So when does episodic migraine transform into chronic migraine? Well, it’s a matter of frequency. The International Headache Society defines chronic migraine as more than 15 headache days per month over a three month period of which more than eight are migrainous, in the absence of medication over use (2-3+ times per week).
Often your patient will be managing their migraine adequately, has a good effective rescue plan, perhaps on a daily medication. Then something happens- a bad viral illness, a mild concussion, environmental stress or trauma, school stress, leading to impaired headache self care- and migraine gets out of control. Intervening quickly in this destructive pattern, if possible, is best to avoid transforming into a chronic pattern.
So what do you do when it seems that headaches or migraine are worsening? There are several things that can be helpful. I will often start with doing a quick course of steroids- Medrol dose pack, to intervene and reduce inflammation, trying to reset the migraine control center. I might look at their daily medications and effectiveness and consider increasing the dose for a time. Or I might start a daily medication. At times, I might consider an ED visit or few nights hospitalization for DHE (or something else) to help reset.
Then I look at figuring out triggering the increase in migraine and intervene with that. Has there been a viral infection? Mild head trauma? Stressful family/school/friend situation? What has been done to intervene already? In the case of an infection, has the patient been taking care of themselves, resting, hydration, sleep, good hand hygiene, etc. Have they checked in with their PCP for anything else going on?
For head trauma, it is important to know that for folks with headaches or migraine, they are much more likely to have concussion-like symptoms from a mild head trauma than other people, due to their baseline neurologic sensitivity. It may not have been a significant blow with loss of consciousness, but the migraineurs can have full blown concussion symptoms, such as severe constant headache, dizziness, nausea, fatigue, disrupted sleep, difficulty with concentration and screens and focus, and so on. It can be difficult at times to get the teens to really maintain cognitive rest, get off their screens, and allow their brains to heal. Pushing through generally just prolongs the recovery. The sooner this is recognized and steps are taken with regards to school accommodations, the better. Then time will help the healing process. I have had many calls and conversations from families about the difficulty managing concussion symptoms. Oftentimes, the teens are very diligent, striving and responsible students, and trying to get them to slow down and let their brains recover is such a challenge. These are families who are great at managing episodic migraine, but concussion issues are always more difficult than expected. Cooperation and understanding from school personnel can really help in these situations.
In the case of increased environmental stress, being open and honest about what is going on, acknowledging the role stress is playing in headache is the starting point for dealing with these issues. Every situation is different, and often we can trouble shoot and problem solve together to help improve the situation. Just talking about it with someone outside the situation can be therapeutic. If there is counseling in place, that’s a plus. I always talk about stress management strategies during visits and have a number of suggestions, including meditation apps, breathing exercises, yoga, exercise, and counseling. There are times when anxiety is significantly contributing to the stressful environment, and an SSRI can be started to help. I have a rule that if I am going to prescribe something for anxiety, they have to agree to get into counseling. It may take some work to get the counseling but quite beneficial. Having a good trusting relationship with the teen and family is the key to being able to have difficult conversations, which can lead to successful care and treatment.
Finally there is an emphasis on getting back to basics of headache healthy habits. I check in on hydration, sleep habits and hygiene, diet, and physical activity. If they are falling down in any of these areas, I encourage getting back to basics. Reviewing their habits can bring unhealthy patterns to light, which allows them to be worked on and corrected. They often do not even recognize they have gone off the track, due to their distress.
Families will call frequently, feeling out of control, in distress. In my opinion, the best thing to do is to get them into the office for evaluation as soon as you can. In fact, any patient going through difficulty should be seen more often in the office. I find that phone contact is useful, but when they are calling nearly daily, face-to-face is needed to get the train back on the tracks. The best way to make sure your instructions are being understood is to interact with them in person. This also communicates to the patient and family that you care about their well-being, want to help, and take them seriously. And there is definitely therapeutic benefit from the in-office personal assessment. Of course, they cannot always get to the office, but outcomes tend to be better when they can.
In my office, we try to not completely fill my schedule every day, in order to accommodate an urgent visit. The wonderful physician I work with is a neurologist, specializing in pain, and sees all the new patients, with some follow ups. I see all follow up patients, so I can be a little more flexible and can make space. This can be helpful in throwing a lifeline to a family in distress, whether they choose to take it or not.
So basically, as soon as it is recognized that migraine has started to transform to chronic migraine, it is important to intervene quickly. This can often prevent true chronicity, which needs to be avoided at all costs.
In my next post, I will talk about chronic migraine, appropriate treatments and interventions for children and adolescents.
HeadFirst PNP 