Refractory Chronic Migraine Article

Hi...we just posted a long new article on possible treatments for severe, refractory chronic migraines...it is on http://www.headachedrugs.com Go to the left hand column(and the long-acting opioid article is just below it). Larry Robbins,M.D.

Thank you for posting Dr. Robbins.

-mgb

Great stuff. Thanks for writing it Doctor. Like looking in my mirror.

Great stuff, very informative. Can I ask a question or two? Why does the diagnosis require that the migraine was previously treated with triptan or ergot? I have used them previously in my migraine history but only about once a month at the time my migraine became chronic (this time around) as they were minimally effective. Is it thought that aside from MOH triptans or ergots may somehow be involved in the development of chronic refractory migraine?

Also the paper mentions bipolar disorder but does not mention mood changes in relation to migraine episode as part of the pre- and post-drome. This is little known about by non-migraine specialists as it is and I do worry (based on my experience) that someone may be misdiagnosed as bipolar when their mood changes are related to migraine episodes. In your experience are mood changes around migraine independent of bipolar disorder or indicative of it in some way?

Thanks for keeping us informed of your latest updates.

Amy

Amy I cant get my head around this at the moment (possibly at all). We have some sort of bomb scare soon and choppers and police meant, well you can imagine.
Can you maybe pick out any salient posts and pm them to me please?

I am glad it is apparently so good, but lot for me to read.

Pen

I think it needs to be read in its entirity really, there is too much to summarise as it is concisely written to start with! Maybe save it for a better day

Amy

I am not going to have that day. I have a lot of trouble reading much and especially on line.
And no I cant print it LOL.
No printer......its HP and they wont do drivers for Vista....printer is onoy 3 years old.
No more HP for me...

I will try to get hub to read it for me.
Maybe if you see anything that would scare or relieve me of my MOH phobia....

Very interesting and informative. Thank you Dr. Robbins!

Becky

Thank you so much, Dr. Robbins! A great read. I love reading about the great trust that can exist between doctor and patient.

And how nice to see Susan on your site and in your practice! Way to go, Susan!

Cheryl

Okay I give up.
Having never even heard of Refractory migraine, can someone start me off please!!!

Definining refractory migraines:

"For the proposed definition for RM and refractory chronic migraine, patients must meet the International Classification of Headache Disorders, Second Edition criteria for migraine or chronic migraine, respectively.

Headaches need to cause significant interference with function or quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy.

The definition requires that patients fail adequate trials of preventive medicines, alone or in combination, from at least 2 of 4 drug classes including: beta-blockers, anticonvulsants, tricyclics, and calcium channel blockers.

Patients must also fail adequate trials of abortive medicines, including both a triptan and dihydroergotamine (DHE) intranasal or injectable formulation and either nonsteroidal anti-inflammatory drugs (NSAIDs) or combination analgesic, unless contraindicated. An adequate trial is defined as a period of time during which an appropriate dose of medication is administered, typically at least 2 months at optimal or maximum-tolerated dose, unless terminated early due to adverse effects.

The definition also employs modifiers for the presence or absence of medication overuse, and with or without significant disability."

Copied directly from http://www.ncbi.nlm.nih.gov/pubmed/18484982

Summary:

As I understand it, you must have tried 2 different types of preventatives, alone or combined without success. You also have no success with triptans or DHE treatments and you do not have success with opioids or NSAIDS. You must also rule out rebound headaches. Once all that has been done, you can be diagnosed with refractory migraines. Hope this helps give you a better understanding of the article posted.

Thanks LG! I had trouble digesting the criteria...especially the part about the abortives.

So what category do people fall into if they meet the other criteria but not the abortives? Just curious as I fit the bill up to the abortives...but not sure if I would qualify as I've not tried DHE and I'm not sure about the opiates (NSAIDS have little effect - like shooting a rhino with a BB gun).

Thank you Dr. Robbins. That was a very interesting paper.

Mary Anne

Thanks a lot LG. Better head than mine...
Doesnt sound like me from the first page of the paper..
Well not so far anyway..

Amy, thanks for reading this really long article...You raise great ??'s, about moods and headache...It is very complicated, as pain fuels depression, and depression fuels pain...both need to be treated. Bipolar tends to be underdiagnosed, in general. It is not a good name, the name inhibits the diagnosis, gives it a stigma..mostly what we are talking about is depression, with irritability, some anger, mind racing......
..and certainly frequent headaches can ruin quality of life, make someone more depressed, cause alot of stress and anxiety. Larry Robbins,M.D.

Heeler,

I bet NSAIDS don't count. They aren't successful because they don't work well for you. You'd have to try narcotics and DHE or Migranal (both have the same active ingredient; Ergot) and if either of those work you wouldn't have refractory migraines. If neither work, then yes you'd fit the bill.

Pen,

Nope. Triptans have success for you so I'd imagine you don't fit the refractory migraine bill. That wouldn't be your diagnosis. Also, you have yet to give the narcotic route a full shot and I believe you mentioned NSAIDS have worked for you if you catch it early enough. This also is an indicator that you wouldn't be a refractory migraine sufferer.

Hope I have helped.

Heelerlady:

Your comment about NSAIDS being about as effective as shooting a Rhino with a BB-gun was welcome. My VA doctors put me on NSAIDS some time ago. They work as good as a placebo. They renewed my perscription, which I had to pay for, and told me to take them anyway. The bottle is still sitting on the shelf. I am relieved to hear that others do not get relief from that type of drug also.

Hal

Hal,

I feel the same way, too. It was a great metaphor

I wish they worked...would be an easy fix if they did. But for whatever reason my neuro put that and phenergan as my step 2 in war. Step one is gabapentin....makes you wonder why. If step 1 doesn't help the pain, the nsaids in step 2 have zero chance. But then, that kind of stuff doesn't help with normal aches and pains - hasn't worked since I was 16. I thought the analogy was appropriate.

LG - thanks for breaking it down. Lately I just can't seem to focus to read and comprehend the deeper stuff. Good thing my other 2 papers from my masters are still sitting on my advisors desk - don't think I could handle the technical thinking at this point. Sounds like refractive is not my problem...nice to rule one out.

Hi All,

Dr. Robbins, thanks so much for posting the article. It is one of the few that I have read that gives a great definitions and treatment options for refractory migraine. Thank you so much for sharing it with us.

I have had chronic intractable (refractory) migraine for 12 years now. Refractory basically means that it is very difficult to treat. I have tried tons of preventatives and abortives. Now, my drs simply focus on controlling the symptoms- pain etc.

Pain free days,
sailingm

Very good article.........and YEAH Susan!!! Very impressed my friend and fellow mommy! ;-)

I'm so glad this got posted on and bumped up. I missed it before.

I swear the articles were written for me. I never realized what a refactory headache was. Well, that be me.

Plus, it's letting me know that I'm not out of line in my quest for pain relief. I've talked til I'm blue in the face to my hubby and son, to my in-laws (who will give me BRUTALLY honest opinions, whether it hurts my feelings or not)to my co-workers and of course my best-friends. None of them want me to try the zonegran. My sister-in-law said I finally have my sense of humor and personality back and that she would hate to lose me again (she was really very sweet about it, it touched me).

If the new neuro wants me to do another drug holiday I understand completely and will (grudgingly) do it if that's what it takes.

I will not sign a pain contract with the back Dr. tomorrow until I see the new neuro. I won't be locked into something that won't take my M's into consideration. Since I won't sign a contract I'll probably be crud out of luck for two weeks with no med's after I run out and before I see the neuro. I guess perhaps I'll just be starting on involuntary drug holiday! But, I think in the long run it will be worth it.

Thank you so much for posting this Dr. Robb. I've been pondering this issue quite a bit in the last couple months and you're informative article helped me a great deal.

Charlotte