Current Series: Chronic Migraine: Current Treatment Options and Recent Advances

Stephen Silberstein, MD: In treating a patient with any headache disorder, including chronic migraine, it starts with the basics. Adequate rest, adequate exercise, regular meals, really good hygiene. We often suggest to our patients if they’re up to it, to exercise regularly and do yoga, and we use [a nondrug] treatment such as biofeedback and meditation. This is crucial to all of us but more crucial to somebody who’s disabled by their headaches.

Patients always ask me about supplemental herbs. My major problem is, what’s in it, and purity. There was a big article in either the Wall Street Journal or the New York Times about a year ago where people wanted all the pharmacies in New York state analyzed, and it found that half of the products didn’t have anything in them that they said in the label.

So, my first point would be, ensure that it’s a good product and see if there’s any certification on the label that it’s been tested and it says what it says. The best example of that is people were taking supplements to give them more serotonin in the past. It wasn’t made right, and it was toxic. So here’s the points I would make. There’s really good evidence that riboflavin and coenzyme Q10 and magnesium are good for the treatment of migraine, and they’re an easily gotten supplement. In addition, there’s some evidence that feverfew [Tanacetum parthenium L.], which is available, can be used for the treatment of migraine. And many of our patients have told us some of the essential oils that have calmed them down also helped for the migraine. I’m not opposed to them, I frequently use them. My major concern is, are you getting what you ask for?

Richard B. Lipton, MD: Cognitive behavioral therapy [CBT] is an important adjunct to treating migraine along with biofeedback. We have psychologists on our staff, and in patients, particularly patients who have stress-related headache, patients who have the common psychiatric comorbidities of migraine-like depression and anxiety, we may well refer for psychological assessment. We know that certain kinds of psychological processes make migraine worse. So there’s a phenomenon called pain catastrophizing where patients may feel, “Oh my God, I’m getting a migraine. Now my life is going to be out of control for a few days, and I’m not going to be able to take care of my kids, and my husband’s going to leave me; or my boss is going to be very angry and I might get fired.” And when people engage in those sorts of catastrophic cognitive processes, it makes pain worse. And so, part of what CBT does is help people identify their unhealthful cognitive processes and replace them with more effective pain management strategies.

As an adjunct to CBT, we often use a methodology called biofeedback. Biofeedback involves feeding biological signals back to the patient and teaching them to control them. So we might teach patients to warm their cold fingers. Or we might teach patients to decrease their muscle tension in certain muscle groups. And those kinds of interventions enhance the patient’s sense of self-efficacy, enhance the sense of self-mastery, and can help reduce feelings of helplessness and also help with the management of pain. So those sorts of behavioral medicine interventions have a solid evidence base and can be important in many patients.

In addition to that, we have almost everyone keep daily diaries where we try to help them identify headache triggers, and patients can then learn to avoid headache triggers. Electronic diaries are very helpful because with paper diaries the patient may get a headache and then record what they believe triggers their headache. Whereas with electronic diaries they’re time stamped so you know when the trigger occurred and when the headache occurred, so they more strongly support inferences about the role of the triggers.

And then there are a number of lifestyle interventions that are quite helpful. Oftentimes they involve doing what your mother always told you that you should do, which is kind of annoying to adolescent patients. But regular meals are helpful because skipping meals, lowering blood sugar, can trigger headache. Good sleep hygiene, regular sleep habits, going to bed and waking up at the same time every morning. Those sorts of lifestyle things can be quite helpful.

Peter Goadsby, MBBS: Migraine can be a horribly disabling and dislocating problem to a patient that makes them unpredictable. I think it’s important to emphasize lifestyle advice and regularity of things, and it’s also important to make sure patients are prepared for their attack. I like to discuss with them things like premonitory symptomatology, prodrome symptomatology. Can you pick when your attack is coming—you’re getting the tiredness, the neck stiffness, the concentration problems; are you passing more urine, is your attack coming? If your attack is coming, don’t have a late night, don’t leave your medicines at home, don’t skip meals, and certainly don’t go chasing any alcohol. Know your disease and be prepared to combat it and you’ll control your life better. So what I say to patients is you’ve really got to, at some level, get a grip on running the disease rather than letting the disease run you.