Managing Chronic Migraine

I’ve noticed that patient and doctor expectations often differ drastically in treating chronic migraine. As a therapist who treats chronic pain, and as a patient who has chronic migraine I am going to attempt to bridge that gap. This is my best stab at a summary on chronic migraine treatment with a focus on some of the rifts between migraineur and headache specialist.

The goal of this article is to provide you with the best information I can find on the best practices out there for chronic migraine management, as well as connecting you with the best resources I can find.

Knowledge really is power, and the key to recovery

The only person who can make you better is you. While it is the job of the headache specialist to help you with your migraines, it is your life and your illness. The best thing we can do is learn about our illness, understand the best practices out there, and be our own best advocates for the best standards of care.

Thankfully in the internet age there are many websites out there that have amazing amounts of information. Sites like this one and many others strive to dig up the research and the data on migraine and write it up for YOU. Those of us who are patient advocates and health writers want to help YOU in YOUR recovery.

The sky is the limit on information. There are listings of headache clinics, tons of information on what we’ve learned about migraine, and what the most promising treatment strategies are.

Some good places to start:

This is about the war, not battles

There is no doubt that chronic migraine is an intensely painful disease, and whether or not you feel your doctor understands, in many cases they do. However, migraine is a neurological disorder that requires a holistic treatment approach. It is a long term condition, and the approach to treating it has to include the big picture.

Doctors and patients tend to butt heads when chronic migraineurs are looking for immediate relief. The neurologist is looking at the long term course of the disease and the negative impact of over medicating individual migraine attacks.

There is also very poor patient and doctor education when it comes to effective ways to break ongoing migraine cycles. Getting good rescue treatment may rely on you asking for it, and here are some of the ways to approach breaking migraine cycles7.

Medication Overuse Headache is a real thing

Since there has been a field for migraine medicine, there has been Medication Overuse Headache (MOH) which was called Rebound Headache back in the day. MOH is suspected if treatment for migraine occurs more than 15 days per month.

In MOH the nervous system becomes dependent on the drugs that are used to treat individual migraine headaches. This includes triptans, NSAIDs, tylenol, narcotics, caffeine, and really just about any medication that is used for individual episodes. The rule tends to be the stronger the drug the higher the risk for MOH.

To make things even more tedious preventative treatment for migraine, and protocols to break headache cycles are a lot less likely to work if medication overuse is occurring. This is why when starting treatment for chronic migraine MOH is one of the first things the neurologist evaluates and tries to assist the patient in eliminating.

However, it is true that there are uneducated neurologists who stigmatize patients who overuse their migraine medication. Though even if there are neurologists who are jerks MOH is a real problem. If stopping abortive/rescue treatment in order to stop MOH is problematic there are rescue protocols7 available. It is important for patients to be their own advocates in seeking the appropriate care for their migraines, and here is some information on migraine cycle breaking protocols7.

More information on Medication Overuse Headache:

For the same reason narcotics are a no go for migraine

Narcotics are avoided in migraine treatment due to their high risk in causing MOH, as well as the fact that they do nothing to treat the disease process. Migraine is a chronic neurological condition. Many drugs used to treat migraines actually aid in treating the related neurobiology: mainly triptans, ergotamines, NSAIDs and benedryl.

Narcotic medications do nothing to treat the migraine, instead they only mask the underlying pain. So in the end they do nothing to stop the disease process and in the end only end up making migraines worse.

Treatment of migraines with narcotics is reserved for the most severe migraine episodes. Meaning that no other treatment is working and the migraine is severe enough that the patient’s vitals are hitting dangerous levels, or the pain is so bad that the patient cannot maintain consciousness.

The only other case where narcotics are used in the rare cases of chronic daily headache which are intractable to all available means of migraine prevention and rescue. It should be also be noted that there is a theory that chronic daily headache which is intractable may be a different condition all together.

Research summaries on narcotics and migraine treatment:

Recognize when you’re losing the battle, and focus on the war

If after two days abortive medications aren’t treating the migraine, get your neurologist on the phone. Most doctors neurologists can even be reached on call. When we continue to focus on treating migraine in the moment, we lose sight of the importance of treating migraine as a whole. The problem really isn’t the migraine, though it hurts, it is the neurological condition that is causing the headache.

Also ERs are for battles, they patch you up and send you home. They are not focused on the long term effects of their treatment. A good ER will want to send you back home in a condition that will allow your long term doctor, your neurologist, to help you heal from your migraines.

Losing battles hurts, migraines are excruciating. However, pain is unfortunately a part of this illness, and only a part of this illness. Getting proper treatment sometimes means dealing with high levels of pain for a period of time, however, there are healthy ways out that can assist with breaking the cycle7.

Prevention is the key to recovery

Chronic migraine is a chronic neurological illness where pain is just a portion of the disease. Through years of study and research we have learned that migraineur brains are more sensitized to certain environmental changes. It is vital to learn your triggers and identify ways to avoid them.

Good mental health is a necessity in treating migraine. The high levels of pain in migraine lead to anxiety and depression, those emotional states create stress responses which in turn make migraines worse. It is important to heal your entire mind, the physical and the emotional parts of it. Migraine is a disease of the entire body, it impacts our emotions as well. However, we’re smart creatures and with the right support we can modulate our own emotions even in the most difficult of circumstances.

For most with chronic migraine coping with triggers and maintaining good mental health will not be enough. It is also important to find preventative medical treatments that work for you. Unfortunately we are still learning how to match preventative treatments to particular migraines. This means a lot of difficult trial and error, as well as side effects. However, many who stick with trying different preventative treatments do find the ones that work for them.

More on migraine prevention:

Be your own best advocate, be your own solution

You have the power to know your headaches, and be the leader in your own treatment. You’re also not alone in this fight. There are organizations of patients and headache specialists around the world seeking solutions to this disease. There are countless resources online to help set you on your path to your recovery.

Many of these resources are provided by people just like you. Migraineurs who have dedicated themselves to sharing their experiences and giving you the information you need. Use us. We are here to help.

Summary of Resources in this Article:

Migraine organizations and reliable information sources

Medication Overuse Headache:

Narcotics and migraine treatment:

Migraine prevention: