Lawrence Robbins, M.D.
Robbins Headache Clinic
Northbrook, Illinois
R
efractory (difficult to treat headaches), which occur frequently, usually are Chronic Migraine (CM). Chronic
Migraine is defined as a headache occurring 15 (or
more) days per month, of which at least eight of the headaches are migraine. For those with CM, preventive medications often help. However, approximately one-half of
patients with chronic migraine continue to suffer frequent
pain, with little relief from medications. This condition is
termed Refractory Chronic Migraine (RCM).
RCM is described as frequent migraines that have failed
adequate trials of various preventive and/or “as needed”
medications. A person must have failed to obtain relief
from at least two categories of preventive medications.
In addition, the person with RCM usually has not found
adequate help from the usual migraine “as needed” medications, such as sumatriptan or naproxen, etc. Those with
RCM also find that their functioning and quality of life is
impaired by the frequent headaches. RCM affects millions
of individuals.
A small minority of those with refractory headaches do
not suffer from migraine. Instead, they may experience refractory cluster headaches or another headache syndrome.
There are many questions about RCM, such as:
1. What role does disability play, and should disability
help define RCM?
2. How resistant to the myriad of available treatments
does the patient need to be to qualify as refractory?
Treatments may differ depending upon the age of the
person; medications prescribed for a 16-year-old may not
be used at age 80. The resistance demonstrated by some
patients may be due to genetics (genetics often plays a huge
role), structural changes in the brain (particularly the white
matter), and medication overuse.
Various subsets of RCM have been identified. These
include post-traumatic headache, headaches exacerbated
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HeadW ise ®
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Volume 4, Issue 2 • 2014
by medication overuse, headaches in a person with severe
psychiatric illness, etc.
OUTSIDE OF MEDICATION
The headache sufferer should not rely solely on medicine
for relief. Lifestyle changes are important too. It is crucial
to avoid caffeine overuse and to encourage “active coping,”
through exercise, physical therapy, yoga, psychotherapy,
etc. It is important to not rely solely on medications.
Exercise (at least, on average, 20 minutes daily) and weight
control may improve headache and quality of life. Yoga or
Pilates may be beneficial. Physical therapy is often useful,
and is primarily aimed at associated neck pain. Although
stress may be a major trigger for the headaches, managing
stress is difficult to achieve. For those with anxiety and/or
depression, psychotherapy is helpful for improving quality
of life. Biofeedback and other relaxation techniques are
also underutilized, and should be considered.
Medication overuse headache (MOH) is a critical issue
that must be addressed. It is important to try to limit “as
needed” medications. If a patient is consuming pain medications or triptans 10 or more days per month, he or she
may be suffering from some degree of MOH. However,
these analgesics often are the only effective treatment for
that person. Withdrawal from the analgesics may be very
difficult to accomplish. MOH tends to be over-diagnosed.
Many patients overuse the pain or triptan medications.
However, overuse of the “as needed” meds does not necessarily mean that the drugs are increasing the headache.
Medication:
Options
Selected
Outpatient
When migraineurs have failed three or more of the “usual”
preventive regimens (for example, topiramate, amitriptyline, beta blockers, etc), the physician should consider
www.headaches.org
|
National Headache Foundation
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