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Difficult Migraine Patient

Ask the Expert from April 2011

Question: What do you do when your patient does not do well on their current migraine medications?

Answer: As a pain management and headache specialist, I often see patients from all across the United States, and several countries, who do not respond well to their present medication regimen for migraine headaches.

Many reasons are possible: either the migraines have progressed in severity or frequency; or the person may be given medications that can actually increase the frequency and severity of migraines. We call this phenomenon medication overuse headache [MOH] and at least 10 medications can contribute to this phenomenon. For example, medications such as hydrocodone, aspirin, acetaminophen, and other short-acting analgesics can cause this problem. Medication patterns also can change over time and 25% of patients with intermittent migraines can develop what is known as transformed migraine, which is more frequent and more difficult to treat, and often associated (80%-90%) with the use of medications as described above.

The first consideration is to make sure that the patient is seeing a headache specialist in their region, as general neurologists and general doctors will treat up to their point of comfort, and may not know what to do further. In our clinic, we use a very active IV treatment approach to flareups of headache, migraine, and pain. This is relatively unusual in our field, as yet. Certainly, headache experts can be very helpful in devising newer medication strategies and maintaining close follow-up of patients. Every specialist practitioner, of course, has his or her choices of medications and these may not be the same as what the patient has been given.

I know this is a brief response to a very broad question. And of course, other medical issues like anxiety, sleep patterns, and comorbid medical conditions, have to be evaluated and thought about. There are 300 medical and surgical items that can be a promoting factor or cause of migraine. I have been interested in endocrine abnormalities and how they can affect or promote headache and migraine patterns. There are more than 70 of these and they are mostly not checked for in routine headache practices. For example, we pick up more than 300 patients a year who have thyroid and sugar dyscontrol issues and other endocrine problems that may be fueling migraine headaches. Because migraines are more common in women than men, other endocrine factors such as estrogen, progesterone and testosterone, and growth hormone may play a role.

Last updated on: December 9, 2011
First published on: May 1, 2011