Advancements in the treatment of chronic migraines, as well as clarity in their classification, have made it easier for doctors to manage the condition and have helped patients enjoy more pain-free days.
Migraine symptoms and classification
Migraines cause throbbing or pulsating pain on one side of the head; about 40% of patients experience this pain over the entire head. Symptoms such as nausea, vomiting and sensitivity to light and noise may also be present. About 20 - 25% of migraine patients might also experience aura (sensory disturbances such as tingling or flashes of light).
Migraines used to be described as “mixed headache syndrome” or “chronic daily headache,” and diagnoses were based on whether patients experienced aura. Today, migraines are classified based on frequency of occurrence. Chronic migraine is defined as 15 headache days a month with at least eight headaches presenting as migraines. Fewer than 15 headache days a month is considered episodic migraine. Patients seeking care from a neurologist or tertiary headache clinic are usually suffering daily, disabling headaches.
Merle L. Diamond, MD, director of the Diamond Headache Clinic and AMITA Health Diamond Headache Inpatient Program in Chicago, IL, explains that “the language describing migraines and understanding their causes have improved. Initially it was thought the migraine was due to the blood vessels constricting and then getting bigger, but that was a very simplistic view. We now know that it is a complicated disorder involving our brainstem, cerebral cortex and everything in between. We’ve identified neuropeptides that modify a patient getting a migraine. These insights led to more effective therapies.”
Innovative treatments
Botox® (onabotulinumtoxinA). This easy, safe treatment is especially effective in patients with severely disabling symptoms. It’s administered by giving the patient 31 injections in the temple (and sometimes the back of the head) using a small butterfly needle. This is done in a 10-15 minute in-office appointment. Botox® is only approved for chronic migraines, and it can reduce the frequency and severity of these attacks. Patients return for injections every three months to maintain relief. Because injections are given subcutaneously, patients are able to drive themselves home.
Neuropeptide-targeted medication. The calcitonin gene-related peptide (CGRP) is found in cerebral blood vessels, the nervous system and other parts of the body. The CGRP causes blood vessels to dilate, creating inflammation, and is the agent that transmits the pain signal for about 60 - 65% of migraines. An injection of monoclonal antibodies targets CGRP by blocking it from binding to the receptor. The antibodies can also “vacuum up” CGRP. Patients administer the injection themselves once a month. The most common side effect is pain during injection and slight inflammation at the injection site. This is not a first-line treatment for all patients but a good proportion have experienced a benefit.
Nerve blocks. Migraine patients may have neck pain or a neck trigger. Administering trigger point injections or a nerve block to the occipital nerve can calm the neck muscles and effectively treat an acute headache. This treatment is also safe for pregnant patients. The sphenopalatine ganglion block, or SPG block, is a newer block that can treat an acute headache. The block is administered by inserting a small, soft tube with lidocaine into the nostril. The block is quick, effective and can be repeated as needed.
Non-pharmacological treatments. Non-medical treatments include headache-specific biofeedback therapy, massage, acupuncture, lifestyle guidance (nutrition, sleep and exercise), psychological therapies and physical and recreational therapy. Non-medical treatments can be used in addition to or in place of medical therapies. With no one-size-fits-all treatment for migraines, patients can try different therapies to see what works best for them. Non-medical treatments are also a safe and useful option for pregnant patients.
“Learning a headache patient’s comfort level with different therapies and modifying is key,” says Dr. Diamond. “I have one adult patient I’ve been treating for years, and even as a young girl she didn’t want to take medicine. But she improved with supplements and biofeedback.”
The goal of migraine treatment is to reduce pain and the frequency and intensity of headache symptoms. With the right combination of interventions, even patients who have struggled with debilitating headaches for years can gain control and return to their lives.
The Diamond Headache Impatient Program at AMITA Health Saint Joseph Hospital in Chicago is one of only two inpatient headache units in the nation. The facility is designed specifically for headache patients and utilizes a multi-disciplinary approach to treatment.
For More information, please contact Mark Greco at 773.665.3724 or via email mark.greco@amitahealth.org.
