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Conari Press, an imprint of Red Wheel/Weiser, LLC  is the publisher of Sharron's book, Migraine: Identify Your Triggers, Break your Dependence on Medication, Take Back Your Life -  An Integrative Self-Care Plan for Wellness," released June, 2013. Follow Sharron on Twitter @murraysharron, and her page Sharron Murray, MS, RN on Facebook, for tips to help you battle your migraines and achieve wellness.

 

Tuesday
Nov182014

Can we use associations between migraine triggers, premonitory symptoms, and migraine attacks to predict our attacks and decrease their frequency? 

"The world is full of suffering. It is also full of overcoming it." -Helen Keller 

For many of us with migraine, our world revolves around painful and debilitating attacks. Addressing this issue, the authors of two recent journal articles have drawn attention to how, if knowledge and understanding of relationships between trigger factors, protective factors, and premonitory features can be established, we may be able to improve our ability to predict, preempt, and reduce the frequency of these acute episodes (Lipton et al., 2014, and Pavlovic et al., 2014).

In this article, we use these journal articles, and the definitions provided within them, to guide us in a discussion of: 

  • trigger factors,
  • protective factors,
  • premonitory features, 
  • self-prediction, and 
  • preemptive therapy. 

Trigger Factors

Before we get to trigger factors, let's review a bit about migraine. Migraine is a neurological disease. As migraineurs, we are thought to have an inherited sensitivity of the nervous system that makes our brains hyper-excitable. This hyper-excitability gives us a predisposition to migraine attacks. 

Attacks, including headaches and other symptoms, are referred to as the ictal state. The goal of treatment in the ictal state is to relieve pain and restore function. The time between attacks, where we may be relatively free of symptoms but have a predisposition to attacks, is referred to as the inter-ictal state. The goal of treatment in the inter-ictal state is to reduce the probability of transitioning to the ictal state. 

Now, let's examine trigger factors. Triggers are internal or external stimuli that provoke or "set off" migraine attacks in those of us who have the disease. It is important for us to know that triggers do not cause our symptoms. "During a migraine attack, a storm of electrical and chemical activity 'switches on' different areas of our brain and surrounding nerves to cause migraine symptoms" (Dr. Andrew Charles, AHS14AZ).

As well, we need to be aware that triggers are different from risk factors. Risk factors like genetics, sex, and obesity, increase the onset of the disease in a person previously free of migraine. 

That said, Lipton et al., (2014), define trigger factors as measurable endogenous (internal) or exogenous (external) events (exposures) associated with an increased probability of an attack over a brief period of time.

Endogenous trigger factors include:

  • altered sleep patterns.
  • hormonal changes like estrogen withdrawal.
  • hunger.
  • dehydration.
  • psychological factors such as stress or relaxation following stress.

Exogenous trigger factors include: 

  • environmental factors like weather changes, bright or flickering lights, loud noises, and strong odors.
  • dietary factors.
  • alcohol.
  • exposure to, or withdrawal from, certain medications.

To help us understand how these triggers can increase the probability of an attack over a brief period of time, let's take a look at observations from a 28-day study of 33 patients with chronic migraine and 22 patients with chronic tension-type headache. The objective was to evaluate the time-series relationships between stress, sleep duration, and headache pain (Houle et al., 2012, cited in Spierings et al., 2014).

Observations for the stress-headache relationship are:

  • High stress yesterday and today predicts very high headache activity today.
  • Low stress yesterday and today predicts low headache activity today.
  • Low stress yesterday and high stress today also predicts low headache activity today.
  • High stress yesterday and low stress today predicts high headache activity today.

The conclusion is that headache precipitation needs at least 2 consecutive days of stress and that it is more likely to occur during let-down stress. Let-down stress was confirmed in a study by Lipton et al., (2014).

Observations for sleep duration and headache are: 

  • Low sleep duration (<4 hours) yesterday and today predicts very high headache activity today.
  • Low sleep duration yesterday and high sleep duration today also predicts high headache activity today.
  • Approximately 8 hours of sleep on consecutive days predicts low headache activity today. 

The conclusion is that headache precipitation needs at least 2 consecutive days of sleep deprivation and that headache is likely to occur with oversleeping.

Observations for stress and sleep duration are: 

  • Low stress and low sleep duration are associated with the lowest headache activity today.
  • High stress and high sleep duration are associated with the most headache activity today.  

Protective factors: 

While trigger factors increase the probability of a migraine attack, protective factors are events that decrease the probability of attacks over a defined period of time (Lipton et al., 2014). Keeping the above observations in mind, the protective factors would be low stress and high quality sleep (8 hours). Other examples include: eating regular meals, practicing relaxation techniques, and preventive medications. Also, we should be aware that things which make us feel better can decrease the length and severity of our symptoms. Examples include: cold packs, sleep, and for some, Essential Oils and aromatherapy .  

Premonitory features (Prodrome)

Premonitory features are defined as subjective cognitive, behavioral, or physical features that precede the onset of aura in migraine with aura, and before the onset of pain in migraine without aura (Lipton et al., 2014, and  Pavlovic et al., 2014). These symptoms may begin within 2-48 hours (some suggest 72 hours as symptoms may develop slowly) of aura or headache onset. Premonitory symptoms may include:

  • fatigue (feeling tired, weary),
  • yawning,
  • difficulty concentrating, thinking, reading, and writing,
  • dizziness,
  • irritability (mood changes),
  • stiff neck,
  • neck pain,
  • light sensitivity,
  • blurred vision,
  • noise sensitivity,
  • sensitive skin,
  • pallor,
  • nausea, 
  • constipation,
  • food cravings,
  • frequent urination,  
  • thirst, and
  • lots of energy.

About one third of patients with migraine seen in headache centers have premonitory symptoms (Lipton et al., 2014). For those of us who have premonitory symptoms (prodrome), it is interesting to note that in a study of 893 patients (Kelman, 2004), where one third of the participants had prodrome symptoms, the most common symptoms were tiredness, mood changes, and gastrointestinal symptoms.  As well, results showed patients with prodrome differed from patients without prodrome in having more triggers, longer duration of aura and  longer time between aura and headache; more aura with no headache; longer time to peak headache and to respond to triptan; longer duration of headache; more headache associated nausea, running of nose and tearing of eyes; and, more and longer duration of postdrome (resolution phase).   

Self-prediction 

Self-prediction refers to our assessment of the probability that we will have a migraine attack over a defined period of time (Lipton et al., 2014). To predict our attacks we need to be familiar with our trigger factors and premonitory symptoms and be able to associate them with headache onset. Finding these associations can be challenging.

Let's take a look at some of the challenges we may face:

Controversial

To begin with, because most of the literature regarding migraine triggers consists of studies performed using patient interviews and surveys, the results may be subject to recall bias and selection bias. With a lack of sound scientific evidence to support our beliefs that a certain trigger initiates an attack, a number of our triggers come under scrutiny.  

For example, many people claim they are 'better than the weatherman" in predicting the weather. However, several studies suggest that our perception of weather as a trigger may be overestimated (Friedman and De Ver Dye, 2009).  This appears to be true for a number of other environmental influences, such as indoor and outdoor lighting, poor air quality, noise, and exposure to strong odors and chemicals (including those in foods and beverages), even though we are believed to be more sensitive to various environmental stimuli than individuals without migraine. 

Unique to the individual 

While specific triggers may be controversial, a vast number of studies show we have a wide range of these precipitating factors. In one of the largest studies to date, when asked, about triggers, 76% of 1750 individuals with ICHD-2 diagnosis of migraine reported triggers. When presented with a list of triggers to choose from, this figure rose to 95% (Kelman, 2007, cited in Pavlovic et al., 2014)). The most common triggers, occurring at least occasionally, were: 

  • stress (80%), 
  • hormones (65% of women),
  • missed meals (57%), 
  • weather (53%0,
  • sleep disturbances (50%),
  • odors (44%).
  • alcohol (38%),
  • heat (30%), and 
  • foods (27%).  

In the Kelman study, we need to know that those of us with triggers were shown to have more severe attacks and symptoms, higher recurrence rates, more associated sleep and mood disturbances, longer lifetime duration of migraine, and more family members with migraine. In addition, migraine with aura and chronic migraine were more frequently associated with triggers than migraine without aura and episodic migraine.

Consistency: 

In this instance we need to know if a specific trigger is always followed by an attack. In a study of 120 patients with migraine or tension-type headache (Wober et al., 2006, cited in Spierings et al., 2014), participants were asked if triggers brought on their headaches always (consistently), or sometimes (occasionally). Of the fifteen most common triggers acknowledged (menstruation, weather, stress, red wine, smoking, hunger, alcohol, skipping meals, noise, change in sleep habits, glare, relaxation after stress, exhaustion, odors, and physical activity), only menstruation was statistically significant as a constant rather than occasional trigger.

Additive: 

This brings us to the inference that single triggers (apart from menses) might not be consistently potent enough to initiate an attack and therefore it may take a combination of triggers (additive effect). For example, we discussed the relationship between sleep and stress. Other examples include stress and hunger, (Turner et al., 2013), and combinations of chemicals in foods and beverages, such as tannin, tyramine, and MSG.     

Mistaken identity 

Here, those of us with premonitory symptoms need to know that, in this phase, we may mistakenly identify triggers or confuse them with premonitory symptoms. For example, many of us believe chocolate is a trigger for our attacks. However, consider hormonal migraines. Declining estrogen levels that occur at the time of menstruation as well as low levels that are encountered during the menopausal transition are migraine triggers for some women. Low estrogen levels are associated with low serotonin levels. Low serotonin levels promote food cravings for starches and sugars, including chocolate. If we regularly eat chocolate during these times, we may be experiencing a chocolate craving as a premonitory feature, not a trigger factor.

Fatigue (exhaustion) is another confusing factor. Feeling tired or weary is recognized as  a trigger, a premonitory symptom, and a feeling of exhaustion that persists through an attack and hangs on for days. Extreme fatigue may be a symptom of chronic stress.   

The way to find a needle in a haystack is to sit down -Beryl Markham    

To help us make associations between triggers, premonitory symptoms, and attacks, which can be like trying to find "needles in a haystack", we are encouraged to keep diaries. In other words we need to "sit down" and record a large amount of data. 

If we are using paper diaries, our recall ability, combined with the chore of flipping through pages to try and figure things out, may make us frustrated, especially if our attacks are high frequency or chronic. Hence, we may give up.

In my case, I opted out of paper diaries and journals and initially used a bank calendar, then my Day-Timer (a monthly calendar I could see at a glance). Appointments, work commitments, social obligations, family responsibilities, etc. were already scheduled in. All I had to do was make a note of perceived triggers, including, stress, what I ate or drank, environmental influences like weather, noise and light, hormonal influences, sleep patterns, and premonitory symptoms, along with medications, protective factors and comfort measures that helped me find relief.

Since then, options for diaries have expanded with technological advances. Data can be captured within the same day and time stamped to eliminate the frustration and inaccuracy of recall. In a large electronic diary study, where patients were asked how likely they were to have a migraine, a close relationship between the estimated probability and observed probability showed 72% accuracy (Giffin et al., 2003, cited in Lipton et al, 2014).)

"You can't stop the waves but you can learn to surf." -Jon-Kabat-Zinn (Amaal Starling MD AHS14AZ)

Once trigger factors are identified, we can avoid or learn to mange them.  For example, we can avoid triggers that are not consistent with a healthy lifestyle such as toxic smells, hunger, dehydration, and lack of sleep. We can learn to manage, "learn to cope" (train ourselves not to over-react to stimuli), with other triggers like  stress (Martin et al., (2014).

Recognizing our premonitory symptoms as signs of an impending attack gives us a window of opportunity to intervene with protective factors.  For example, in my case, fatigue, blurred vision and irritability are definite indications that a headache phase is on its' way. Since I have become accomplished at protective measures such as biofeedback, diaphragmatic breathing, and meditation, I can often take action to avoid, or lessen, the pain and associated symptoms (ictal state).

Preemptive therapy 

Preemptive therapy (or short term prophylactic treatment) is an emerging strategy with features of both acute and preventive treatment (Pavlovic et al., 2014). The advantage for people who spend most of their time in the inter-ictal state and are able to reliably predict attacks is that medication may be taken only when it is needed, that is in advance of an anticipated attack to avoid a headache, not on a daily basis (Lipton et al, 2014). An example of this approach is the short-term prevention of menstrual migraine. An additional advantage is that, because medication is taken only when necessary, it reduces exposure to medication and the harmful effects of medication overuse.

"Life is 10% what happens to you and 90% how you can handle what happens to you." -Anonymous 

There is no cure for migraine disease. However, as research continues to progress, we can increase our knowledge and understanding of associations between trigger factors, protective factors, premonitory features and attacks, and improve our ability to predict attacks , as well as decrease their frequency.

Sharron :)

References:

Friedman, D., I., MD., MPH., & De Ver Dye, T., PhD. (2009). "Migraine and the Environment." Headache. Feb;25:941-950.

Kelman, L. (2004). "The premonitory symptoms (prodrome): a tertiary care study of 893 migraineurs." Headache. Oct;44(9):865-72. 

Lipton, R., B., Pavlovic, J.,M., Haut, S. R., Grosberg, B. M., and Buse, D., C. (2014). " Methodological Issues In Studying Trigger Factors and Premonitory Features of Migraine". Headache. Nov;54(10):1661-9. doi:10.1111/head.12464. Epub 2014 Oct 23. 

Martin, P., R., & Reece, J., et al. (2014). "Behavioral management of the triggers of recurrent headache: A randomized controlled trial." Behavioral Research and Therapy. 61: 1-11.    

Pavlovic, J., M., Buse, D., C., Sollars, M., Haut, S., & Lipton, R., B. (2014). "Trigger Factors and Premonitory Features of Migraine Attacks: Summary of  Studies." Headache.  Nov;54(10):1670-9. doi:10.1111/head.12468.   

Spierings, E., L., H., Donoghue., S., Mian, A., & Wober, C. (2014). " Sufficiency and Necessity in Migraine: How do we Figure Out if Triggers are Absolute or Partial and, if Partial, Additive or Potentiating?" Curr Pain Headache Rep. 18:455. DOI. 1007/s11916-014-0455-y.  

Turner, D., P., et al. (2014). "Nightime snacking, stress, and migraine activity." J Clin Neurosci.  

Sharron is a health and wellness author. A migraineur herself, her most recent book, "Migraine: Identify Your Triggers, Break Your Dependence On Medication, Take Back Your Life-An Integrative Self-Care Plan For Wellness", (2013), is a Conari Press Publication.

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN and her website www.sharronmurray.com .

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.

Copyright December, 2014, Sharron E. Murray

 

 

 


 

 

 

 

 

Tuesday
Oct072014

Migraine-15 steps to create an environment conducive to wellness

"Things may happen around you, and things may happen to you, but the only things that really count are the things that happen in you." -Eric Butterworth   

Migraine is a complex neurological disease thought to affect our nervous systems. Although the exact cause is not known, evidence suggests we have an inherited (genetic) disruption in brain function that makes our brain cells more excitable than others. Because we have sensitive nervous systems, we are vulnerable to changes in our internal and external environments.

There is no cure for migraine. However, an environment conducive to wellness can flourish when balance and harmony exist within ourselves (internal environment) and our surroundings (external environment); in other words, with homeostasis. Constructive steps I learned when my migraines were chronic and I had medication overuse headaches, and that help me thrive today, include:

  1. Identify, manage and, where possible, eliminate your personal triggers.  For example, chemicals and additives in foods and beverages, environmental factors, hormones, magnesium deficiency, and alterations in our physical and emotional states. Maintaining a daily diary can make the task easier, as well as provide a wealth of information for you to share with your doctor.
  2. If the task of identifying your individual food and beverage triggers seems overwhelming, it may help you to begin by eliminating the most popular like alcohol, caffeine (exposure to or withdrawal from), fast food, junk food, sodas, and anything with additives, preservatives, MSG, pesticides, and nitrites. Keep in mind that sweet (including chocolate), rich, salty, and fatty foods may be cravings we experience related to fluctuations in serotonin levels during our attacks and in a prodrome (premonitory symptoms) may be mistaken for a trigger. In addition, many of these may contribute to development of comorbid disorders like hypertension, stroke, heart disease, and obesity. As well, some of them put us at risk for the development of type 2 diabetes.
  3. While avoiding your individual triggers, eat a healthy diet (organic, if possible) of fresh fruits and vegetables (lots of green, leafy), whole grains, fish, chicken and smaller amounts of dairy and red meat to keep serotonin and magnesium levels in balance (low serotonin and magnesium levels are linked to migraine attacks).
  4. Establish regular meal times as hunger (hypoglycemia) can trigger an attack.
  5. Avoid fasting as hunger (hypoglycemia) can trigger an attack.
  6. Stay hydrated as dehydration can trigger an attack.
  7. Avoid environmental pollutants and toxins whenever you can.
  8. Use medications, herbs, and supplements under the guidance of your physician or other health care practitioner and follow directions to avoid toxic reactions and medication overuse headaches.
  9. Maintain a regular sleep schedule and avoid stimulants like caffeine (up to 6 hours), and alcohol and electronic devices at least 2 hours before bedtime. Altered sleep patterns (poor sleep quality) may trigger an attack.
  10. Correct bad posture and reduce the strain on muscles in your neck and shoulders.
  11. Check with your doctor and then begin a moderate exercise program to maintain serotonin levels.
  12. Learn to balance your emotions and control your physiological response to perceived stressors through techniques like self-awareness, cognitive behavioral therapy, daily meditation, biofeedback, guided imagery, and similar focused-breathing techniques.
  13. Incorporate other integrative therapies such as acupuncture, mind-body exercises like tai chi and yoga, reflexology, healing touch, massage, and/or Reiki into your wellness plan to promote relaxation.
  14. If you are an overachiever, learn to set priorities, delegate, say "no", and keep a balance in your daily schedule so one activity does not impose on another.
  15. As much as possible, maintain a positive attitude (on my rough days, it helped me to think of something that made me smile). Positive thoughts have been shown to boost our immune system and contribute to wellness.

Focusing on my good days gave me strength to make it through my bad days and as the good days began to outnumber the bad days, I gained the motivation I needed to succeed. Warm wishes for the best possible wellness for you.

Sharron :)

Note:

This article is part of the series "Bridging The Gap Between East and West: Principle IV: Healthy Lifestlyle Habits For Optimal Health With Migraine."

References:

Murray, S. M.S., R.N. Migraine: Identify Your Triggers, Break Your Dependence on Medication, Take Back Your Life-An Integrative Self-Care Plan For Wellness. San Francisco: Conari Press, 2013.

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN, and her website www.sharronmurray.com

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

Copyright 2014, Sharron E. Murray

Updated September 13, 2016

 

Thursday
Aug072014

Risk of high frequency migraine increases by 40-60% during perimenopause and menopause - "Are you ready for the ride of your life?" -What you need to know 


"Do not become alarmed when you experience yourself in totally new ways," sighs Grandmother Growth, tenderly. "You are changing, getting ready to be initiated into the third stage of your life. Are you ready for the ride of your life? -Susan Weed, Menopausal Years the Wise Woman Way

Menopause marks a major life transition for women, an end to our reproductive years and the cessation of menses. While the end to menstruation and the fear of an unwanted pregnancy may be welcomed by some, others may experience a sense of loss as their last opportunity for conception disappears. Many women may have concerns about cognition and memory, mood disorders, weight gain, increased signs of aging like wrinkles, curtailed sexuality, and decreased libido.

For those of us with migraine, "the ride of our lives" may come with additional challenges. A new study reported at the 56th Annual Scientific Meeting of the American Headache Society found the risk of high frequency migraine attacks increases by 40-60% during perimenopause and menopause for some women.

Data from the 2006 American Migraine Prevalence and Prevention (AMPP) Study survey was used for the analysis (Poster Presentation, Martin et al, 56th Annual Scientific Meeting of the AHS, 2014):

  • Women between ages 35-65 years who met the modified ICHD-3 beta criteria for migraine were included.
  • Women who had never menstruated, were pregnant, breast feeding or using exogenous sex hormones were excluded. Other exclusions included polycystic ovarian syndrome, hysterectomy, or oophorectomy.
  • Women with migraine were classified into a high frequency group if they experienced 10 or more headache days per month and into a low or moderate frequency migraine group if they had less than 10 headache days per month based on responses to the Migraine Disability Assessment Scale (MIDAS).
  • Women were classified as premenopausal (regular menstrual cycles without variation in cycle length), perimenopausal (cycle lengths varied by 7 or more days or periods of amenorrhea lasting 2-11 months) and postmenopausal (absent menstrual periods for at least 12 months) based upon responses to the questionnaire.
  • Women also completed the Patient Health Questionnaire Depression module (PHQ-9) and 3) and Allodynia Symptom Checklist-12 (ASC-12).  

The study authors conclusions were as follows:

  • To our knowledge, ours is the first study to demonstrate that high frequency headache is increased by 40-60% in women during the perimenopause and postmenopause compared to the premenopause.
  • The effect of the menopause and postmenopause on headache frequency is robust to adjustment by depression and allodynia.
  • The strongest predictor of high frequency headache was depression, with odds of high frequency headache being 131% higher for those with depression than without.
  • It is quite likely that the changes in ovarian hormones that occur during the perimenopause and the early postmenopause trigger headaches in these women.

"Persistance in scientific research leads to what I call instinct for truth." -Louis Pasteur

In a press release from the  AHS, Dr. Martin, study lead author, is quoted as saying, "These results validate the belief by many women that their headaches worsen during the transition into menopause." He adds, "We hope our work spurs researchers to develop novel treatments for migraine during this period given that many of the headaches encountered are thought to be hormonally triggered." Dr. Richard Lipton, study co-author adds, "We believe that both declining estrogen levels that occur at the time of menstruation as well as low levels that are encountered during the menopause are triggers of migraine in some women."

To appreciate the significance of the results and conclusions in this study, as well as the implications these findings have for our unique journeys with migraine, this article addresses:

  • the influence of estrogen on migraine.
  • depression and migraine.
  • association of allodynia in migraine with mood disorders and other chronic pain conditions.
  • perimenopause, menopause and migraine.

The influence of estrogen on migraine

Although the association between estrogen and migraine warrants further research, some of the explanations of how estrogen influences migraine that we need to be aware of include:

  • Genetic predisposition (MacGregor, 2010, Sacco et al, 2012). 
  • Estrogens may interfere with cellular excitability (MacGregor, 2009, Sacco et al, 2012). 
  • Estrogen is thought to influence the pain pathway associated with migraine by binding to its receptors on the trigeminal nerves. The trigeminovascular system consists of a network of cranial vessels and their trigeminal innervations that convey pain information to the central nervous system where pain is perceived. The pain response increases by the release of vasodilating neuropeptides especially calcitonin gene-related peptide-CGRP (Milan, 2012, and Sacco et al, 2012).
  • There is an interrelationship between estrogen and brain neurotransmitters, including serotonin, dopamine, norepinephrine, and endorphins. In particular, estrogen is believed to have a potent effect on the serotonergic system (Sacco et al, 2012).
  • Estrogen is associated with increased production of serotonin, reduced serotonin reuptake and decreased serotonin degradation (MacGregor, 2010).
  • Low serotonin levels have been linked to migraine.
  • Because serotonin enhances endorphins (natural analgesic found in the gray matter of the brain), low levels can increase sensitivity to pain. 

Depression and migraine

At this point, it is helpful for us to take a quick look at serotonin. Serotonin is a neurotransmitter in our brain important for managing mood, appetite, sleep and dreaming. For example, high levels make make us feel full, calm, relaxed and even drowsy. Low levels may cause us to feel anxious, irritable and depressed. 

Given the strongest predictor of high frequency headache in this study was depression, we need to know that several studies have linked migraine with mood and anxiety disorders. Some studies suggest mood and anxiety disorders are 2-10 times more prevalent among persons with migraine (comorbid) than in the general population. As well, increased migraine frequency (chronic migraine) is associated with higher rates of depression. (Buse et al, 2012). It has been suggested:

  • serotonergic and dopaminergic dysfunction underlies the comorbidity of depression and migraine (Buse et al, 2012), and
  • "conditions that are comorbid with migraine such as depression and anxiety have presumptive serotonergic mechanisms "(Shapiro, 2008, p 29).

Keeping these things in mind, we also need to be aware that a recent study on "Depression in women: windows of vulnerability and new insights into the link between estrogen and serotonin", (Lokuge, 2011), suggests the effects of estrogen on serotonin may have implications on female mood disorders such as premenstrual disorders and depression during pregnancy, postpartum, and during the menopausal transition.

Association of alloydynia in migraine with mood disorders and other chronic pain conditions

Now, let's peek at cutaneous allodynia (CA). CA is thought to be a result of central nervous system sensitization, which makes us hyperresponsive to otherwise innocuous tactile stimuli. For example, it may hurt to brush our hair or try to put it into a ponytail. As an attack progresses, we may experience sensitivity on extracranial locations such as the arm (Shapiro, 2008, p. 30).  Here, we should be aware that in an estimation of the prevalence and severity of  CA in headache sufferers, results of the AMPP Study (2008) showed CA was more common among migraineurs with female sex, high attack frequency, increased body mass index, disability and depression. 

That said, in a study examining the relationship of migraine with comorbid mood disorders and other chronic pain conditions, (Tietjen et al, 2009), results demonstrated symptoms of CA in migraine were associated with current anxiety, depression, and several chronic pain conditions, including irritable bowel syndrome, fibromyalgia and chronic fatigue syndrome.   

Peri-menopause, menopause and migraine

Holding on to what we have learned so far, it's time to review some general information about perimenopause, menopause, and migraine. To begin with, let's take a brief look at what happens to every women during perimenopause and menopause.

We need to know that as we age and enter perimenopause, our ovaries lose their ability to undergo ovulation and produce estrogen and progesterone. Our pituitary gland, via the hypothalamic-pituitary-ovarian axis, attempts to compensate by releasing follicle-stimulating hormone (FSH) to stimulate an ovarian follicle to produce estrogen. Transient increases of estrogen can occur during this time as FSH surges to stimulate remaining follicles. Menstrual irregularities occur, with sometimes prolonged and heavy menstruation mixed with periods of amenorrhea. When no more follicles remain for stimulation, estrogen levels dramatically decline and menstruation ceases.

Approximately 75-80% of women experience perimenopausal and menopausal symptoms.  Sources vary, but, in general, symptoms are thought to emerge up to 4 years prior to cessation of menses (perimenopause) and may persist for several years postmenopause. Symptoms are believed to be related to the withdrawal of estrogen. Many of them are thought to be associated with resultant changes in the central nervous system neurotransmitters, including serotonin, dopamine and norepinephrine.; and, serum electrolytes, including calcium, magnesium, sodium and potassium. They include:

  • Vasomotor disturbances ("hot flashes", "night sweats"). Although the exact cause is not known, vasomotor disturbances are believed to be caused by a narrowing of the thermoneutral zone in the brain related to the central nervous system neurotransmitters (Archer et al, 2011). In other words "our thermostat is broken". The feeling of intense heat that begins in our upper chest or neck, proceeds up to our face and head and may spread throughout our body, can last for several seconds or minutes and be accompanied by profuse perspiration. When "hot flashes" occur at night, they interrupt our sleep (insomnia). We need to know that they can be precipitated by heat, alcohol, spicy foods, and stress.
  • Sleep impairment.
  • Fatigue.
  • Depression, irritability and other mood disturbances.
  • Cognitive difficulties (loss of concentration, poor memory).
  • Weight gain. Numerous factors may be involved, including decreased metabolism; decreased serotonin levels, with resultant increase in food cravings; and, increased sympathetic nervous system activity, with resultant fluctuation in hormones like cortisol. It is important for us to know that weight gain during this period is often associated with fat deposit in the abdomen, which can increase our risk for developing insulin resistance, diabetes, hypertension and heart disease. Hypothyroidism may become prevalent and exacerbate symptoms like fatigue, weight gain, and mood changes.
  • Sexual dysfunction, including decreased libido.
  • Urinary incontinence.
  • Musculoskeletal pain.
  • Osteoporesis.

Now, let's relate these symptoms to migraine. As you can see, many of these symptoms are the same as (and may be easy to confuse with and exacerbate) migraine triggers (e.g., sleep impairment and fatigue), migraine symptoms (e.g. cognitive difficulties, musculoskeletal pain), and comorbidities (e.g. depression and anxiety).

To add to our discomfort, perimenopause and menopause are the very busiest years of our lives. Many of us are juggling family and career responsibilities, or perhaps, financial worries about college for our children and retirement for ourselves and our partners. The added stress can contribute to migraine as a trigger and a factor that makes us more susceptible to all of our triggers. When chronic, stress can deplete our estrogen levels, decrease our serotonin levels, increase anxiety and depression, and increase the frequency of our attacks. In addition, chronic stress may precipitate an earlier perimenopause and menopause.

"Are you ready for the ride of your life"?

Given I went through a surgical menopause at the age of 42 because of an ovarian cancer scare, I was not prepared for the "ride of my life". Twelve years later, I was diagnosed with chronic migraine, accompanied by medication overuse headaches.

Acknowledging surgical menopause has more severe consequences, to help you prepare and "cushion your ride" through a natural perimenopause and menopause, along with an accurate diagnosis for migraine, it would seem appropriate for you to know where you sit in the menopausal transition:

  • "Despite the increased prevalence of headache and migraine in women in their 40s, migraine is underdiagnosed in this population" (MacGregor, 2009).
  • If you have symptoms suggestive of perimenopause and menopause, along with headaches and other symptoms of migraine, it is important to talk to your doctor about all of your symptoms so they can be managed effectively, with the potential to reduce progression to chronic migraine, comorbidities like depression, unpleasant symptoms such as allodynia, and resultant disability. Blood tests to measure FSH and estrogen levels can determine where you are at in the menopausal transition.
  • The lack of an accurate diagnosis for migraine has been shown to be a barrier to our care,  which may include pharmacological and non-pharmacological interventions. (Buse. et al, 2014).

That said, while we wait for novel treatments to emerge, current pharmacological and non-pharmacological  management of migraine in perimenopause and menopause addresses the same issues as management of migraine at any time, with perhaps the addition of hormone replacement therapy (HRT) at the lowest dose possible to maintain a stable estrogen environment (MacGregor, 2012). It is important for you to know that the benefits and risks of HRT vary with the individual and warrant a thorough discussion with your physician.

In  conclusion, keep in mind our migraine brain likes peace and harmony (homeostasis). Avoiding your other migraine triggers, maintaining a healthy diet and lifestyle habits, and participating in a regular exercise program, along with stress management strategies like mind-body and relaxation techniques, and other modalities like acupuncture, can help you decrease the influence of perimenopause and menopause on your migraine attacks, take control of your attacks and, as I do now, assist you to live a happy and healthy third stage of your life, with migraine.

Sharron :)

References:   

American Headache Society. "Women With Migraine Experience More Headaches During The Menopausal Transition: Results From The American Migraine Prevalence And Prevention (AMPP) Study." Press Release: Wednesday, June 25, 2014, !2:01 a.m. EDT

Archer, D. F., Sturdee, D. W., et al (2011). "Menopausal hot flushes and night sweats: where are we now?" Climateric.  Oct 14;(5):515-28 doi: 10.3109/13697137.2011.608596. http://www.ncbi.nlm.nih.gov/pubmed/21848495 

Bigal, M. E., Ashina, S., et al (2008). "Prevalence and characteristics of allodynia in headache sufferers: a population study. Neurology. Apr 22;70(17):1525-33. doi: 10.12/01.wnl.000031064 http://www.ncbi.nlm.nih.gov/pubmed/18427069

Buse, D. C., Silberstein, S. D., et al (2013). "Psychiatric comorbidities of episodic and chronic migrane." J. Neurol. Aug;260(8):1960-9. doi: 10.1007/s00415-012-6725-x. http://www.ncbi.nlm.nih.gov/pubmed/23132299

Buse, D. C., Lipton, R., et al (2014). "Barriers to Chronic Migraine Care: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study." Poster presented at the 66th Annual Academy of Neurology Annual Scientific Meeting, Philadelphia, PA. April26-May 3.

Edyta, J. Frackiewicz, N. R., Cutler. (2000). "Women's Health Care During the Perimenopause." J Am Pharm Assoc. 40(6). http://www.medscape.com/viewarticle/406706_print  

Lanje, M. A., Dr., Bhutey, A. K., Dr. et al (2010). "Serum Electrolytes During Different Phases of Menstrual Cycle." International Journal of Pharma Sciences and Research.  Vol.1(10), 435-437. ISSN: 0975-9492.

Lokuge, S., Frey, B. N., et al (2011). "Depression in women: windows of vulnerability and new insights into the link between estrogen and serotonin." J Clin Psychiatry.  Nov;73(11):e1563-9. doi: 10.4088/JCP.11com07089. http://www.ncbi.nlm.nih.gov/pubmed/22127200  

MacGregor, E. A. (2009). "Estrogen replacement and migraine." Maturitas. May 20;63(1):51-5. doi: 10.1016/j.maturitas.2009.03.016. http://www.ncbi.nlm.nih.gov/pubmed/19375252   

MacGregor, E. A. (2009). "Migraine Headache in perimenopausal and menopausal women. " CurrPain Headache Rep. Oct;13(5):399-403. http://www.ncbi.nlm.nih.gov/pubmed/19728968

MacGregor, E. A. (2010). "Menstrual Migraine: Therapeutic Approaches." Ther Adv Neurol Disord.  May;3(3):197. http://www.ncbi.nim.nih.gov/pmc/articles/PMC3002599/

MacGregor, E. A. (2012). "Perimenopaual migraine in women with vasomotor symptoms." Maturitas. Jan;71(1):79-82. doi: 1016/j.maturitas.2011.11.001. http://www.ncbi.nlm.nih.gov/pubmed/22115567

Martin, V. T., Pavlovic, M. J., et al (2014). "The menopausal transition is associated with higher headache frequencies in women with migraine: Results from the American Migraine Prevalence and Prevention (AMPP) Study." Poster presented at the 56th Annual Meeting of the American Headache Society. Los Angeles, CA. June 25-29th. 

Milan, A., Puri, V., Puri, S., PhD.(2012). "Effects of estrogen on the serotonergic system and calcitonin gene-related peptide in trigeminal ganglia of rats." Ann Neurosci. Oct;19(4): 151-157. doi: 10.5214/ans.0972.7531.190403. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117063/

Murray, S., M.S., R.N. Migraine: Identify Your Triggers, Break Your Dependence on Medication, Take Back Your Life-An Integrative Self-Care Plan For Wellness. San Francisco: Conari Press, 2013.

Sacco, S., Ricci, S. et al (2012). "Migraine in women: the role of hormones and their impact on vascular diseases." J Headache Pain. Apr;13(3): 177-189. doi: 10.1007/s10194-012-0424-y. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3311830/

Shapiro, R. E. (2008). "Pathophysiology and Genetics of Migraine and Cluster Headache." In M. Levin (Ed.), Comprehensive Review of Headache Medicine. (pp 21-32). New York: Oxford University Press.

Tietjen, G. E., Brandes, J. L., et al (2009). Allodynia in migraine: association with comorbid conditions." Headache. Oct;49(9): 13333-44. doi: 10.1111/j.1526-4610.2009.01521.x. http://ncbi.nlm.nih.gov/pubmed/19788473

Sharron is a health and wellness author. A person with migraines herself, her most recent book is, "Migraine..."

Follow Sharron on twitter @murraysharron, her Facebook page SharronMurray, MS, RN, and her website www.sharronmurray.com

This article is not intended as a subsitute for medical advice. If you have concerns about your health or nutrition, please see a qualified professional.

Copyright, October: 2014, Sharron E. Murray 

Sunday
Jul272014

Family Burden of Chronic Migraine - Heartbreaking results of the CaMEO study - And hope for change

 

"The practice of patience toward one another, the overlooking of another's defect, and the bearing of one another's burdens is the most elementary condition of all human and social activity in the family, in the professions, and in society." - Lawrence G. Lovasik 

An estimated 37-38 million Americans live with migraine, a debilitating neurological condition with episodic manifestations known as migraine attacks. Although the frequency and duration of our attacks varies between us as individuals, those of us who have migraine are familiar with the personal and family burden of our disease.

However, given migraine is often referred to as "just a headache" that will disappear if we take a "pill", it is believed that the burden of migraine is not well understood by many who do not experience it. Keeping this in mind, this article addresses the: 

  • personal burden of migraine,
  • family impact of migraine, and
  • the results of a new study, "Family Burden of Chronic Migraine to the Migraineur".  

Personal burden  

In a review of the literature, "The burden of migraine to the individual sufferer: a review," (Dahlof and Solomon (1998), the authors report, "Migraine attacks can have a profound effect on the day-to day lives and well-being of the sufferer." They go on to say, "In the long term, migraine may cause profound emotional changes and result in coping strategies that interfere with working, social and family life and many normal activities. These effects are apparent in quality of life studies on migraine patients."

Family impact of migraine

To assess the impact of migraine on family life both from the perspective of those with migraine and from the perspective of their partners (Lipton, Bigal et al, 2003), individuals in the USA and UK with six or more migraine attacks per year and living as married with partners were asked, along with their partners, to participate in a computer-assisted telephone interview. Results of the study showed: 

  • 85% reported substantial reductions in their ability to do household work and chores.
  • 45% missed family social and leisure activities.
  • 32% avoided making plans for fear of cancellation due to headaches.
  • 50% believed that because of migraine, they were more likely to argue with their partners, 52% children.
  • 52-73% reported other adverse consequences for their relationships with their partner, and children, and at work.
  • 36% believed they would be better partners but for their headaches.

Of the participating partners, 29% felt that arguments were more common because of headaches and 20-60% reported other negative effects on relationships at home.

Another study on the impact of migraine on work, family, and leisure among women 18-35 years of age in Israel and eight European countries (Dueland, Leira, et al, 2004), found substantial migraine-related impairment of productivity at work and school as well as of family and leisure time.   

Family burden of chronic migraine (CM)

Now, we come to the focus of this article. In general, CM is defined as migraine with headache days occurring 15 or more days per month. About 3-7 million people in the US live with this painful and debilitating condition.

To show that CM is a burdensome and difficult condition, not only for the people who live with it but also for the people they love, a web-based study of 994 men and women with CM was used to measure the perceived nature and extent of CM-related burden on family relationships and activities (Buse, Dodick, et al, 2014). The results presented at the 56th Annual Meeting of the American Headache Society revealed:

  • 64.1% of respondents felt their headaches made their partners lives difficult, and 72.5% felt they would be better partners if they did not have headache.
  • 70.2% of respondents reported being easily angered or annoyed by their partners because of headache, and 67.2% stated they avoided sexual intimacy because of their headaches.
  • 64.4% experienced guilt about how their headaches affect their partner.
  • 59.1% felt that they would be better parents if they did not have headache.
  • 20% of respondents reported missing a family vacation within the previous year and 53.6% had reduced enjoyment while on vacation because of headache.

Females consistently reported lower percentage rates of absenteeism because of headaches than males across many activities. The researchers attributed this to possible differences in headache severity between genders, differential denominators in that females may have more activities and responsibilities, or females may feel more obliged to keep commitments despite migraine occurrence. When asked about these findings in an interview, the lead author of the study, Dawn C. Buse, Ph.D., said, " females (mothers and wives) may simply feel they cannot miss a family event and soldier on despite debilitating pain and associated symptoms". 

In the same interview, when asked if the study results surprised her, Dr. Buse replied, "The results are heartbreaking, but not surprising. I hear how difficult CM is on family life from my patients on a daily basis. I have shared the results of this research with several people with CM over the past few weeks and they say that these data describe their lives."

"Families are the heart of our society. We need to do everything that we can to nurture, support, and protect them." - Dawn C. Buse 

As the interview continued, when asked what consumers and health providers should take away from the study, Dr. Buse responded as follows:

"CM is a debilitating disease that affects all aspects of life including roles, responsibilities, and relationships with the family. We hope that people living with CM realize they are not alone in feeling guilty, worried, or sad about how their condition affects their family. We hope that by shedding light on this experience, people with CM and their families will realize that this is a difficult condition for most people who live with it.

We hope that people who do not have migraine may understand a little better the far reaching burden this condition imparts on sufferers, and hope they will be a little more caring and understanding in response to a friend, colleague or family member with CM. We also hope that by shedding light on the normal and common response to this condition, that we can help remove the stigma and shame that those who bravely live with CM may feel.

We also hope that health care professionals will realize the scope of the burden of this condition on sufferers, and be diligent in providing accurate diagnoses and thorough treatment plans, which include both appropriate pharmacological and non-pharmacological (e.g. cognitive behavioral therapy, biofeedback, relaxation training) interventions. We hope that they will recognize that feeling sad, overwhelmed, guilty, frustrated, irritable, depressed and anxious is common for people living with CM and that they will encourage and facilitate patients seeking professional mental help when these feelings become overwhelming.

We hope that third party payers, policy makers, and government agencies who fund research will recognize the serious and damaging effects of this condition on families and put necessary funds towards research and care."

"Hope begins in the dark, the stubborn hope that if you just show up and try to do the right thing, the dawn will come." - Anne Lamott 

For me, I have been on a roller coaster ride with migraine since I was five years old. When I was in my early forties, at the height of my career and deeply involved in family responsibilities, my migraines began increasing in frequency and severity. At the age of 54, I was diagnosed with CM and medication overuse headache (MOH) and my life was put on hold. Like so many others, a career I loved disappeared and I struggled to cope with day-to-day living and several of the findings we have looked at.  

However, I am extremely fortunate and my story is one of hope. With the help of two amazing doctors and a combination of a preventive medication (which I have been able to reduce) and non-pharmacological strategies like biofeedback, meditation, breathing techniques, acupuncture and healing touch, in my mid 60's I was able to remit from CM and MOH to infrequent episodic migraine (EM).  Consequently, my pain, disability and family burden is much, much less and I enjoy a wonderful quality of life.

I share the results of this study, along with Dr. Buse's interview, in the hope that with the assistance of informed health care professionals, increased funding for research and accurate diagnoses and appropriate pharmacological and non-pharmacological interventions, people who have episodic migraine (EM) can be prevented from progressing to CM, those who live with CM have the opportunity to remit, and if remittance is not possible "that those who bravely live with CM" are able to lead a better quality of life, and because of a more compassionate society, without the stigma they may feel.  

Sharron :).

References:

 Buse, D., C., Dodick, D. W., et al (2014). "Family Burden of Chronic Migraine to the Migraineur: Results of the CaMEO study". Poster presented at the 56th Annual Meeting of the American Headache Society. Los Angeles, CA. June 25th-29th.

Buse, D. C., director, Behavioral Medicine, Montefiore Headache Center and associate professor, Clinical Neurology, Albert Einstein College of Medicine. Interview ( 2014) presented with permission.

Dahlof, C. G., & Solomon G., D., (1998). "The burden of migraine to the individual sufferer: a review." Eur J Neurol.  Nov;5(6):525-533.  http://www.ncbi.nlm.nih.gov/pubmed/10210887

Dueland, A., N., Leira, R., et al (2004). "The Impact of Migraine on Work, Family and Leisure Among Young Women - A Multinational Study." Curr Med Res Opin.  20(10). http://www.medscape.com/viewarticle/491091_print    

Lipton, R.B., Bigal, M.,E., et al (2003). "The family impact of migraine: population-based studies in the USA and UK. Cephalalgia. Jul;23(6):429-40.  http://www.ncbi.nlm.nih.gov/pubmed/12807522  

Sharron is  a health and wellness author. A person with migraines herself, her most recent book is, "Migraine: Identify Your Triggers, Break Your Dependence on Medication, Take Back Your Life - An Integrative Self-Care Plan For Wellness." San Francisco: Conari Press (2013).

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN, and her website www.sharronmurray.com  

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

Copyright, 2014, Sharron E. Murray

 

 

Tuesday
Jun172014

The spectrum of migraine: Barriers to our care - Gaps in diagnosis, treatment and knowledge of individuals with CM in the US

 

"Awareness is the greatest agent for change." - Eckhart Tolle

Migraine is a debilitating neurological condition characterized by migraine attacks. The disease affects about 38-39 million of us in the US. 

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 our headache-related disability. In an effort to help us have a better understanding of the challenges we may face and offer suggestions on ways to overcome these burdens and receive optimal care, this article addresses: 

  • the spectrum of migraine and associated characteristics, and
  • results of a new (CaMEO) study: gaps in diagnosis, treatment, and knowledge of individuals with chronic migraine. 

THE SPECTRUM OF MIGRAINE AND ASSOCIATED CHARACTERISTICS  

To begin with, let's review what happens as we progress from episodic to chronic migraine in relation to our diagnosis; comorbidities; sociodemographic, disability, and employment characteristics; and, risk factors for progression of episodic to chronic migraine (CM).

Diagnosis

In a study that estimated remission rates of subjects with CM, identified predictors of CM remission, and assessed the influence of remission on headache-related disability, (Manack, Buse et al, 2011), our migraines were classified as follows: 

  • Episodic migraine (EM) includes a range of attack frequency with headache days 0-14 per month. If we have headache days 0-9 days per month, we are believed to have low-frequency EM (LFEM). If our headache days occur 10-14 days per month, we have high frequency EM (HFEM). 
  • CM is defined by attack frequency with headache days greater than 15 days per month.

Comorbidities and Sociodemographic, Disability, and Employment Charactersitics  

We need to be aware that, as we progress along the spectrum from LFEM to CM:

  • our comorbidities (obesity, heart disease, angina, high cholesterol, high blood pressure, stroke, circulation problems, arthritis, chronic pain disorders, pulmonary disorders, anxiety and depression) and our individual, family, and societal burdens increase.
  • some psychiatric comorbidities, including depression, are associated with worsening disease progression and disease outcomes, including suicide attempts (possible these comorbidities may be related to shared biological, environmental or genetic risk factors), (Buse, Silberstein et al, 2013).  
  • people with HFEM are thought to share characteristics similar to CM.
  • people with CM are significantly more disabled than those who have EM, have higher levels of unemployment, lower personal and household incomes, increased psychiatric and medical comorbities, and have a greater impaired quality of life both inside and outside the home (Lipton, Serrano, et al, 2014).
  • studies have shown that each year about 2.5% of those of us with EM develop CM.

That said, returning to the study by Manack and Buse, results showed:

  • CM remitted to EM at a 2-year transition rate of 26%.
  • patients with allodynia ( neurons are abnormally excited leading to a reduced pain threshold and hypersensitivity to stimuli); highest frequency of migraines (25-31 days); and, those using preventive medications were less likely to remit (authors mention preventive medications may also increase remission rates but in the study the effects may have been offset by factors like high headache frequency, wrong medication or dose, and poor compliance with regimen).  
  • persistent CM demonstrated increases in headache related disability.
  • remitted CM demonstrated decreases in headache related disability.  

Given this information, it would seem that, as the study authors propose, an accurate diagnosis is necessary to determine where, as individuals, we fit in the migraine spectrum. Once our position is established, the goal of our treatment can be directed toward reducing attack frequency so that:

  • LFEM does not progress to HFEM or CM
  • CM remits to EM.

Risk factors for progression of EM to CM

In line with this approach, a review defining the differences between EM and CM, (Katsarava, Buse, et al, 2011), outlined non-modifiable and modifiable factors that are believed to increase our risk of progression from EM to CM. This is important for us to know because once we identify our personal risk factors, we are able to work with our doctor to improve or eliminate our modifiable ones, decrease the frequency of our attacks and, if we have CM, increase our chances for remission.

Non-modifiable risk factors are reported as:

  • age,
  • female sex,
  • Caucasian race,
  • low education level,
  • low socioeconomic status, and
  • head injury.

Modifiable risk factors are listed as:

  • obesity,*
  • depression,*
  • anxiety,*
  • other chronic pain disorders,*
  • stressful life events,
  • medication overuse, and
  • caffeine use/misuse.

*As mentioned above, these risk factors may be comorbid with migraine. Here, it is beneficial for us to know that along with directing treatment towards our personal comorbidities and individual risk factors, preventive pharmacological and non-pharmacological treatments and strategies have been shown to help decrease the frequency of our attacks.  

GAPS IN DIAGNOSIS, TREATMENT, AND KNOWLEDGE OF INDIVIDUALS WITH CHRONIC MIGRAINE IN THE US   

Now, let's look at CM. About 3-7 million people in the US are believed to live with CM. In an effort to bring more awareness to the individual, society and the health care systems about the burden of CM, a recent study (CaMEO) examined self-reported headache diagnosis rates, health care consultation patterns, and knowledge and use of preventive treatments among a large, US population-based sample of individuals with CM (Buse, Lipton et al, 2014).

Gaps in diagnosis, treatment and knowledge

In this instance, headache types were classified as migraine, CM/transformed migraine (TM), or CM/TM/chronic daily headache (CDH). Results demonstrated:

  • rates of headache subtype diagnosis and consultation for headache were low among individuals with CM (most CM respondents did not receive a diagnosis of CM, even among those consulting  "headache specialists"). This is a barrier to care as diagnosis is necessary for designing an optimal treatment plan, which may include diagnosis-specific treatments.
  • those meeting CM criteria who did seek care from a "headache specialist" were more likely to report being diagnosed with CM, but also with migraine, TM and CDH.
  • awareness of daily preventive medication for headache was high, especially among those currently seeing a "headache specialist", although awareness of injection was low in the same group, and even lower among those who reported they were not under the care of a "headache specialist".
  • knowledge and use of empirically and guideline-supported non-pharmacological treatments for migraine prevention was low among those under the care of a "headache specialist" and very low among those not under the care of a "headache specialist".

Awareness of preventive treatments and strategies among all respondents with CM was as follows:

  • avoiding things or activities that trigger my headaches - 62.7%
  • taking a daily prescription medication - 53.0%
  • receiving injections every few months - 17.4%
  • vitamins or herbs - 33.5%
  • biofeedback - 16.8%
  • relaxation techniques (meditation, visual imagery, diaphragmatic breathing) - 47.5%
  • cognitive behavioral therapy (CBT)/psychotherapy - 12.9%
  • acupuncture - 33.5%
  • yoga - 29.2%
  • exercise - 48.8%
  • weight management/dieting 34.6%
  • not aware of any ways to prevent headaches or reduce their severity - 17.9%
  • don't remember - 1.9% 

The authors conclude these data demonstrate gaps in the diagnosis, treatment, and knowledge of individuals with CM in the US and offer opportunities for improvement in care.

Opportunities for improvement in care

"The natural healing force within each of us is the greatest force in getting well." - Hippocrates

Another finding in the CaMEO study showed more respondents who were under the care of a "headache specialist" consulted a "nonprescribing" health care professional for a headache than those who were not under such care. These "nonprescribing" health care professionals included: chiropractors, massage therapists, acupuncturists, physical therapists, psychologists or other health care professionals, naturopaths, and occupational therapists.

A recent article addressed the use of complementary alternative medicine, "CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don't," (Cowan, 2014). The author suggests "that until such time as the body of scientific literature adequately addresses non-conventional approaches, physicians must acknowledge and understand, as best as possible, CAM approaches which are in common use by patients." 

Given this information, it is important to know that even though more research is necessary to establish evidence-based guidelines for some non-pharmacological therapies, many of us use these treatments and strategies because along with quieting our minds, calming our bodies, combating feelings of hopelessness and despair, and decreasing the frequency and severity of our attacks, they give us a feeling of empowerment. As well, because medications alone do not work for a number of us and lead to medication overuse headaches,  (MOHs) they give us a viable option for therapy.  

"The difference between a stumbling block and a stepping stone is how high you raise your foot." -Benny Lewis.

To overcome barriers to our care, it would seem that those of us with migraine need to:

  • receive an accurate diagnosis within the migraine spectrum, including CM,
  • work with our doctors and other health care professionals to identify and manage our comorbidities and risk factors, and
  • as research continues to unfold, increase our knowledge as we share and explore pharmacological and non-pharmacological treatment options with our doctors and other health care professionals to improve our care.

For me, effective communication with my doctor facilitated my diagnosis of CM and MOHs. And, even though they were foreign to me at the time, non-pharmacological therapies like biofeedback, acupuncture, meditation, diaphragmatic breathing, and healing touch, became instrumental in my remittance to EM. As well, along with trigger management, regular exercise, and a healthy diet and lifestyle habits, they continue to be the foundation of my remission.

Sharron:).

References:

Cowan, R.P., M.D., F.A.H.S., F.A.A.N. (2014). "CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don't." Headache Currents.  April, 25. DOI: 10.1111/head.12364.

Buse, D., C., Lipton, R., et al (2014). "Barriers to Chronic Migraine Care: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study" Neurology. April 8, 2014 vol. 82 no. 10 Supplement I9-1.004.

Buse, D., C., Lipton, R., et al (2014). "Barriers to Chronic Migraine Care: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study." Poster presented at the 66th annual Academy of Neurology Annual Scientific Meeting. Philadedelphia, PA. April 26- May 3.

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.

Lipton, R., 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, 2014 vol. 82 no.10 Supplement S41.002.

Katsarava, Z., Buse, D.C., et al. (2012). "Defining the Differences Between Episodic Migraine and Chronic Migraine." Curr Pain Headache Rep. February; 16(1): 86-92.

Manack, A., Buse, D.C., et al. ( 2011). "Rates, predictors and consequences of remission from chronic migraine to episodic migraine." Neurology.  Feb 22;76(8):711-8. doi: 10.1212/WNL.0b013e31820d8af2.

Sharron is a health and wellness author. A person with migraines herself, her most recent book is "Migraine: Identify Your Triggers, Break Your Dependence on Medication, Take Back Your Life - An Integrative Self-Care Plan For Wellness". San Francisco: Conari Press, 2013.

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN, and her website www.sharronmurray.com

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