For as long as I could remember, I considered myself a headachy person. At some point the headaches progressed to migraine. Fortunately, for most of my life I had infrequent episodic migraine (EM). An attack would start, I’d treat it with ibuprofen and I was better in an hour. I sought treatment when I began losing a few days per month to terrible attacks that didn’t respond to over-the-counter (OTC) remedies. Over time, my frequency of attacks increased and I “chronified” while under the care of my well-intentioned primary care physicians.
Differences Between Chronic and Episodic Migraine
I was diagnosed with chronic migraine after seeking help from a headache specialist. Simply put, episodic migraine is characterized by 0-14 migraine days per month. Chronic migraine is when you have headache for 15 days or more of the month where 8 or more of the attacks meet the definition of migraine. When this occurs for 3 months or more, you meet the criteria for chronic migraine. It’s a horrendous place to be. Most of us can avoid it. In my case, I had unrelenting head pain, round-the-clock for about 3 months before things started to get better.
Migraine Strong dedicates much of our time to helping people with CM. This is the first part of a series dedicated to helping people with episodic migraine. My goal is to help you get the frequency and duration of your attacks to back-off. I’ll help you understand the concept of chronification of migraine. I’ll share some basics about episodic migraine and include links for blogs that I consider required reading. According to a prominent headache specialist, Dr. Carolyn Bernstein, a headache specialist at Brigham and Women’s Hospital, 50% of managing migraine is education. Kudos to you for being here to educate yourself. Let’s figure out your personal action plan to discover noticeable, lasting relief.
How It All Starts
Your migraine is likely due to genetic factors beyond your control. Migraine brains are hyper-responsive to normal, benign stimulation. The combination of factors that triggers your headaches and migraine is unique to you. It’s worth spending some time trying to identify the set of factors that bring about your dreaded attacks. Just because migraine is overwhelming due to genetics and some triggers are beyond your control doesn’t mean that you cannot significantly decrease your attacks.
Required reading assignment #1 is this informative blog about The Bucket Theory. This is fundamental to understanding what contributes to headaches and migraine overall and why it can be hard to pinpoint specific triggers. We will dive deeper into identifying triggers later in this series.
Chronification – What It Means
I haven’t checked a standard dictionary, but I doubt I’d find the word “chronification” on its pages. Migraine attacks and headaches can chronify when they happen more frequently over a long period of time. It seems that the structure and function of some of the neurons in the brain change and “learn pain.” The overly sensitive brain starts interpreting more everyday, normal stimulation as pain.
During the 2018 Migraine World Summit, Dr. Alan Purdy, the president of the American Headache Society said “migraine literally just hijacks normal pathways of your brain to produce its symptomology” in chronification. For me, my brain definitely felt hijacked when I became chronic. One of my doctors said that my pain switch was stuck in the “on” position. What an awful and depressing image. What’s worse is that it was avoidable.
According to Dr. Robert Cowan, Director of the Division of Headache and Facial Pain at Stanford University, two risk factors for converting episodic to chronic migraine that are within our control are medication-overuse and ineffective acute treatment of headaches and migraine attacks. Let’s take a deeper look at these two controllables.
Medications For migraine
Acute medications – I have a love-hate relationship with the medications I used most for treating my acute attacks. I will start with a cautionary tale before helping you understand some of your options. I used to joke about buying stock in the company that makes Advil. Between my neck problems (herniated discs) and my head pain, I took a LOT of Advil plus a little Aleve and Excedrin Migraine. I went to my primary doctor when Advil wasn’t working as well and I was losing more and more days to the welcoming darkness and quiet of my bedroom. My doctor prescribed sumatriptan. This was a miracle drug for me. The attack went away in 20 minutes and I felt better than I had before the attack started. I had a new love and I was never given any warning about taking it too often.
I was never advised to limit the number of treatment days each week. Treatment days meant the total of ALL my treatment days – sumatriptan plus ibuprofen, Excedrin and naproxyn (Aleve). Between treating my neck pain and headaches with Advil or Aleve and migraine attacks with sumatriptan and Excedrin, I fell into rebound. The meds that gave me my life back ultimately hurt me as I was uninformed. To spare you from this experience, required reading assignment #2 is here. Avoiding this common pitfall is critically important. These medications can be truly wonderful when used properly. There is no need to be afraid of them. Keep reading and educate yourself.
Here is a handy graphic that you can download to your phone as a reminder of the limits:
Medication Options And Timing
Now that you are familiar with a common pitfall of OTC and prescribed migraine medications you should know that you have quite a few choices. The most commonly prescribed medication in the class of meds called triptan is sumatriptan but there are many others. If one does not work for you, you can try others as they are all slightly different. Some come in nasal sprays or injectable forms so you can still use them if you have nausea and vomiting. If you have a medical concern and cannot take a triptan, you still have options. Some people find relief from prescribed ant-nausea meds and muscle relaxers.
The timing and dose of acute medications is important. Typically, doctors will advise their patients to take the acute medication as soon as they notice migraine symptoms starting. So, make sure you have your meds with you! Don’t leave home without them. For some, treating in the middle of a full-blown attack often fails. Regarding dose, take the full amount that your doctor prescribed. Because many of us only have a few triptans to use each month, some people cut their pills in half. This often is not enough to knock the migraine out.
Some doctors advise their patients to boost the effectiveness of the triptan by combining it with Aleve (naproxen sodium), Benadryl and a nap when practical. As always, consult your doctor before combining medications in this way. I am sharing what works for me as well as what I commonly hear reported by others. This is not medical advice.
Medications To Avoid
A few words of caution about 2 medications that were used decades ago to treat headaches and migraine; Fioricet and Fiorinal. Many neurologists and doctors who specialize in headache disorders refuse to prescribe them for good reason. These meds, especially when not strictly limited can cause rebound quickly, sometimes in as little as four doses a month, according to the American Migraine Foundation. If you take these meds, you will likely need a plan to find an alternative in order to get yourself better.
The Conundrum Of When To Treat
As I said above, treat migraine at the first signs. But what if you are afraid of needing to medicate more often than 2-3 times per week? What if you only have 6-9 tablets of prescribed medications per month and you typically have symptoms on more that 6 days per month? This is quite a quandary that many of us find ourselves in. It’s hard to know if the sensation you feel is going to be a full-blown attack. Nobody wants to run out of their precious few pills before they can get a refill. And, now that you know the risks of rebound, you want to minimize the chances of that complication. Here are two handy lists of things to do before you reach for the triptan or other medication.
Additionally, this blog about ginger is required reading #3. Ginger is an excellent non-pharmaceutical abortive for migraine.
Medications Taken For Other Health Issues
This was a very interesting topic during the Migraine World Summit in 2018. Dr. Andrew Charles, Director of Research and Treatment at UCLA’s headache center, discussed medications that can be problematic for those of us prone to migraine. He and many on the community of migraine specialists are frustrated there is little or no research to confirm their observations. Their experience has shown that the below medications are sometimes part of the problem with their patients. He urges a careful look at the below classes of medications to see if they remain necessary for you. Your doctor may be able to recommend a suitable alternative:
Medications to Evaluate
- SSRI anti-depressants like Prozac, Paxil and Zoloft- Anxiety and depression often occur along side of migraine. The class of anti-depressant medications that may be a better alternative for people with migraine is the class called SNRIs. Example brand names are Effexor, Cymbalta and Pristiq. Make any changes with your doctor after careful consideration. You might find this blog about migraine and anxiety helpful.
- GE reflux meds like Nexium and Protonix.- The class of medications called proton-pump inhibitors (PPI) serve as migraine triggers for some people. Some in the class seem to be worse than others and it’s possible that you may benefit from a change in type or a lower dosage. If your PPI is prescribed, check with your doctor to see if transitioning to a Histamine-2 blocker will be effective. An OTC example of this is Pepcid. To avoid rebound effects from discontinuing PPIs, your dose should be tapered and not abruptly stopped.
- Nasal steroids like Flonase and Nasonex and decongestants like Claritin D- Dr. Charles acknowledged that some people have disabling allergies that need frequent or daily treatment. He encouraged people to only take these medications when truly needed and consider anti-histamines as possible alternatives.
- Oral contraceptives and hormones for menopause- Dr. Charles discussed this at length. In summary, taking oral contraceptives may exacerbate migraine attacks or blunt them. It’s important to consider these medications and their possible role in your overall approach to managing migraine attacks. Regarding hormones for menopause, many postmenopausal women take estradiol for extended periods of time. Many headache specialists believe this can also exacerbate migraine. There may be local preparations that address symptoms of menopause rather than taking an oral hormone.
- Pain medications- Dr. Charles was clear to state that pain medications can be a particular problem for people with migraine, but that it’s not an issue of addiction or dependence. Aside from the issue with rebound, pain medications seem to make migraine worse. The mechanism isn’t known, but the theory is that certain pain medications like codeine, hydrocodone and oxycodone change the way the brain perceives pain and are harmful overall. He was very specific about potential harm from Fiorinal and Esgic. Dr. Charles was also specific about caffeine-containing pain meds like Excedrin Migraine worsening and/or sustaining the problem.
Your Personal Plan to Roll-Back Your Attacks:
What probably brought you to this part of the internet was your desire to get your increasing migraine attacks to back-off. We are glad you are here educating yourself. Now is the time to make sure you do not chronify and have your brain hijacked.
Step 1 – Seek effective medical help. If you have seen a general practitioner and things are not getting better in several months, seek the advice of a general neurologist or headache specialist. This blog may be helpful as you prepare for your visit. If you don’t have access to a specialist, this blog has great info on what you can do.
Step 2 – Track your headaches and migraine attacks in a tracker like Migraine Buddy. This info is vital to seeing patterns in your potential triggers as well as in treatment frequency and effectiveness.
Step 3– Look at current usage of medications you take for migraine. Can you make it more effective after consulting with your doctor? Maybe your current plan just needs to be tweaked. If you are in rebound or at risk for it, address this right away so you do not develop chronic migraine. This blog can help you escape rebound.
Step 4– Look at the medications you may be taking for other conditions that may be adding to “your Bucket” (see required reading #1). Consider alternatives if you and your doctor believe you need continued treatment.
Migraine attacks of increasing frequency, duration and intensity can be rolled-back. Education and the right medical team are critically important. Look for our next installment in this series on episodic migraine soon. In the meantime, if you’d like more information about managing migraine in an upbeat, supportive community, please join us in our closed (private) Facebook group called Migraine Strong.