Treating Chronic Migraine: Remember the Fundamentals

Headache, by itself, is just a symptom. It’s like saying someone has arm pain; there are many causes of arm pain. There are over 300 different causes of headache; some of them are threatening, secondary headaches; some of them are not threatening but problematic--those are primary headaches. Once you know that your patient has a primary headache, then you want to find out with as much specificity as possible what kind of a headache is it--is it in fact a migraine and if so, is it episodic migraine meaning less than half the month, or chronic migraine meaning 15 or more days a month. Secondary headaches are due to something else. They’re often threatening headaches that can be due to a variety of things. Many patients who have come to the clinic think they have a brain tumor.  Fortunately, most don’t but occasionally sometimes they do. They might have a history of a different kind of headache, a change in their pattern, a worsening pattern. When you examine them, you might find some abnormality on their examination that would tell you there’s something wrong.

When you’re choosing an acute treatment for a patient with headache, you really need to know the characteristics of the patient’s attack--does it wake them up at night full blown so there’s really little time to treat; do they have nausea or vomiting which suggest that giving a pill isn’t a great plan.  They’re going to use a nasal spray or an injection or maybe a suppository; whereas the person whose headache comes on leisurely over several hours during the daytime might use an oral medication if they can catch the headache fast enough. But some patients need more than one option. The Migraine Treatment Optimization Questionnaire is a set of questions that you ask the patient. They’re yes/no questions--is their treatment reliable, can they count on it, does it work quickly, can they go ahead and plan their life.  There are five questions and each answer should be a yes.  It really addresses unmet needs. So if your patient says no, they can’t count on their acute treatment to relieve an attack, that’s an unmet need and you need to address that. Or they can’t make plans for a family event on the weekend because they don’t know if they’re going to be able to control their headaches; or does their medication, the formulation, work some of the time or some of the time not. Anytime on those five questions you get a no, it means it’s an unmet treatment need.