What's Known About Refractory Migraine? Migratude Monday
Refractory Migraine (RM) isn't a specific diagnosis or type of Migraine. It describes Migraines that don't respond to treatment. The subgroup of Migraineurs who have RM experience disability and impaired quality of life because of their Migraines, despite even the best of treatment.
In a new review article, Dr. Elliott Schulman discusses what RM is, the pathophysiology of RM, aspects of treatment, comorbid factors, medication overuse, potential pitfalls for treatment, and areas for future study.
The Review Article:
- Refractory Migraine has long challenged both patients and Migraine specialists.
- RM patients may experience even greater disability than patients with chronic Migraine.
- Combining treatment options of all types increases the chances for successful treatment.
- It's important to address all comorbid conditions, especially mood and sleep disorders.
- A consensus-based definition of RM is needed to allow the development of evidence-based treatments and for the epidemiology of RM to be characterized.
Promising areas for future research include:
- the effects of placebo and patient expectations,
- using newer imaging technology to investigate the pathophysiology of RM,
- the role mood and cervical issues play in RM, and
- if childhood abuse contributes to Migraine being refractory.
Pathophysiology of refractory Migraine:
- The pathophysiology of RM is still not fully understood.
- Migraine itself is complex and involves multiple pathways and neuropeptides (group of polypeptide compounds that act as neurotransmitters).
- The systems of the brain and their function that could lead to better understanding RM include impaired modulation, cortical hyperexcitability, genetic factors, and differences in receptor binding.
Treating refractory Migraine:
- Check for comorbid mood disorders. They can contribute to Migraine progression.
- Evaluate for medication overuse headache MOH) and consider detoxification if it's present. It's easy to develop MOH, especially if using multiple abortive or rescue medications. Keep in mind that alternating these medications won't prevent MOH. It's the frequency of use of all abortive and rescue medications together that must be monitored to avoid MOH.
Most doctors agree that opioids should be used for rescue only:
- The use of opioids can result in an increase in frequency and severity of Migraines.
- Opioids cause an increase in pain sensitivity.
- Even after removing opioids, MOH is less likely to stop, more likely to relapse, and can cause Migraines to be less responsive to Migraine preventive medications.
- Consider sleep issues and perform a sleep study if indicated. Sleep and Migraine are closely, yet paradoxically related. Too much or too little sleep can trigger a Migraine, but sleeping can help abort a Migraine attack. Common sleep disorders to screen for include obstructive sleep apnea, insomnia, hypersomnia, periodic limb movement disorder, and circadian rhythm disorders.
Preventive medications: Schulman comments that polytherapy (the use of more than one medication) has been shown to be more effective for Migraine prevention than one medication alone. He lists some "unique agents" that have been recently cited in medical literature for Migraine:
- memantine (Namenda)
- IV lidocaine
Other suggested treatments:
- peripheral nerve blocks
- occipital nerve stimulation
- surgery for deactivation of frontal, temporal, and occipital trigger sites following successful trial of Botox (Guyuron procedure)
Schulman's "Pearls" of RM treatment:
- "Don't rest until you test." Other possible conditions must be ruled out.
- A Migraine diary is essential, paying attention to triggers, patterns, and medication overuse.
- Reasonable goals and expectations must be set. Improvement will be slow, and there may be setbacks.
- "Patient education is essential. Patients who were supplied with education materials reported improvement in their headache frequency, as well as the cognitive and emotional aspects of headache management. Those who participated in an intensive migraine education program exhibited a significant reduction in their MIDAS scores compared with those treated with medical management alone."
- Schulman tells doctors to, "Be a cheerleader and always have another plan," noting that if the doctors give up, so will the patients.
- If the RM patient is getting discouraged, Schulman urges doctors to encourage a second opinion from a trusted Migraine and headache specialist since a fresh perspective can be valuable.
- Identify medication overuse and the problems that cause it. Are medications being overused because of pain, anxiety, or other reasons? Addressing why patients get into medication overuse is essential.
- Patients must take responsibility for their health and their Migraines. Only one doctor should prescribe and make medication changes. When other doctors are involved, they must collaborate and work as a team.
"RM patients pose a challenge for all practitioners. These patients experience both disability and impaired QoL (Quality of Life). Yet the recent attention this group has received has stimulated interest in the field and has resulted in additional proposed RM definitions and both pharmacological and invasive trials that address RM. Successfully treating RM patients requires enlisting all of the modalities and refining them. Identification of 'Best Practices' and further defining the pathophysiology will benefit all headache patients."
Summary and comments:
Any patient with refractory Migraine can attest to how devastating and frustrating it is and its impact on their lives. Schulman has done a masterful job of reviewing that medical literature to date, and his "pearls" demonstrate one of the qualities of a true Migraine specialist, especially when it comes to patient education, helping patients not give up, and looking for the reason for medication overuse. He has written a review article that any doctor treating Migraine needs to read.
Continuing to learn about our Migraines or other headache disorders helps build our Migratude, which helps ease the burden of living with these disorders.
For more about Migratude, see Living with and Managing Migraines - Exploring Our Migratude!
Schulman, Elliott, MD. "Refractory Migraine - A Review." Article first published online: February 13, 2013.
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