Can Your Headaches Worsen and Why?
Frederick R. Taylor, MD
Key Points:
- An increase of frequency from low to high is called progression
- Progression or transformation may lead to “chronic migraine”
- Chronic migraine is greater than 15 days/month of headache and greater than 8 days of migraine or headache that responds to acute migraine specific medications like triptans
- Progression occurs in about one in five with certain risk factors
- Anxiety and obesity are two critical risk factors to control
- Acute medication overuse must be recognized and removed for improvement.
Many individuals with migraine suffer their first headaches as children or adolescents. Over time, headaches may become more severe or frequent, with some individuals having headaches increase to a daily occurrence. This increase is called “headache progression or transformation.” Transformation in this case means a turn or change to more headaches. A goal of current headache research is to understand the reasons for this progression. Might this change be largely due to physical, environmental or inherited tendencies or some combination?
Why it is important to understand what causes headache progression? There are several reasons:
- With headache progression understood, patient and provider may be informed of transformation risks and seek to identify them.
- If patients at risk are identified, close observation and preventive methods can be aggressively encouraged and used.
Chronic or Transformed Migraine
Recognizing migraine as both chronic and potentially progressive may encourage redefining migraine as a chronic disorder with episodic attacks that progresses in some migraineurs. This is important since most individuals who experience migraine do so at least periodically over time and therefore suffer headaches “chronically.” Yet both the sufferer and medical provider often think of migraine in terms of the last headache and use acute treatments only. When migraines are recognized as chronic both the sufferer and provider may think about preventing headache. Headache medicine practitioners “officially” make a diagnosis of chronic daily headache, when headache totals exceed 15 days per month, and chronic migraine when headache with migraine symptoms or medications used to treat the headache exceed 8 days per month. Other chronic conditions such as epilepsy, hypertension, asthma or diabetes are managed and controlled by reducing trigger factors, appropriate lifestyle changes and additional treatments. Approaches to prevent progression and manage chronic migraine should be to reduce triggers, use healthy lifestyles and other prevention as mutually agreeable between you and your provider.
What do medical studies tell us about chronic migraine?
- Certain migraineurs have greater risk of suffering more frequent attacks
- Specific brain changes occur in some of these migraine patients
- Iron deposits identified by special imaging (not available to providers) are found in a pain control area of the brain.
- White matter lesions, of unknown importance, have been identified in routine brain MRI imaging in migraine.
- The brain becomes sensitive and overactive to several kinds of stimuli during migraine and sometimes between attacks. This is known as central sensitization. This is experienced in different ways but described as pain from a non-painful touch or other sensation. An example of this is pain from the hair pulled back in a ponytail and is referred to as allodynia. Allodynia occurs in many but not all migraineurs and should be thought of as a marker for the need for prevention of headache due to this overactive nervous system.
What should the typical migraine suffer learn from these studies? That it is very important to identify any change in headache frequency. When any type of headache becomes more frequent or more severe, it is very important to consult your practitioner and discuss the risk of headache progression. As a migraine sufferer, it is important to learn about risk factors and control them. This will reduce the chances of progression to chronic migraine.
What factors create risk for developing chronic migraine?
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Adaptable risk factors- factors that the patient can influence with lifestyle changes and appropriate treatment
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(1) analgesic overuse, including caffeine
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(2) sleep troubles (poor sleep and snoring)
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(3) obesity (BMI ≥ 30 or waist ≥ 35 inches
for women and 40 inches for men
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(4) depression and anxiety
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(5) stressful life events
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Non-changeable risk factors – factors not easily altered
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(1) female gender
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(2) inherited genes - genetic susceptibility
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(3) closed head injury
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(4) societal and economic variables
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Studies to better understand how to identify migraineurs at risk of headache progression and to establish effective treatment are ongoing. This undertaking is important given the frequent presence of the condition among the general population and in women. The impression of migraine from one of an episodic to chronic illness with progression of disease in individuals at risk is an important idea. If we can influence the public and medical provider mind, then sufferers should benefit from a change in priorities of insurers and health care providers.
What’s new in the medical literature on progression or chronification of headache?
The January 2008 edition of Headache: the Journal of Head and Face Pain provides a series of comprehensive reviews written for medical professionals on the chronification of headache. While difficult for the average patient to read, unless you are very acquainted with medical writing, if you want in-depth reviews on the mechanisms of migraine chronification, risk factors for progression, treatment of chronic headache, and behavioral strategies aimed at prevention and progression of chronic headache these may be worth your reading efforts. Specific reviews in this edition include:
- Migraine chronification
- Concepts and mechanisms of migraine chronification
- Risk factors for headache chronification
- Screening and behavioral management: medication overuse headache—the complex case
- Chronic headache and potentially modifiable risk factors: screening and behavioral management of sleep disorders
- Stress and headache chronification
- Headache chronification: screening and behavioral management to co-morbid depressive and anxiety disorders
- Screening and behavioral management: obesity and weight management
Looking to the future: research designs for study of headache disease progression
Medication Overuse Headache
Analgesic overuse is the most widely recognized and best agreed upon risk factor associated with migraine progression. The current concept of medication overuse headache (MOH) is defined as greater than 15 days of headache/month. Regular overuse of pain drugs for greater than 3 months is also required. The overuse consists of one or other medication greater than 10days per month or any combination of drugs greater than 15 days per month regularly. Finally, headache has worsened during this overuse. Beware: The risk of using non-specific medications is the risk of creating MOH.
Simple MOH is defined as less than one year’s overuse with modest doses. The individual also has limited psychological difficulties and no failures in past removal. Complex MOH is everyone else. Simple MOH may require only short-term prevention and an optimal acute therapy used properly, while complex MOH absolutely requires behavioral headache management.
Each practitioner and provider system will manage MOH differently as each sufferer is unique. Several overarching ideas to any management program are outlined here. Treatment of MOH requires stopping use of the offending medication(s). Removal is nearly always successful as an outpatient for simple MOH in a patient who strongly desires to rid themself of overuse and its problems. For complex MOH patients inpatient is frequently necessary.
Outpatient therapy can proceed as a slow or fast taper of the overused medication. In selected instances, based on your decision, abrupt withdraw with a medication “to bridge” the initial week of withdrawal is typically considered. Success is likely with strong support of family or friends in highly motivated individuals. Necessary steps to successful removal include 1) education, 2) removal of the offending medication, (3) possible ” bridge therapy” to treat withdrawal symptoms, (4) medication prevention with non-pharmacologic interventions where appropriate, (5) specific acute treatment, without contraindications, with limits on usage, (6) a time to follow up within the month ideally. Education includes helping patients understand the differences in overuse from abuse, habituation, dependency and addiction; which is nearly always appropriate to do. Expect that improvement will take time, typically longer than one expects or hopes and that worsening is typical even for several weeks before improvement. But improvement occurs in the majority and headache frequency improves with prolonged avoidance or abstinence. Sticking with a program and followup are crucial. Behavioral management has been shown to produce additional benefits beyond pharmacotherapy alone. Behaviors include regular eating, exercise, and sleep hygiene with active better than passive therapies. The headache calendar identifies possible triggers, medication intake and effect of treatment. Biofeedback training, stress and time management includes understanding “my time” with cognitive therapy and psychotherapy make for long term success.
Slow taper-takes place over about 4-5 weeks typically with standard migraine therapies for age for both acute and prevention therapy. Acute therapy is restricted to no more than 2 days per week with limited quantities. A short course of steroids is often added. Rapid elimination is used for individual with 3 or less tablets per day use of acute medication often with a short 7-10 day bridge of anti-inflammatory, steroid, or triptan use dependent on history. Prevention is typically increased more rapidly and botulinum neurotoxin when possible often offered.
Prevention of Progression and MOH
Migraine progression can be minimized as a risk with attention to reducing triggers, maintaining healthy lifestyles and avoiding overuse of acute medication for headache or any other pain reason. When headache increases seek your providers help. Cut back on acute therapy no matter how hard it is to cope if more than 2 days per week. Emphasize your preventive lifestyles. Consider the role of any anxiety or obesity and life stressors. Seek a mutually agreeable preventative from your health care provider. Stick with a program that begins to pay off.
By Frederick R. Taylor, MD ACHE On-Line Articles and Newsletter Editor Adjunct Professor of Neurology University of Minnesota School of Medicine Director, Park Nicollet Headache Clinic & Research Center.