Dr. Dougherty was one of 32 migraine experts featured at the sixth annual Migraine World Summit, held March 17 through 25, 2021. Her presentation on the latest strategies for chronic migraine control offered insights into treating the disease, as well as tips on how to improve overall quality of life while living with chronic migraine. Dougherty finds that people tend to underreport migraine days to their doctors and often ignore headache days if the headaches don’t cause disability. By way of explanation, she says, “They may be self-conscious because they have so much pain or are taking so much medication. Or they may have a family history of migraine and think it’s normal.” “Disability” can mean different things for different diseases. In migraine, disability is measured by scales like the Migraine Disability Test, which asks questions about missed days of social or leisure activities, missed days of work or school, and how many days or parts of days that migraine impacted work productivity, including both household and paid work. Headache days can be assessed more accurately, Dougherty says, by asking people how many days they have zero headache, then working backward from there. If your own doctor hasn’t taken this approach to counting migraine and headache days with you, why not try it on yourself, then let your doctor know your results?
Risk Factors for Developing Chronic Migraine
It’s estimated that chronic migraine affects about 1 to 2 percent of the general population and approximately 8 percent of people with migraine. About 3 percent of people with episodic migraine convert to having chronic migraine each year, according to a paper published online in July 2016 in Nature Reviews Neurology. An analysis published in March 2019 in the journal Headache looked at risk factors for developing chronic migraine. The factors that had the strongest evidence for progressing from episodic migraine to chronic migraine include the following:
Acute medication overuse, which by definition is three or more days per week of using acute medications to treat headacheDepressionIncreasing headache day frequency
The good news is that chronic migraine is often reversible. About 1 in 4 people with chronic migraine go into remission within two years of chronification (the transition from acute to chronic migraine), according to the paper in Nature Reviews Neurology.
The Challenge of Taking Acute Medication Early Enough but Not Too Often
Many people with migraine are prescribed triptans to stop a migraine attack in its early stages. But if you have chronic migraine, it can be difficult to know when to take them, says Dougherty. “People are told, ‘Don’t treat too often,’ but in order for the triptan to be effective, you need to treat really early,” Dougherty says. If you’re a rule follower trying to heed both of those things, that can be a real challenge, she adds. Dougherty tells her patients that triptans can be a double-edged sword, in the sense that they can effectively relieve a migraine attack, but if taken more frequently than recommended, their use can lead to medication-overuse headache and raise the risk for chronic migraine. Medication-overuse headache, also called rebound headache, is a chronic daily headache that happens when acute medications for headache or migraine are used more than two or three days per week, according to the American Migraine Foundation. In addition to triptans, these headaches are linked with ergotamines, opioids, and over-the-counter pain relievers such as Tylenol (acetaminophen), nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen, and combination pain relievers that contain aspirin and caffeine, according to the American Migraine Foundation. Because of these concerns, there are people who have angst every time they take a triptan, says Dougherty, adding that they may “feel guilty and think they are contributing to their disease process.” But trying to suck it up or feeling guilty about taking a triptan doesn’t help anything in managing your disease, she says. “On weekends, when you have more reserve, time, and family support, that’s the time when you double down on your cognitive behavioral therapy, your biofeedback, your nonmedication techniques, and we develop a plan,” says Dougherty. It’s different for every person; there’s not one answer, she adds. Dougherty advises being concrete about your goals for function and what you want to get done, whether it’s attending a family event or completing a 5K race. “Those kinds of goals can be helpful,” she says. “What do you want to do and how can we set realistic expectations and make a plan to move toward that?”
Utilize Nonmedication Therapies Whenever Possible
Dougherty likes to give patients a big toolbox in how they can address their migraine, and medications are just one part of that. Nonmedication interventions are often underutilized because they aren’t covered by insurance, she adds. A few of the therapies and practices that can have a positive impact on migraine include the following: Mindfulness-Based Cognitive Therapy for Migraine This psychotherapy is focused on helping people shift negative thought patterns and change behaviors that may increase the likelihood of a migraine attack. A study published online in September 2019 in Headache found that the method demonstrated efficacy, especially when used in conjunction with medication. Mindfulness-Based Stress Reduction This eight-week program has been shown to reduce psychological distress in a broad range of people. It was shown to improve disability, quality of life, and depression in adults with migraine in a study published in 2021 in JAMA Internal Medicine. Lifestyle Changes The efforts you make to improve your sleep hygiene, exercise regularly, manage stress, and talk to your family about what you need can all help improve migraine, says Dougherty. Acupuncture There is evidence that acupuncture can reduce the frequency of headache in people with migraine, according to the American Migraine Foundation. A review published in July 2016 in the Cochrane Database of Systemic Reviews found that in the 22 studies considered, the frequency of headache dropped by 50 percent or more in up to 59 percent of people receiving acupuncture after six months of treatment.
What to Do if You Feel Like Nothing Helps Your Migraine Pain
Many people with chronic migraine may see reductions in their migraine days with the available treatments but still have a lot of days with headache, says Dougherty. “You’re going to have to have other resources and ways to channel that because it’s really unlikely where we stand right now that we’re going to have a cure. We have a long way to go. It’s frustrating,” she says. In the meantime, here’s what you can do.
Channel Your Frustration Into Something Positive
Dougherty suggests getting involved in educating others and advocating for chronic migraine through an advocacy group such as the Association of Migraine Disorders or a support community such as Migraine Again. You can also just talk to your neighbors, family, and friends and be honest with them when they ask how you’re doing, she says. “Tell them about migraine and what it is — it’s more than a headache, it’s a life-altering condition,” says Dougherty. That can help with recognition and acceptance of migraine as a disease, she adds.
Take Advantage of Available Resources
Dougherty recommends exploring available resources for chronic migraine.
The Coalition for Headache and Migraine Patients is an advocacy group for people with migraine and headache. The organization provides information about migraine and treatment options, as well as tips on overcoming insurance barriers and how to take advantage of financial assistance for migraine treatments.Telemedicine can help you connect and follow up with your care team more easily. That’s one silver lining of the pandemic in terms of access, says Dougherty.The Centre for Health, Exercise, and Sports Medicine at the University of Melbourne offers a free resource called painTRAINER. The program offers sessions that teach pain coping skills and how to use them in everyday life.
Be Honest With Your Provider
If you’re feeling as if nothing is working for your migraine, or if the treatments are causing financial strain, let your doctor know. Having that conversation before it becomes a crisis can help you and your provider find solutions together, says Dougherty.
Focus On Doing What You Can
Dougherty recommends the NPR podcast Hidden Brain, hosted by Shankar Vedantam. The episode released December 14, 2020, called “Minimizing Pain, Maximizing Joy,” featured a quote from Theodore Roosevelt: “Do what you can, with what you have, where you are.” “I think that speaks to my patients and persons with chronic migraine: Your situation is not ideal, but you have a lot to give and a lot to offer, and I want you to focus on that. There’s really so much possibility in that,” Dougherty says.
