As the Science & Health Editor, my role is to share information about Chronic Migraine: breakthroughs in understanding its origins and its treatments. I’m not a medical expert. I don’t even have a degree in a health related field. However, I do have Chronic Migraine and a research background. That’s made me an eager consumer of Migraine-related research.
In this first edition, though, I thought I would break down some common Migraine terms and treatments for those who are new to their migraine diagnosis and looking for a place to start.
CHRONIC VERSUS EPISODIC
The terms “chronic” and “episodic” are used frequently in the migraine community, but their meaning can differ and that can be confusing. For example, people describe migraine as a “chronic” disease with “episodic” attacks. Everyone with migraine has a chronic disease in the sense that it is persistent and has no cure; you always have “Migraine Disease”.
However, there might be days you don’t have a migraine attack. When you do, each of these discrete attacks are considered an “episode”. Many migraine advocates have begun to speak of migraine in these terms to convey its magnitude and seriousness to others.
You have likely heard similar terms used in the clinical context, perhaps, in the diagnoses your doctor gave you. Maybe you had “Episodic Migraine” for some period of time, but were more recently diagnosed with “Chronic Migraine”.
In this clinical context, the number of individual migraine attacks per month determines whether one is diagnosed with episodic migraine or chronic migraine. To be diagnosed with Chronic Migraine means you experience headaches on 15 or more days per month. Of those 15 “headache days,” you have the full-blown symptoms of migraine on eight or more days. Additionally, these symptoms must last for at least three months. (International Classification of Headache Disorders)
MIGRAINE PREVALENCE & THE CHRONIC MIGRAINE RISK FACTORS
Migraine Disease affects about 12 percent of the U.S. population, or roughly 38 million people. About three to four percent of those people with Migraine Disease have Chronic Migraine. Each year, about two to three percent of people with Episodic Migraine will transition to Chronic Migraine. (Lipton 2009; Scher et al 1998)
Risk factors of transitioning to Chronic Migraine vary; some factors can be changed with migraine treatments and others are just part of who we are. For example, the risk of transitioning from Episodic Migraine to Chronic Migraine varies by age and gender, but those aren’t characteristics we or our doctors can easily change. On the other hand, risk of transitioning from Episodic to Chronic also includes things we can proactively affect, and thereby, lessen our risk: migraine attack frequency, obesity, stressful life events, snoring or sleep apnea, caffeine consumption, and using our abortive medications too frequently. (Bigal 2006)
HOW TO PREVENT THE TRANSITION TO CHRONIC MIGRAINE
We can do lots of things to prevent or reverse this transition from Episodic to Chronic Migraine; many focus on lifestyle modification: they develop good sleep hygiene, elimination of common food triggers, incorporate stress-reducing practices like meditation or distractions, maintain regular exercise, and stay hydrated. All of these are topics the My Chronic Brain team will seek to cover in this and other issues.
However, it is important to remember that Migraine is a neurobiological disease. For some of us, we can minimize every trigger and still experience migraine attacks. For that reason, an important step to take is talking with your primary care doctor or headache specialist about your migraine treatment plan. If you aren’t already on a treatment and are experiencing increasing migraine attacks, talking with your doctor about available preventive and abortive treatments can be a step in the right direction.
For clarity, “preventive” treatments are used in order to stop migraine attacks from occurring. Most preventives are taken daily, however there are some preventive treatments for Chronic Migraine that are administered every month or every three months. Preventive treatments are generally recommended for people who experience four to five migraine days per month or about one migraine attack per week.
On the other hand, “abortive” or “acute” treatments are used as needed, at the first sign of an attack, in an effort to stop or slow a migraine attack from getting worse.
If you experience four or more migraine days per month, you will likely want an effective abortive treatment, too. However, for people with migraine who experience fewer than about 4-5 migraine days per month may need only an abortive treatment.
When it comes to prevention, currently, the only FDA-approved treatment specifically for Chronic Migraine is Onabotulinumtoxin A, better known by its brand name Botox®. Botox is administered as a series of injections into the head, neck, and shoulders by a healthcare professional every three months.
Aside from Botox, people with Chronic (and Episodic) Migraine have relied on medications borrowed from other diseases and disorders. The three major categories are anticonvulsants, antihypertensives, and antidepressants.
Topiramate (Topamax®), an anticonvulsant drug initially developed for epilepsy, is commonly used in migraine prevention. It is thought to calm the “hyperexcitability” in the brain that leads to migraine attacks. (American Migraine Foundation)
Antihypertensive drugs, developed to treat high blood pressure, include the beta blockers, calcium channel blockers, and angiotensin receptor blockers. Though they can reduce blood pressure and block neurotransmitters in the body, it less clear how this translates to a reduction in migraine symptoms. Candesartan is an angiotensin that is often used to treat chronic migraine. Antidepressants such as tricyclics, SSRIs, and SNRIs, have also been prescribed; medications like amitriptyline and venlafaxine. These appear to work on neurotransmitter levels in the brain, in turn, affect pain levels. (Migraine.com)
In May 2018, the FDA approved the first preventive treatment developed specifically for Migraine: the CGRP antibodies. CGRP stands for “calcitonin gene-related peptide.” This is a neuro peptide – or protein – that is released within our brains brains and causes inflammation which, for many people, can trigger a migraine attack.
Three CGRP antibodies have been approved by the FDA already. The first, Aimovig® (erenumab) was approved in May 2018. Ajovy® (fremanezumab) and Emagality® (galcanezumab) were approved in September 2018. Eptinezumab has yet to be submitted for FDA approval.
There are other preventive treatments that your doctor might also suggest. Some are over-the-counter supplements like magnesium, riboflavin (vitamin B2), or Coenzyme Q10. Ohers, like nerve block injections, require a doctor to administer. Some can require big out-of-pocket expenses, like neuromodulation devices (e.g., sTMS®, Cefaly®). (American Migraine Foundation)
There are three main categories of acute medications used to abort migraine attacks: triptans, anti-nausea medications, and anti-inflammatory medications. Triptans are commonly prescribed treatments for migraine attacks and include brand names such as: Imitrex (sumatriptan), Maxalt (rizatriptan), Frova (frovatriptan), and Relpax (eletriptan).
Triptans do not work for everyone and are not indicated for use by people with cardiovascular diseases. Alternatives to triptans include ergots, anti-nausea medications, and anti-inflammatory medications.
Ergots (dihydroergotamine 45) are some of the oldest acute treatments, but can exacerbate nausea. (Mayo Clinic) Whereas, anti-nausea medications such as promethazine, metoclopramide, thorazine, and prochlorperazine can play double-duty by managing nausea and relieving migraine-associated head pain.(VeryWellHealth.com)
Anti-inflammatory medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), include ibuprofen, diclofenac, and naproxen sodium. While NSAIDs may not work for everyone and can be contraindicated in people with gastrointestinal issues, they do not appear to put you at as a high of a risk of developing medication overuse headache as triptans. (American Migraine Foundation)
These treatments need to be taken at the first sign of a migraine attack to be most effective.
FIND A SPECIALIST
I want to stress that My Chronic Brain isn’t a substitute for the wealth of medical advice you could receive from a certified headache specialist. Headache specialists can be difficult to access given how few there are; but it can be worth the effort to visit one. Remember, the more attacks you experience, the greater your risk of developing Chronic Migraine, so don’t wait to treat your attacks. Stay on top of them!
Here are some tips to get you started in the process. Also check out “Finding the Right Doctor to Treat Your Chronic Migraine” for more details!
1.Find a headache specialist. We suggest that you use the following lists to find a certified headache specialist near you. While you might have been seeing your local primary care physician to this point, effectively managing Chronic Migraine can often surpass their expertise. Adding a headache specialist to your healthcare team can open new treatment opportunities.
American Migraine Foundation
National Headache Foundation
Migraine Research Foundation
2.Track your migraine attacks. It may take a while to get in for your first appointment. Use this time to track your migraine attacks if you
haven’t been. Tracking simple items like the date, pain rating, other symptoms, medications taken and whether they worked, and possible triggers (e.g., food, weather, menstruation, poor sleep, etc.) can be very helpful at your first appointment. Some of the available migraine tracking apps allow you to export reports to take to your appointments.
Apps for migraine tracking
(Note: Curelator is now called N1-Headache.)
3.Gather other health information. There is a good chance your new headache specialist will send a packet of new patient forms to fill out in advance, but if not, try to gather other information like all the medications you have tried currently and in the past (and dosages), personal and family health history, and any other notes you can think of that might be helpful in regards to your migraine patterns.
Sample new patient forms from Thomas Jefferson Headache Center
Write down your questions. Do you have a lot of questions? Prioritize them and keep them short. Chances are, you won’t have a lot of time in your appointment.
We will dive deeper into many of these topics in future editions of our magazine. If you have specific topics you want to hear about, feel free to reach out!
Beth Morton, PhD
Beth lives in Vermont with her very furry cat Sophie. She was forced to leave her blossoming career in education program evaluation in Boston when her episodic migraine turned chronic. She spends her days advocating for migraine research and awareness, baking, and listening to audio books. Find her on Twitter @beth_morton or on her blog The Counterfactual Brain