Chronic MigraineChronic Migraine occurs when attacks of migraine do not settle completely. Each year about 2-4% of people with ordinary migraine will go into a phase of chronic migraine. Unfortunately, people with this type of severe headache are frequent visitors to doctors surgeries and emergency departments because the pain is very difficult to control. They are at risk of opiate addiction if the diagnosis is not recognised and powerful painkilling injections like diamorphine, morphine or cyclimorph are given regularly. In the past these people will have had definite migraine headaches. At some point one of these migraine pains failed to resolve quickly. The common things leading to a phase of chronic migraine are:
Between severe migraine headache episodes there is usually a background dull ache that will not shift. Painkillers are taken regularly to try and bring about headache relief - but they are no good. Every few days there is a further increase in pain, to a level where the poor person has to take to bed and stops daily activity. Normal painkillers do not help and the patient or their family go looking for stronger treatment from a doctor. People with chronic migraine become increasingly frustrated, and often try more and more powerful painkillers, but they get more and more desperate as the headache symptoms persist. In the person (and their family too) there is often a great fear that "there is something going on inside the head" - usually a worry that there is a brain tumour. However, this pattern of headache is not a typical brain tumour symptom. Brain scans in chronic migraine do not show brain tumours as a cause of the headache symptom. By the time people with severe migraine headache get to my clinic, they are usually exasperated. The good news, however, is that there is a definite strategy for trying to reduce the frequency and severity of these severe head pains.
Chronic Severe Migraine TreatmentChronic Migraine treatment it is a bit like carefully following a recipe: there are positive things to add in, and there are things which should be avoided at all costs.This is especially true when dealing with severe migraine headaches which are now also known as chronic migraine.
Severe Migraine Headache Treatment - Sleep Pattern60-70% of people with chronic migraine will report a disturbed sleep pattern.A recent study from mid-west USA by Dr Anne Colhoun of women who adjusted their sleep habits showed that this was an efective migraine headache treatment. Up to 30% experienced a significant reduction in headache symptoms. Dr Colhoun (and I completely agree with her) suggested the following plan of action in her paper from 2007:
How does sleep help you with migraine? Well the orexinergic pathways in your brain are a switch between the onset and waking from sleep. It has recently been discovered by scientists from The University of California that the orexinergic system is very much involved with the onset of migraine pain. Drugs which influence the orexinergic system will almost certainly be developed one day. Severe Migraine Headache Treatment - Drink More WaterAlthough not tested as rigorously as sleep, a majority of migraine suffers will report dehydration as a trigger for severe headaches. One well documented observation was by a meticulous Portuguese Engineer. He set a timer to alarm every 15 minutes to remind him to sip some water. His daily water intake increased by almost 2 litres at that time. He realised that during weeks of timer-triggered-water-sipping his headaches reduced by about 50% compared to weeks when he drank normally (<200ml per day of water). Again a very simple intervention, which could have a significant impact. Why not drink one glass of water each hour as a migraine headache treatment? Severe Migraine Headache Treatment - ExerciseIt is actually known that unaccustomed severe exercise can provoke a migraine attack in susceptible people. It is not advised that you suddenly take up vigorous exercise as a means of trying to control migraine headaches. There have been some studies of exercise performed. The best of these suggest that if you adopt a program of mild to moderate exercise (maybe one hour twice a week of cycling or brisk walking) you may reduce the amount of migraine attacks by about 30%. Severe Migraine Headache Treatment - Weight ManagementIt seems like obesity has become an easy target these days and that all health problems are linked to being overweight. There is some good evidence that the risk of severe migraine headaches is increased with higher "body mass index". For those who are obese (Body Mass Index >30) the risk of severe headache is almost 6 times that of those with normal Body Mass Index (<25). Weight reduction is very difficult to achieve in societies surrounded by cheap, continuously available food. However, successful management through reduced intake, increased exercise and other lifestyle changes can lead to sustainable reductions in weight. Severe Migraine Headache Treatment - Stress AvoidanceStress is an inevitable part of life. Stress can be good stress, e.g. motivation of an athlete to try to perform his best, the motivation of a deadline to try and get work completed, or the motivation of a deadline such as planning a wedding or social event. However, some stresses are bad. Bad stresses are inevitably those where you feel out of control and the consequences for not completing or resolving the stress are bad. There is no doubt that major life events are associated with the development of frequent or persistent migraine called chronic migraine. In one interview over 700 people major life events occurred in the year prior to the onset of persistent chronic migraine headaches. Daily hassles can also be a factor in headaches and this has been observed many times by many different researchers. Reducing stress levels is a sensible means of reducing headache. Bio-feedback is a way of changing your behaviour and thinking to try and alter a physical symptom. Bio-feedback has been studied widely in migraine. In bio-feedback you are trying to retrain your behaviour to responsd positively to either the threat of pain or the actual presence of pain. A successful bio-feedback program could reduce your amount of migraine by anywhere between 30 and 55%. A study published in 2006 suggests that a combination of bio-feedback and a beta-blocker tablet could reduce migraine disability by up to 80%. The importance of the stress avoidance and the bio-feedback techniques is that once more they do not involve any medication and be learned yourself. This is another way of putting you in control of your headache disorder. Restrict use of Powerful PainkillersReducing regular use of powerful painkillers sounds like a completely stupid thing to do! You (or your patient) is in the middle of the worst bout of headaches they can remember and you need to reduce painkillers?? In fact excessive use of painkiller, especially those that contain
probably account for much of the problem. Some studies would suggest that successful withdrawal of pain killers is an effective migraine headache treatment (I know it doesn't seem to make sense!), but will reduce headache intensity by between 50 and 75%. People are often persuaded to part company with painkillers when they realise that they are still getting headaches in spite of excessive painkiller usage. Use Migraine Painkilllers in a Controlled WayIf you can avoid the migraine medication mentioned above, you will still require some painkillers if the situation gets out of control. A mixture of anti-inflammatories such as diclofenac suppositories or Tolfenamic Acid Rapid Release and an anti-emetic such as prochlorperazine or metoclopramide should be used if pain starts to build. Other (unlicensed) migraine headache treatments, reserved for severe chronic migraine include intravenous treatment with:
If test dose is tolerated (does not cause severe spasm of blood vessels in fingers and toes), then give a 1mg infusion over an hour. 1mg can be repeated avery 8 hours until pain settles. NB - This preparation is not licensed in the UK, but is widely used in USA. Can be used in UK if local approval sought from local health authority by a supervising doctor. Opiates like codeine, morphine, diamorphine, should be avoided, but I have occasions where their use has had to be sanctioned in carefully controlled clinical settings. The worry about opiates is that they could be addictive. Use a Migraine Prevention treatment that has been proven to helpMigraine prevention is definitely better than cure. There are many preventative migraine treatments, and those that are widely recognised as having stood the test of clinical trials include the following, which have been included in the recently published American Academy of Neurology Migraine Prevention Guidelines (2008):
Of these topiramate has recently been tested in clinical trials for severe chronic migraine. Use of topiramate was associated with a 50% reduction in headache severity, and should be considered when trying to break the cycle of severe migraine headache and overuse of painkilling migraine medication.
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