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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.
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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).

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