This is ReachMD. Welcome to this special series, Rethinking Migraine, sponsored by Lilly.
I’m Dr. John Russell. On this episode, we caught up with Dr. Jessica Ailani after hours in her office, where she spoke with ReachMD about a patient suffering from migraines and how she utilized a preventive therapeutic approach. Dr. Ailani is an associate professor of neurology at Georgetown University Hospital and director of the MedStar Georgetown Headache Center. Here’s Dr. Ailani to walk us through her patient’s case.
Ms. Casey is a 28-year-old woman who presents to our clinic with symptoms of a headache. She has headaches that start very mild in the beginning of the day and within a couple of hours becomes very severe. If she took nothing at all and did nothing, they could last the entire day. When we asked her to describe her headaches, Ms. Casey says that the headaches are throbbing. They’re most often over her right eye and can spread to her right temple. When the headache is at its worst, she has to sit still, otherwise, the pain will get worse. If she moves around, if she goes up and down the stairs, or walks around the office, and if she even gets out of her chair, she doesn’t feel well. she gets an upset stomach and gets irritated when her coworkers are talking. She also can’t use the computer because she notes the light from the screen makes her feel a lot worse.
So how do we determine what type of headaches Ms. Casey has? The diagnosis of headache disorders is made using an international criteria called the International Classification of Headache Disorders, or ICHD. These criteria use the description of headache along with associated features to help make the diagnosis. What symptoms make Ms. Casey’s headaches different from other types of headaches? She doesn’t just have headache pain. She has what we call associated symptoms, like stomach upset or nausea. She’s sensitive to light; that’s why the computer screen bothers her, and she’s sensitive to sound; that’s why she gets irritated when her coworkers are talking when she has a migraine. We commonly see this in migraine. If we take her associated symptoms and we combine it with the fact that she has a headache that’s on one side and it’s throbbing, it will go on all day if it is untreated, we know that she now meets the criteria for migraine without aura.
We ask Ms. Casey a couple of more questions about her headache. She takes some over-the-counter medication to dull the pain when she gets a headache, but the headache usually does not go away until she goes to sleep that night. She thinks she’s having at least one headache per week, but some weeks it can be up to three days in a week. There are certain things that she’s noticed can trigger her headache like not sleeping well or skipping a meal, or she’s very stressed out, like the time she had to make a presentation in front of her boss. We asked Ms. Casey if she missed any work in the last three months because of her headache. She says that she misses about one day of work a month on average. She’s missed a lot of social events. More often, she misses about three social events per month. The day she has a headache she often notes that she just wants to go home and lay down. She doesn’t make dinner that day and she doesn’t exercise. So she ends up missing out on other activities that she really enjoys.
We tell Ms. Casey that she has migraine without aura. While discussing the diagnosis, we mention that migraine is a brain disease and it can occur because of genetics, like family history. This disease can be affected by environment, like stress, lack of sleep, skipped meals, or dehydration. The more frequently they occur, the more frequently they can occur. So we stress the importance of trying to reduce the frequency of her migraines. We discuss the idea of prevention and the goal to reduce the frequency of attacks and improve the quality of her life. Prevention is not a cure, but a way to reduce the frequency of migraines. Prevention is important to reduce the risk of disease progression to chronic migraine. There are different times we should consider prevention in migraine and I think the top three that are the most important is looking at the frequency of migraines. When they’re occurring once a week or more, we want to start a patient on a preventive to reduce the risk of progression from episodic to chronic migraine. And that’s when migraines are happening more than half the month. If migraines are impacting patient life with missed work or missed events at home, that’s another good reason to start them on prevention, so that they can get back to living their life. If a patient is having infrequent migraine attacks, but when they do have an attack it’s extremely disabling, or the migraine itself can last several days and is not responding to acute medication, it’s another good time to bring up the idea of prevention, to reduce the frequency of these attacks.
After this discussion, Ms. Casey is interested in starting a preventive therapy. At her follow-up visit, we evaluate her headache frequency after the start of her prevention. We also ask her if she’s had any potential side effects, or if she’s missed any work or life events since starting medication. Ms. Casey notes that she’s having two headache days a month, they only last a couple of hours, and they’re responding much better to acute therapy. She has not missed any work or social events since the start of therapy. She has some mild side effects but finds them acceptable in comparison to frequent migraines.
Ms. Casey is much improved. It’s really important at this point to encourage her to continue treatment as migraine is a disease process that improves with prevention, but again prevention is not a cure. We discussed with Ms. Casey the possibility of stopping prevention in the future if she continues to do well for a period of time.
To conclude, migraine is a neurological disease that’s often caused by genetic predisposition and can be affected by a person’s environment. The diagnosis is based on international headache criteria, which uses signs and symptoms, along with a normal neurological exam to make the diagnosis. There’s not a cure for migraine, but frequency can be reduced by the use of prevention and preventive medications. It is important to take into account missed work and life events when evaluating patients with migraine and discuss this when discussing a need for prevention.
I’d like to thank Dr. Ailani for taking time out of her day to speak with us. This is Dr. John Russell for ReachMD, inviting you to be part of the knowledge.
The preceding program was sponsored by Lilly. Content for this series is produced and controlled by ReachMD. This series is intended for healthcare professionals only. To revisit any part of this discussion and to access other episodes in this series, visit ReachMD.com/RethinkingMigraine. Thank you for listening. This is ReachMD. Be Part of the Knowledge.