By William B.Young, MD, as told to Stephanie Watson
I've been practicing headache medicine for 30 years now. The impact of chronic migraine on my patients is enormous.
Migraine is the second most disabling condition in the world, after low back pain, according to some studies. People miss more activities because of migraine than for almost anything else.
On any given day, about a third of the people I see in my office will have lost their job due to migraine. A lot of them are struggling at work. Many of them put everything they can into work and then come home and collapse. They have nothing left for their kids, their family, or themselves. Then there is the emotional toll of the stigma and blame that society puts on people with migraine, a disease they haven't caused.
Today, we have very effective ways to manage migraine. Our understanding of migraine and its treatments have improved dramatically since I first started to practice.
How I Diagnose Migraine
We define chronic migraine as more than 15 days a month of any kind of headache. Half or more of those 15 days are migraine.
When patients come to me complaining of chronic migraine, I take a headache history. I ask a series of questions to identify all the things that could be mimicking migraine, such as seizures or a tumor.
If the examination is abnormal, that's going to lead to testing with magnetic resonance imaging (MRI) or computerized tomography (CT). But if there are no red flags and the exam is normal, I generally won't do any testing.
A Revolution in Migraine Treatment
As a physician, I’m responsible for coming up with the migraine treatment plan with medication. But I sometimes end up taking away medicine. Migraine will get worse when people overuse headache medicines. It's called rebound headache.
We've come a long way in our understanding of what migraine is. Thirty years ago, we used to think it was caused by a narrowing of arteries. Now we know that it's a brain disease and some people are born with a susceptibility to it. Migraine is a genetic condition that's modified by the environment.
When I started, triptans were the first class of abortive medicines (those that stop migraine attacks that are in progress). They were revolutionary, helping so many people who either couldn't be helped before, or who had to take medicine that had awful side effects. Yet triptans have side effects, too.
Then came valproic acid and topiramate (Topamax), which for many people were effective preventive medicines (those that prevent attacks from starting), with lots of side effects.
Newer medications have raised the bar in the treatment of migraine. Botox has helped a lot of chronic migraine patients, and it has few side effects. Then in the last few years, we've had the CGRP (calcitonin gene-related peptide) revolution.
These drugs include four monoclonal antibodies -- medications that people get either once a month or once every 3 months via an IV or shot. They can prevent migraine in a lot of people for about a month at a time, and they have very light side effects.
The next class of medicines is called gepants. There are three of them, both abortive and preventive.
The new medicines are revolutionizing migraine care. One of the best things about these new drugs is that they don't seem to cause rebound headache. If one of these medications works, you don't have to worry about overusing it.
My Approach to Treatment
How I treat a patient with migraine depends on the person and what other conditions they have. For example, if someone also has severe anxiety, a couple of antidepressants are fabulous for anxiety and good for migraine, so I might try one of those. If they have a problem with sleep or muscle pain, other medicines help those conditions plus migraine.
For chronic migraine, the insurance companies generally require me to try two or three triptans before I can give a patient one of the newer medications. Only if the triptans don't work or if they cause side effects can I switch them to one of the newer CGRP medicines or Botox.
I also look at behavioral and lifestyle changes. Are they getting enough exercise? How are they sleeping? Are they under stress? What could they change in their lifestyle to make things better? They don't need to make enormous changes, just little ones to improve migraine slowly over time.
The Biggest Mistakes People Make in Managing Migraine
Overuse of abortive medication is the No. 1 mistake I see, and it leads to rebound headache. It's so hard, because my patients are treating a legitimate disease and the treatment that works also makes them worse over time.
The best treatment for rebound headache is to quit the medicines cold turkey. But you will feel worse for some days, and you really have to commit to that for 6 months, which most people don't want to do. I try them on gepants, which appear not to cause rebound headache.
The other issue I see is people blaming themselves. People with migraine hear smarty-pants opinions from everyone. "Why don't you drink more water?" or "You must have done something to get these migraine attacks."
A lot of them are completely invested in the mostly mythological concept of the migraine trigger. They think, "If I stop eating chocolate and salami, I can have a better life." For people with chronic migraine, that's very unlikely to be true. The kinds of triggers they actually have are very hard to manage, like insomnia and stress.
Another issue is not painting for their doctor the whole picture of what the disease is doing to their life. They might tell their doctor, "I had four migraine attacks last month." What they don't say is that each of those migraine attacks lasted 3 days and they had a nonmigraine headache every other day. They don't tell their doctor that they're barely hanging on to their job and their spouse has to do three-quarters of the child rearing because they're just trying to stay employed.
If a patient doesn't tell their full story, their doctor, who might only have 7 minutes to figure this whole thing out, might just put them on an abortive drug without knowing the whole picture.
Migraine Management Today
I can only get a small percentage of my patients 100% headache-free. But with our new tools, I can reduce the number of headache days for most of them.
I have patients who started with me when they were teenagers. They were dropping out of high school and having all kinds of other problems because of their migraine. I haven't cured them. But the treatments I prescribed helped them get through college successfully, find jobs, get married, and have kids. I managed their migraine differently at every stage of the way.
My patients' success is meaningful to me. And I truly believe that with all the options we have available today, we are in the golden age of migraine treatment.
The Journal of Headache and Pain: "Migraine remains second among the world's causes of disability, and first among young women: findings from GBD2019."
William B. Young, MD, professor of neurology, Jefferson Headache Center, Philadelphia.