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10 Articles in Volume 17, Issue #5
Cross-Linked Hyaluronic Acid Injection for Neuropathic Pain
Discussing Migraine: What to Try When Nothing Is Working
IV Propofol for Treatment of Chronic Intractable Cluster Headache: A Case Series
Letters to the Editor: Rapid Opioid Metabolizer, Intractable Pain, Adrenal Suppression, Traumatic Brain Injury
Migraine Treatment: What’s Old, What’s New
Schizophrenia Spectrum and Chronic Pain: Is Pain Insensitivity a Myth?
Spinal Fluid Flow and Pain Management
Step-by-Step Technique for Targeting Superficial Radial Nerve Pain
The Primary Care Provider’s Role in Diagnosing and Treating Rheumatoid Arthritis
What is the appropriate use of phone texting between physicians and patients?

Discussing Migraine: What to Try When Nothing Is Working

As migraine frequency increases, so does the required expertise. There are 2 headache experts in the room: the provider and the patient. The clinician is going to know generalities about why something did not work, but the patient is the only one who knows specifics.

When migraine remains refractory, approach the patient as a cold case. Go back to the beginning. Repeat the physical examination. Inquire with greater detail about the origin of the headaches. Was it a slow transition of episodic migraine transforming into chronic migraine, or was it a pattern of episodic migraine that suddenly became daily (as seen in new daily persistent headache)? Did the headache start as a unilateral headache (hemicrania continua) and then transform into chronic migraine? Has cluster headaches become comorbid with migraine?

As frequency of migraines increases so does the need to involve the patient in pain management.

If not already in place, engage the collaborative care model. This model recognizes that there are 2 headache experts in the room: the provider and the patient. The provider is a coach offering guidance to the patient, who executes the plays. As migraine frequency increases, so does the required expertise. However, at a certain point, what likely will determine successful migraine management is not the clinician’s expertise but the patient’s. When you reach the point where “nothing is working,” the most important thing to understand is why something did not work. The clinician is going to know generalities, but the patient is the only one who knows specifics (Figure 1).

Leadership and Commitment

When the patient does not achieve satisfactory results, it is time for the clinician to demonstrate leadership-cultivating migraine expertise in the patient.

We must help lead patients to a plan that fosters commitment. Our patients must commit to the collaborative model and to becoming a headache expert. Commitment is the single biggest predictor for success in any human endeavor. Commitment leads us to dissatisfaction with the passive observation that a therapy didn’t succeed. Commitment drives us to learn why it failed. Failure to improve may occur for several reasons:

  • A diagnosis may be incorrect or incomplete
  • Perpetuating factors may not have been identified or appropriately addressed
  • There may have been poor adherence to pharmacological and/or nonpharmacological treatments,1 rational polypharmacy may not have been incorporated, or medication overuse may have blunted improvement

Other nonanalgesic substances, such as caffeine, vitamin A, or vitamin D, might have precipitated a sensitized nervous system. The patient might have unrealistic expectations regarding improvement (ie, expecting pain freedom). When expectations exceed reality, disappointment leads to disengagement and distress.  

When reformulating a therapy plan, focus on attack frequency instead of attack severity. In my 17 years of providing migraine care, I have yet to have a patient say he or she had a good migraine. They are all bad. By definition, migraine is a disabling attack of headache. Focusing on individual attacks fosters catastrophizing—it is akin to focusing on the battle and not the war. It is difficult to win any war if you don’t win at least several battles, but successful migraine managers will know they have a brain that can be provoked into having a disabling attack of headache. That fact cannot be changed. What the patient can do is develop a “war” strategy. Not having a plan for migraine prevention, acute care, and rescue care is asking to get caught off guard.

Return to the Beginning

The first questions are always: Is the headache a primary or secondary headache? Is headache the condition or the symptom? This determination may be a particular challenge since the principal manifestation of head pain is expressed along the migraine pathway.

Over time, secondary headaches may evolve into a primary headache phenotype (as seen in a post-meningitis or post-traumatic headache). A re-examination should take place to rule out any secondary headaches. Once a secondary headache has been ruled out, examine for common and uncommon migraine progression factors (Table 1).2,3

Clinicians need to identify these perpetuating factors and understand any interactions to fully address them. Separate plans and consultations for certain factors (eg, sleep and depression) may require outside consultation.

Headache Procedures

Several procedures have demonstrated benefit in migraine management, including lower cervical intramuscular injections,4 nerve blocks,5 pericranial injections,6 and onabotulinum-toxinA (Botox) injections.7,8 While the mechanism of action for headache procedures is unclear, these procedures have been shown to reduce migraine frequency and intensity. These procedures may all be performed in the clinic, and the sphenopalatine ganglion block may be used by patients at home on an as-needed basis.9

If migraines aren’t improving, it may be appropriate to consider medications less commonly used. These include monoamine oxidase inhibitors,10,11 stimulants,12 steroids,13,14 and atypical analgesics (eg, ketamine).15 While these medications come with risks and challenges, they can be part of a plan that turns failure into success.

The Brain, Pain, and the Brain in Pain

An effective headache expert needs basic knowledge of the brain, pain, and the brain in pain. We should never think of the brain as an enemy, but we do need to realize that sometimes the brain has a mind of its own.

The Brain

Understanding brain basics helps direct productive behavioral interventions. The brain is designed for action (to respond to input), and it does not respond to an absence of stimulation. Being wired for action, the brain will only recognize painful exacerbations, not improvements. It must be trained to look for and embrace better moments (ie, “black duck” moments16).

It is also important to understand that our brains do not want to think. When the brain is thinking, it isn’t acting. This is easily understood when we consider how the brain would be limited if it had to think about every action the body takes during a day. The brain solves this problem by trying to do as much as possible automatically through reflexes and learning. However, the learning the brain does to function automatically is associative, not cognitive  (lightning → thunder, water → wet, water on the floor → slippery). The brain does not want to think about what to do when it perceives pain. The brain’s prime directive is survival, guiding the body successfully through today into tomorrow. An important tool the brain uses for this is pain recognition. The brain does not want to think about responding to pain, it only understands pain as damage directing a response (as if threatened). This pain-perception-as-threat draws attention to pain to elicit a response. In migraine, this presents a unique challenge in that we may not be able to do anything about the pain. Thus, the brain’s attention over time reinforces the pain as “what we pay attention to grows.”

Pain

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”17 The brain intuitively draws a single straight line from an event (occurrence/nociceptive input) to the experience. It is essential to recognize that the pain experience is not a straight-line transmission of a nociceptive event but an integration of sensory and emotional components as represented by the IASP definition. There is always an emotional response to the sensory input. If there is not an emotional response, then there is no pain experience.

Pain Pathways

The pain experience is a perceptual experience based on how the brain understands the event. It is the summation of the sensory-discriminative and the affective-motivational pathways.18

Recently, it has been proposed to view pain as a hologram.18 A hologram is a 3-D image created by a convergence of at least 2 laser beams. Additional laser beams make the hologram more vivid, so, the more inputs to the pain experience, the more vivid the experience becomes.

The sensory-discriminative pathway conducts the transmission of peripheral nociception from sensory receptors along heavily myelinated fibers to synapse in second-order neurons in the dorsal root ganglions of the spinal cord. There, they cross over and rise via the spinothalamic tract to the thalamus and then to the contralateral somatosensory cortex. This pathway provides specific detail about the nature of the signal (sharp, dull, hot, cold, light touch, deep touch) and its precise location.

The affective-motivational pathway principally uses the poorly myelinated C fibers rising in the spinothalamic tract, but branching off to the parabrachial tract to synapse in the thalamus and onto the anterior cingulate cortex, prefrontal cortex, amygdala, hippocampus, insula, and limbic system to be distributed bilaterally throughout the cortex.19 This pathway is associated with suffering. The multiple inputs to affective-motivational pathway explain many of the comorbidities seen in migraine. The amygdala, hippocampus, caudate, anterior cingulate cortex, supraorbital cortex, and prefrontal cortex have all been documented as having a role in the mood disorders associated with migraine. These connections also allow us to understand the concept of “limbically augmented pain” (pain greater than the sum of its parts) by showing that pain and mood share many common pathways/programs.20 These common pathways help us understand how unmanaged stress, past traumas, or depression amplify suffering.

The sensory-discriminative and affective-motivational pathways are integrated in the caudate nucleus via tonically active neurons (TANs). It is here that the cognitive and emotional inputs interact with the experience/memory output to the thalamus, basal ganglia, and ultimately to the motor cortex, so the integrated signal may be acted upon.21 The absent or diminished higher-level cognitive input will allow the reflexive brain to drive the perceived integration. The result is a more emotionally programmed pain experience yielding greater suffering.

As the number of inputs to the experience (as in the case of a hologram) is maintained or increased, the nervous system becomes sensitized to the point where lower signals are required to perpetuate the pain experience.22 The result is that the brain learns pain.

In the chronic pain state, neuroplastic changes sensitize the pain experience by coloring it in a negative way. This sensitization may occur in either the affective-motivational or sensory-discriminative pathway, or both.                                  

Advanced Behavioral Management

Behavioral interventions for refractory migraine require the commitment and knowledge that the pain experience is based on component parts and neuroplastic changes (learned programs). The goal of behavioral pain management is learning how to be “comfortable with being uncomfortable.” I will often ask my patients to become the “garbage collector.” When you ask the garbage collector, “What’s that smell?,” the most likely response will be, “What smell?” It is not that the garbage collector’s olfactory nerves are not functioning, but he or she has learned over time that the smell can be ignored. Over time, if attention is redirected, it will be difficult for the brain to maintain the neuroplastic changes that perpetuate the pain experience.

Do not accept the answer that someone doesn’t have time for behavioral interventions. Our patients have the same 24 hours in a day that everyone else has, they have just made different choices on how to spend their time. If our patients cannot make different choices, then they cannot expect different results.

Migraine is like a child throwing a tantrum. The tantrum is not providing any useful information. The tantrum is not telling you any specific needs, such as “I am hungry, cold, or frightened.” It is stating, “I want my way.” It does not guide you toward a wise choice; it just does not make sense. The tantrum is “nonsense.” The trouble is that when you pay attention to the tantrum, you get more tantrum. Accordingly, when we pay attention to the pain, over time we get more pain. Neuroplastic adaptations in the central nervous system lower the levels for nociception perception and the already sensitive nervous system becomes more sensitive.

Gait ignition failure, as seen in some Parkinson’s disease patients, is the inability to initiate a forward step. Similarly, many of our chronic migraine patients cannot see a way to move forward. In the case of the Parkinson’s patients, a visual cue is placed in front of them to help them move forward. We may also lead our patients to step forward by incorporating mantras (“all I have to do is get through today”) or using inspired distraction, such as a theme song or a role model. The use of mantras is beneficial, as it taps into the automatic brain. Mantras allow words to become actions over time by repetitively pairing words to actions. Positive neuroplastic changes are then made as “what fires together wires together.”23

Drawing Attention Away From Pain

Aggressive behavioral pain management strategies are those that do not deny the existence of the pain, but rather seek to draw attention away from the pain with other activities. An example of this is seen in the movie The King’s Speech. Portraying Prince Albert, Colin Firth was able to read without his impenetrable stutter because he was wearing headphones playing classical music, which effectively distracted his brain from running his automatic stuttering program. In the absence of the competing interests, the sensitized nervous system will run the preprogrammed learned pain program. In this instance, what is needed is a recognition that we must rewrite the program of our daily activities.        

Additional examples of drawing attention away from the pain include acceptance,24 resilience, understanding, benefit finding,25 positive affect, mindfulness,26 and hypnosis.27 One need look no further than the pages of this journal to find beneficial behavioral skills patients need to successfully become comfortable with being uncomfortable. These were outlined by Dr. Ted Jones in his article “The 5 Coping Skills Every Chronic Pain Patient Needs.”28 These skills include understanding, acceptance, calming, balancing, and coping.

Lastly, I’ve encouraged my patients to adopt a spirit animal. A spirit animal is an animal whose essence the individual would like to embody. For migraine sufferers, I believe there is only one choice: the honey badger. The honey badger is considered the bravest and fiercest mammal on Earth. It derives its name from its tendency to feed on beehives. It was initially thought that it was seeking the honey, but it was pursuing the larva. As such, the honey badger encounters multiple bee stings, which it ignores because its loose, thick skin makes it impervious to the stings. Additionally, approximately 20% of its diet consists of venomous snakes. If the honey badger is bitten while killing a snake, it will not die—it will only sleep for about 10 minutes. In a similar way, a migraine sufferer experiences the stings of sights and sounds, and endures the day. On those occasions when a migraine drives a person to bed, he or she arises like the honey badger. Encourage your patients to be the honey badger.  

           

Last updated on: June 15, 2017
Continue Reading:
IV Propofol for Treatment of Chronic Intractable Cluster Headache: A Case Series

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