Welcome to Ask the Migraine Knowledgeable, a column about managing life with migraine from Deena Kuruvilla, MD. Kuruvilla is a board licensed neurologist and director of the Westport Headache Institute in Fairfield County, Connecticut. Obtained a query for the migraine knowledgeable? Submit your query through this form.
Pricey Migraine Knowledgeable,
Why does remedy cease working, or not work as properly for some because it does for others? What makes some folks refractory or proof against remedy?
— Courtney Lynn, Migraine Healthline neighborhood member
Although a whopping 40 million folks have episodic migraine (fewer than 15 headache days per 30 days) and round 4 million folks in the US have persistent migraine (15 or extra headache days per 30 days), receiving an correct prognosis and an optimum remedy plan can have a number of hurdles.
Even should you do obtain an correct prognosis, discovering an efficient remedy routine may be difficult. Migraine is a posh situation that entails a number of totally different pathways inside your mind.
Typically, it might take a mix of two or extra preventive remedies to handle your ache.
Based on the American Headache Society, migraine medical doctors ought to take into account a preventive remedy if migraine complications are occurring 4 or extra days per 30 days or if any migraine headache is leading to important incapacity.
The targets of preventive remedies are to scale back:
- the variety of general headache days
- the severity of every particular person headache
- the quantity of as-needed remedy getting used
- migraine-related incapacity
When somebody hasn’t responded to 2 courses of preventive remedies and three courses of acute remedies, we name this “refractory migraine.”
It’s vital for migraine medical doctors to determine folks with refractory migraine, as a result of they’ve extra day-to-day incapacity. They could require a number of specialists on their care group, together with a:
- headache specialist
- sleep specialist
- bodily therapist
Migraine episodes are considered attributable to a number of totally different mechanisms, akin to:
- an inflammatory storm
- atypical electrical exercise within the mind
- the fluctuation of chemical compounds like serotonin, dopamine, and norepinephrine within the mind
The totally different migraine prevention remedies we have now out there goal these totally different mechanisms.
Since a person with migraine could have one, two, or extra mechanisms inflicting their migraine episodes, a multifaceted strategy could also be essential to successfully present remedy.
To make an individualized remedy plan, I usually talk about the next with my sufferers:
- way of life modifications
- nonmedication approaches, akin to gadgets
- mainstream preventive drugs
- rescue drugs
We additionally work to deal with different well being considerations which are widespread with migraine, akin to anxiousness and sleep issues.
Particular threat components can convert episodic migraine into persistent migraine.
A few of the nonmodifiable threat components embody:
- having been assigned feminine at beginning
- being white
- having a earlier head or neck harm
- hectic life occasions, akin to divorce or work adjustments
Treatable threat components embody:
- overuse of as-needed drugs
- weight problems
- melancholy or anxiousness
- sleep issues, akin to obstructive sleep apnea
As I’ve talked about, migraine remedy may be sophisticated. There are three principal components that may make migraine tougher to deal with.
Medicine adaptation headache, often known as remedy overuse headache, has the next traits:
- headache current on at the very least 15 days per 30 days
- common overuse for at the very least 3 months of a number of medicine that may be taken for acute or symptomatic remedy of headache
- headache has developed or markedly worsened throughout remedy overuse
- headache resolves or reverts to its earlier sample inside 2 months after discontinuation of overused remedy
I’m regularly requested, “What counts as overuse?”
If you happen to’re utilizing sumatriptan, opioids, or drugs that comprise a mix of caffeine, acetaminophen, opioid, or aspirin 10 or extra days per 30 days, you’re in danger for remedy adaptation headache.
If you happen to’re utilizing easy over-the-counter analgesic drugs, akin to ibuprofen or naproxen, 15 or extra days per 30 days, you’re in danger for remedy adaption headache and your complications may turn into extra frequent and extreme.
If somebody is utilizing as-needed drugs this regularly, I usually optimize their migraine preventive remedies to help them in decreasing the quantity they’re utilizing.
Nervousness and melancholy
Temper issues are generally a bundle cope with migraine.
In my expertise, about half of individuals with migraine have anxiousness dysfunction and about 1 in 4 folks with migraine have melancholy.
Temper issues should be addressed when assessing migraine. If one in all my sufferers shares emotions of hysteria or melancholy, I usually suggest a preventive remedy that has been studied for each temper issues and migraine prevention.
It’s additionally vital for us as neurologists to companion with psychologists so we are able to supply nonmedication approaches to temper administration, akin to:
- cognitive behavioral remedy
- mindfulness-based methods
I generally encounter obstructive sleep apnea and insomnia in my headache apply.
Many sufferers report that they’ve hassle attending to sleep or placing their minds to relaxation at night time, get up regularly, snore, or get up with complications and feeling unrested.
Partnering with a sleep specialist and psychologist may be elementary to managing migraine.
Many sufferers will go for a sleep research to see if they’ve any pauses of their respiration in a single day or to only examine their sleeping sample. Typically, a machine to assist respiration, a medicine to assist with sleep, or cognitive behavioral remedy with a psychologist may be extraordinarily useful instruments so as to add to an individualized remedy routine.
Migraine is an advanced situation and it’s comprehensible to really feel discouraged in case your remedies have stopped working.
Nevertheless, many individuals do see enchancment after working with their care group to deal with underlying points and new remedies. You don’t want to surrender on the trail towards fewer ache days.
Deena Kuruvilla is a neurologist who’s captivated with all issues headache. She has made it her life’s mission to deal with, educate, and produce consciousness to headache situations akin to migraine. She is the director of the Westport Headache Institute and has performed analysis on medical gadgets, complementary and integrative medication, and procedures for headache remedy. She has been featured in Prevention Journal, Neurology At this time, the Hartford Courant, and the Wall Avenue Journal. She lives in Fairfield, Connecticut, along with her husband and two kids and loves watching “The Masked Singer” along with her household. Join along with her on Facebook or Instagram.