Chronic Migraine - Essential Information

Teri Robert Health Guide February 20, 2014

The following article was written by Teri Robert. I take no credit for any of the information contained in this post. Thank you. http://www.healthcentral.com/migraine/c/123/167463/chronic-essential-information/

What Is Chronic Migraine?

In the simplest of terms, Chronic Migraine (CM) is:

"Headache occurring on 15 or more days per month for more than 3 months, which has the features of Migraine headache on at least 8 days per month."1

For diagnosing and classifying Migraine and other headache disorders, the International Headache Society's (IHS) International Classification of Headache Disorders, 3rd Edition (ICHD-3), is considered the gold standard. In 2013, the IHS Classification Committee revised and released ICHD-3 with this criteria for Chronic Migraine:

1.3 Chronic Migraine1

Diagnostic criteria:

A. Headache (tension-type-like and/or Migraine-like) on 15 days per month for more than 3 months and fulfilling criteria B and C

B. Occurring in a patient who has had at least five attacks fulfilling criteria B-D for 1.1 Migraine without aura and/or criteria B and C for 1.2 Migraine with aura

C. On 8 days per month for more than 3 months, fulfilling any of the following:

1. criteria C and D for 1.1 Migraine without aura
2. criteria B and C for 1.2 Migraine with aura
3. believed by the patient to be Migraine at onset and relieved by a triptan or ergot derivative

D. Not better accounted for by another ICHD-3 diagnosis.

The Burden and Impact of Chronic Migraine

Studies have revealed data about CM and the difference in the impact of CM when compared to that of episodic Migraine (EM):
- Based on the MIDAS questionnaire (The Migraine Disability Assessment Test), the impact of CM is significantly greater than that of episodic Migraine (EM).
- Over a three-month period:4
  - 8.2% of those with CM reported missing at least five days of work as compared to 2.2% of those with EM.
  - 33.8% of those with CM reported at least five days of reduced productivity at work as compared to 2.2% of those with EM.
  - 58.1% of those with CM reported at least five days of reduced productivity in household work as compared to 18.2% of those with EM.
  - 36.9% of those with CM reported at least five days of missed family activities as compared to 9.5% of those with EM.
Chronic Migraine and stigmaIn a study designed to "characterize stigma in patients with Chronic and episodic Migraines," researchers found:5
- Participants with CM scored higher on the Stigma Scale for Chronic Illness scale (SSCI) than participants with EM.
- Participants with CM also scored significantly higher on the SSCI than a mixed panel of patients with chronic neurologic diseases; stroke, epilepsy, multiple sclerosis, Alzheimer’s, ALS and Parkinson’s disease.
Chronic Migraine and social anxiety disorder (social phobia)6
- Research has shown social anxiety disorder to be more prevalent in adults with Migraine than adults without Migraine.
- In adolescents:
  "Chronic Migraine is strongly associated with high social anxiety score, regardless of demographic data and pain intensity. The total burden of Migraine may be increased with social anxiety disorder comorbidity."
Utilization of health care resources in the U.S. and Canada:8
http://www.healthcentral.com/migraine/c/123/167463/chronic-essential-information/
In the United States, there are more than 37 million people who have Migraine disease. Of those 37 million American Migraineurs, it's estimated that between two and four million of them have Chronic Migraine, which means that they have a Migraine or headache more often than not.2
The most common medical services utilized include:
- Migraine-specific medications,
- health care provider visits,
- emergency room visits, and
- diagnostic testing.
In the U.S.:
- 26.2% of Chronic Migraine participants reported visiting a primary care physician in the preceding 3 months vs. 13.9% of episodic Migraine participants.
- Total mean Migraine-related costs for participants with Chronic Migraine in the USA were $1,036 over 3 months compared to $383 for persons with episodic Migraine.
In Canada:
- 48.2% of Chronic Migraine participants had visited a primary care physician, compared with 12.3% of episodic Migraine subjects
- total mean headache-related costs among Chronic Migraine subjects were $471 compared to $172 for episodic Migraine subjects.
Treating Chronic Migraine

At this point, there are no acute, preventive, or rescue medications that were developed specifically for the treatment of Chronic Migraine. For prevention of CM, treatment usually begins with the same medications used for the prevention of episodic Migraine.

Although it was developed for other conditions, onabotulinumtoxinA (Botox) was approved by the FDA for the treatment of Chronic Migraine in 2010. It is the only medication that's FDA approved for treating CM. It was not found effective for EM. When considering Botox for CM, it's essential to work with a physician who has been trained to administer Botox for CM as the specific injections protocol is vital to the success of the treatment. The protocol is for 31 injections in these sites:

The same acute and rescue medications used for EM are also used for CM. Due to the frequency of Migraine and headache days in CM, it's exceedingly difficult to treat every Migraine or headache day.

Using Migraine abortive medications and / or pain relievers more than two or three days a month can lead to medication overuse headache (MOH). Unfortunately, even people who are aware of MOH often don't realize that alternating different types of medications doesn't reduce the risk of MOH. It's important to know about "8.2.6 Medication-overuse headache attributed to multiple drug classes not individually overused." In ICHD-3, this is defined as:

"Regular intake of any combination of ergotamine, triptans, simple analgesics, NSAIDs and/or opioids on a total of 10 days per month for more than 3 months without overuse of any single drug or drug class alone."

Most Migraine specialists recommend limiting the use of these medications to no more than two or three days per week.

Summary and Comments

The burden of living with Chronic Migraine, the stigma associated with it, and the health care utilization and costs are even more significant that that of episodic Migraine.

Treating Chronic Migraine can present a gargantuan challenge for both the Migraineur and their health care team. Trying preventive treatments can take a great deal of time and patience. The good news here is that there are now over 100 preventive treatments in use, so there are many options. To give each available preventive treatment a good three-month trial would take in excess of 25 years.
Many people with Chronic Migraine find it necessary to work closely with a Migraine and headache specialist to make progress. It's vital to realize that neurologists aren't necessarily Migraine and headache specialists, and Migraine and headache aren't necessarily neurologists. (See Migraine and Headache Specialists - What's So Special?) If you need help finding a Migraine specialist, check the Find a Health Care Specialist on the ACHE web site.

One of the most important aspects of living with Chronic Migraine is hope. Dr. Peter Goadsby expressed this very well when I talked with him about being better treatment partners. He said:

"Please bring hope... we will provide expertise, and together we will make progress."

Chronic Migraine can indeed go back to episodic. By partnering with a good Migraine and headache specialist, I was able to go from Chronic Migraine to episodic — twice. The first time, we were able to get my Migraines down to an average of one per month. That lasted for several years until other health issues caused me to discontinue one of my preventive medications and reduce the dosage of another. Within a few months, I was back to CM with 25 headache and Migraine days in one month. Yes, I was heartboken, but I was also determined, and now am averaging eight days per month. We must not lose hope.

____________
Resources:

1 Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd edition (beta version).” Cephalalgia. July 2013 vol. 33 no. 9 629-808 10.1177/0333102413485658

2 Silberstein, Stephen D., MD. "Managing Chronic Migraine in 2011: Background." Medscape Neurology. April 18, 2011.

3 Natoli, JL; Manack, A; Dean, B; Butler, Q; Turkel, CC; Stovner, L.; and Lipton, R.B. "Global prevalence of chronic Migraine: A systematic Review." Cephalalgia 2010;30: 599. DOI: 10.1111/j.1468-2982.2009.01941.x.

4 Bigal ME, Serrano D, Reed M, Lipton RB. "Chronic Migraine in the population: burden, diagnosis, and satisfaction with treatment." Neurology. 2008;71(8):559-566. DOI 10.1212/01.wnl.0000323925.29520.e7.

5 Park J.E.1; Kempner J.2; Young W.B. "The Stigma of Migraine." Poster presentation. 52nd annual meeting of the American Headache Society. Los Angeles. June, 2010.

6 Manrusha, Marcelo R.; Lin, Jaime; Minett, Thais S. C.; Vitalle, Marie Sylvia de S.; Fishberg, Mauro; Vilanova, Luiz Celso P.; Peres, Mario F. P. "Social anxiety score is high in adolescents with chronic Migraine." Pediatrics International vol. 54 no. 3 393-396.

7 Rothrock, John F. "Botox-A for Suppression of Chronic Migraine: Commonly Asked Questions." Headache. Volume 52, Issue 4, April 2012, Pages: 716–717. doi: 10.1111/j.1526-4610.2012.02121.

8 Stokes, Michael, MPH; Becker, Werner J., MD; Lipton, Richard B., MD; Sullivan, Dean H., PhD; Wilcox, Teresa K., PhD; Wells, Leandra, PhD; Manack, Aubrey, PhD; Prokorovsky, Irina, MSc; Gladstone, Jonathan, MD; Buse, Dawn C., PhD; Varnon, Sepideh F., PhD; Goadsby, Peter J., MD, PhD; Blumenfield, Andrew M., MD. "Cost of Health Care Amont Patients with Chronic and Episodic Migraine in Canada and the USA: Results from the International Burden of Migraine Study." Headache 2011;51:1058-1077. doi: 10.1111/j.1526-4610.2011.01945.x

Live well,