sporadic hemiplegic migraine), and retinal migraine.
  • premonitory symptoms, (prodromal) which may begin hours or a few days prior to the aura in migraine with aura, and headache in migraine without aura, and continue through to the postdrome. These include stiff neck, neck pain, nause, fatigue, blurred vision, yawning, sensitivity to light and sound, pallor, and difficulty concentrating.

It is important for us to know that we may have: 

  • both migraine without aura and migraine with aura, and
  • migraine with aura without a headache, or with a less distinct headache.

In addition, we need to be aware that frequent episodic tension-type headache often coexists with migraine without aura. Because treatment of migraine differs from that of tension-type headache, we need to be able to distinguish between these two types to help ourselves and our doctors select the right treatment, while avoiding medication overuse (ICHD-3 beta, p. 661). Characteristics of frequent episodic tension-type headache include at least 10 episodes of headache occurring on 14 days or less for >3 months, lasting from 30 minutes to 7 days and, at least two of the following four: 

  • headache typically bilateral location,
  • may be pressing or tightening in quality,
  • is of mild to moderate intensity,
  • does not worsen with routine physical activity.

And, both of the following:

  • headache is not associated with nausea and vomiting, and
  • may be associated with photophobia or phonophobia (only one). 

Diagnostic criteria for EM and CM

EM and CM are differentiated in the number of headache days per month. In EM, headache occurs on less than 15 days per month. If our headaches occur on 15 or more days per month (tension-type-like and/or migraine-like) for more than 3 months, with the features of migraine headache on at least 8 days per month, we are given the diagnosis of chronic migraine (ICHD-3 beta). We should know that response to triptans is not diagnostic of migraine headache as secondary headaches attributable to other disorders like subarachnoid hemorrhage or meningitis, may respond to triptans (Lipton and Silberstein, p. 106).

About 2.5% of persons with EM progress to CM per year. We need to be aware that as our attacks increase in frequency, so do a host of other problems that can complicate our treatment and contribute to headache related disability. For example: 

Given this information, along with ensuring an accurate diagnosis for migraine, we need to work with our doctors to set goals and direct our treatment to reducing our attack frequency, as well as determining and treating comorbid disorders. 

Risk factors for progression to CM: 

It is important for us to know that overuse of acute medications, in particular opioids and barbiturates, is a risk factor for progression to chronic migraine and a common cause of chronic migraine symptoms. However, it is difficult to determine whether medication overuse is the cause of or a response to CM (Lipton and Silberstein, 2015). Some of us  revert to EM after medication overuse is stopped, but many of us do not. Patients who overuse opioids are thought to have the highest relapse rate after withdrawal treatment.

Other modifiable risk factors for progression include comorbidities like obesity (2 to 5 times more likely to develop CM than persons normal weight), moderate or severe depression, anxiety, asthma, and allergic rhinitis; snoring; stressful life events; and, caffeine use/misuse (combination medications containing caffeine). Non-modifiable risk factors for progression are thought to include age, female sex, genetics, low education level, low socioeconomic status, and head or neck injury (potentially modifiable).

Once we identify our personal risk factors, our role is  to work with our doctors to improve or eliminate our modifiable ones, decrease the frequency of our attacks, and if we have CM, increase our chances for remission.

"When a lot of remedies are suggested for a disease, that means it cannot be cured." -Anton Chekhov

Acute and Preventive Treatment

Now, let's take a closer look at the study noted at the beginning of this article (Lipton et al., 2015). The authors predicted that poor treatment efficacy among individuals with EM, leading to longer periods of exposure to pain, might increase the risk of new-onset CM. Using the AMPP study survey, respondents identified all medications they used to treat "their most severe type of headaches." For analysis, medications were combined into simple analgesics, combination analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and triptans. Opioids and barbiturates were combined in one category.

Respondents who used NSAIDs and simple analgesics were less likely to be in the high treatment efficacy categories while persons who used triptans were more likely to be in favorable treatment efficacy categories. The authors note opioids and barbiturates were associated with increased risk of CM in prior studies (Bigal, Serrano et al., 2008).

Results indicated that those with ineffective treatment are at risk for CM onset while those with more effective treatment have better outcomes over 1 year follow-up. The study authors report that these findings support their prediction that exposure to longer periods of pain may be in the causal pathway that leads from EM to CM and suggest that improving treatment outcomes might prevent new onset CM.

If we have EM and a poor response to acute treatment, to decrease the frequency and severity of our attacks, and reduce our chances of progressing to CM, we need to talk to our doctor about acute and preventive treatments as soon as possible. Given individual response to acute therapy varies with the specific drug and dose, and side effects of preventive medications can be unpleasant, to increase responsiveness and compliance, effective communication with our doctor about our progress is essential.

Along with pharmacological treatment and educational interventions, lifestyle modifications and trigger management can help reduce attack-related impairment and decrease the frequency and severity of our attacks. Non-pharmacological approaches for the prevention of EM that have demonstrated efficacy include cognitive behavioral therapy (CBT), relaxation techniques, and biofeedback. These therapies, along with acupuncture, can be used alone or in conjunction with medication (Lipton and Silberstein, 2015).

Electronic Diaries  

One of the most effective ways we can help our doctors improve our treatment outcomes is to keep a diary. Whether a notebook, electronic, or a calendar, a diary can help our doctors and ourselves: 

  • identify possible triggers (trigger patterns) and suggest strategies to minimize or avoid them.
  • recognize premonitory and aura symptoms.
  • recognize the frequency, severity and duration of our migraine attacks (with and without aura, and aura without headache) and headaches (migraine-like and tension-type-like).
  • differentiate tension-type headache from migraine-like headache.
  • identify the location and severity of our pain.
  • assess our functional disability (attack-related impairment).
  • assess the effectiveness of our treatment and recognize the need to adjust doses, alter routes of administration, and add or change our medications.
  • recognize a pattern of medication overuse.
  • assess the effect of lifestyle habits including sleep patterns, skipped meals, exercise, sexual activity, and stress, on the frequency and severity of our attacks.
  • assess the impact of protective factors and nonpharmacological therapies on the frequency and severity of our attacks. 

Given the limitations of paper diaries, including multiple daily entries that have to be made by hand, along with recall bias, in the past few years, electronic diaries have become very popular. However, the authors of a recent review of commercially available mobile apps available in Canada expressed concern about the lack of scientific expertise and evidence base associated with headache diary apps. None of the 38 apps included in their review met all 7 criteria established by the study authors for an ideal diary. Three apps met 5 of the criteria: iHeadache (developed by Better QOL), ecoHeadache (developed by eco TouchMedia), and Headache Diary Pro (developed by Froggyware). Only 18% of the apps were created with scientific or clinical headache expertise. 

An example of a scientific approach to the identification of migraine triggers, as well as to advance basic understanding and management of migraine with the practical intention of reducing suffering and costs associated with the condition, is N1-Headache (developed by Curelator Incorporated). The simple to use app tracks triggers, associations between single or combinations of triggers and the occurrence of migraine headaches (Spierings, Donoghue, et al., 2014). The clinical advisory board includes neurologists and headache specialists active in clinical practice and research. "Although initial clinical trials have ended, Curelator Headache will constantly run a cohort 1000-2000 patients in clinical trial." (Interview with Alec Mian, CEO at Curelator, March 5th, 2015).

References: 

Bigal, M.E., Serrano, D., Buse, D., et al. (2008). "Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population based study." Headache.  48:1157-1168.

Buse, D.C., Silberstein, S.D., et al. (2013). "Psychiatric comorbidities of episodic and chronic migraine." J Neurol.  Aug;260(8):1960-9. DOI 10.1007/s00415-012-6725-x. 

Headache Classification Subcommittee of the International Headache Society. The International Headache Society. "The International Classification of Headache Disorders: 3rd edition (beta version). Cephalalgia.  2013;33:629-808.

Hundrert, A.S., Huguet, A., et al. (2014). "Commercially available mobile phone headache diary apps: a systematic review." JMIR Mhealth Uhealth.  Aug 19;2(3):e36 doi: 10.2196/mhealth.3452.

Lipton, R.B., Fanning, K., et al. (2015). "Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine." Neurology. Jan 21. doi: 10.1212/WNL.0000000000001256.

Lipton, R.B., Serrano, D., et al. (2014). "Sociodemographic, Disability, and Employment Differences Between Persons With Chronic and Episodic Migraine: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study." Neurology. April 8, vol. 82 no. 10. Supplement S41.002.

Lipton,  R.B., & Silberstein S.D. (2015). "Episodic and Chronic Migraine Headache: Breaking Down Barriers to Optimal Treatment and Prevention." Headache: The Journal of Head and Face Pain. Volume 55, Issue Supplement S2. DOI: 10.1111/head.12505_2.

Spierings, E.L., Donoghue, S., et al. (2014). "Sufficiency and necessity in migraine: how do we figure out if triggers are absolute or partial and, if partial, additive or potentiating? Oct;18(10):455. doi: 10.1007/s11916-014-0455-y.

Sharron Murray MS, RN is an author and coauthor CaMEO Study, "Life With Migraine". Currently, Sharron is active in the migraine community as a writer, advocate, American Migraine Foundation Partner, moderator for the American Migraine Foundation "Move Against Migraine" Facebook Group, and member of the National Headache Foundation Patient Leadership Council. 

Follow Sharron on twitter @murraysharron, her Facebookpage: Sharron Murray, MS, RN 

This article is not intended as a substitute for medical advice. If you have any specific concerns about your health or nutrition, please consult a qualified health care professional.

Updated November 28, 2018

Copyright, March 24, 2015: Sharron E. Murray

 

 

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  • Response
    The usage of the scientific method will be consumed on the different new basis. These all are the main causes of the new work as well. This is the first development of the same cases. This is known as the first development in front of the new advancement.
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Reader Comments (2)

Sharon, fantastic post. I hadn't seen the systematic review of apps study before so thank you for bringing that to my attention. As someone who has a built an interactive migraine diary at migrainepal.com this is a great resource to have. I think we'd score quite well actually, although we are still web based app so no doubt we were not included in the study : )

April 2, 2015 | Unregistered CommenterCarl

Thank you for your kind comments , Carl. Much appreciated.

April 6, 2015 | Unregistered CommenterSharron Murray

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