Our expert is Anne H. Calhoun, MD, FAHS, Professor, Department of Anesthesiology and Professor, Department of Psychiatry, University of North Carolina, and Partner/Co-Founder, Carolina Headache Institute, Durham, NC.
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MOST HEADACHES SEEN BY PRIMARY CARE PHYSICIANS ARE MIGRAINES
Ninety percent of patients who see their Primary Care Physician (PCP) for a headache are there because of a migraine headache. Further, almost 30% of patients in a PCP’s waiting room are there because of migraines, even though half of patients with migraine are undiagnosed. The fact is, 27.9 million Americans experience migraines, and women get them between 3 and 4 times as often as men do.
MIGRAINES HAVE MANY UNDERLYING CAUSES
The pain of migraine occurs when brain cells trigger the trigeminal nerve, which then releases irritating chemicals that cause blood vessels on the surface of the brain to swell. These swollen blood vessels send pain signals to the brainstem, an area of the brain that processes pain information. The person with an inherited lower threshold for trigeminal nerve activation may get a migraine from many possible causes, including such factors as: disrupted sleep, hormonal swings, missed meals, dietary triggers, barometric pressure changes, stress, lights, and odors. Her migraines may also be maintained from overuse of her acute medications.
IN TREATING MIGRAINE, BEGIN WITH A HISTORY
First, determine if your patient’s headache is a migraine. To classify as a migraine, the headache must include two of the following:
3. Moderate to severe pain
4. Aggravation by movement
1. Nausea &/or vomiting
2. Photophobia & phonophobia
Next determine if her headaches are episodic or chronic. If your patient has 14 or fewer headache days per month, and in between, she tells you she’s pain free, her migraines are episodic; however, if she experiences headaches on more than 14 days per month, and 8 would reach criteria for migraine, her migraines are chronic. If her migraines are chronic, your immediate therapy goal is to address the causes that are making the migraines chronic. Often these causes are non-restorative sleep and medication overuse. Both can be treated.
By the way, many women have had migraines for so long that an individual may not fully understand what you mean when you ask about pain-free days. There may be low-level background pain that she takes for granted. To help with communication, I tell her, “A pain-free day means you are no more aware of your neck, face, or head than you are of your middle left toe.”
HELP YOUR PATIENT GET OFF THE CYCLE OF MEDICATION-CAUSED MIGRAINES
If your patient is routinely treating more than two days a week, she has likely developed medication-overuse headaches (MOH), the secondary headache disorder that develops as a consequence of regular overuse of acute headache medication for more than 3 months.
To help break the rebound cycle, she’ll need to cut back sharply on their use. This will be an uncomfortable time for her. One short-term strategy is to have her mix up the medications she uses. She might initially try interspersing triptan use (limited to 2 days a week) with another 2 days a week of a potent NSAID.
HORMONAL MIGRAINES CAN BE SUCCESSFULLY TREATED
Hormonal migraines are those that are triggered by the menstrual drop in estradiol levels. Menstrual-related migraine (MRM) occurs in a 5-day window that spans from 2 days before the onset of menstruation through the third day of bleeding. Knowing that the trigger is the luteal phase drop in estrogen, therapy consists of either eliminating that drop or minimizing it to a 10g EE decline or less. This can be accomplished with extended-cycle dosing of her combined hormonal contraceptive or with only a couple of the newer contraceptive options. Most combined hormonal contraceptives will either intensify MRM or leave it unchanged; only a very few will prevent it.