The Migraine Patient Journey: Episodic Migraine and CGRP Inhibitors - Episode 2

Episodic Versus Chronic Migraines

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Jessica Ailani, MD, a neurologist from MedStar Health, describes the difference between episodic migraines and chronic migraines and highlights potential risk factors associated with attacks.

Philippa Cheetham, MD: I also think that when you experience migraine yourself, you have so much more empathy when somebody talks about how difficult it is to get through a day. I have certainly been at work with a waiting room full of patients or even in the operating room, and the dreaded day comes, the day when your rescue medication is in a different bag and you know what is coming, you know it is inevitable. Any migraine sufferer knows that you need to act quickly to get control of an attack, and once that vice has got a grip around your head, migraine can go on for days. We are not just necessarily talking about a few hours of a bad headache where a few strip lights in the ceiling annoy you. There is a huge spectrum of migraines; patients can be vomiting. I have even seen patients who have been admitted to the emergency department with a suspected brain hemorrhage; the pain can be so intense. Dr Ailani, how do we classify the different types of migraine? There is a lot of terminology around episodic vs chronic migraine. How important is it to define these terms, and does it really affect how you classify or even manage a patient?

Jessica Ailani, MD: Understanding the type of migraine a person is having can impact what you use for treatment. The first way we really classify migraine is looking to see if a person has migraine with aura. An aura is a neurological phenomenon that occurs prior to a migraine attack for most people, and it is most often visual. You see zigzag lights or flashing lights, and you sometimes lose part of your visual field. It can last for minutes, or it can last up to an hour. Seeing an aura is often followed by a migraine attack of pain, where people with migraine have moderate to severe pain with nausea, vomiting, light or sound sensitivity, and other typical features of migraine.

When we are looking at frequency, when we are talking about episodic vs chronic migraine, it starts to get a little murky and difficult for clinicians to understand. Often, they do not communicate with patients. When you have migraine or you have chronic migraine, it is important that a person understands that the clinician understands as well, because that understanding can impact treatment. For most people with migraine, it is an episodic disorder, where they get attacks of moderate to severe pain with these associated symptoms: nausea or vomiting, light or sound sensitivity, and a host of other associated symptoms that I am sure Jill is going to talk to us about a little later.

About 3.2 million people in the United States have what we call chronic migraine. That occurs when you are having attacks at least 15 days a month of some sort of severity and at least 8 of those attacks are migraine-like in nature if untreated. You mentioned that a migraine attack can last days, and the average migraine is somewhere between 4 and 72 hours. Just imagine—72 hours of your life. Just having that once a month, if you ask me, is more than enough. But if you are having attacks like that 8 to 15 times a month, it is devastating for many people.

Philippa Cheetham, MD: That’s the point. That’s right.

Jessica Ailani, MD: The disability and the burden can be very high.

Philippa Cheetham, MD: You touched on this earlier—that, in the early days when migraine was first termed, women were affected more than men, and there was this concern about a hysteria-related disease. Do you think that because there tends to be a female preponderance, there is any relationship to the hormones of monthly cycle, pregnancy, menopause, or changes? Consider that now compared with, say, 30 or 40 years ago. We now manipulate the hormonal system so much more with birth control, and IUDs [intrauterine devices] with hormonal medication implanted in them. Do you think there’s any association with that?

Jessica Ailani, MD: We do know that migraine is more common in women, with about 18% of women having migraine and about 8% of men experiencing migraine. We do think there is a hormonal link, with up to 60% of women having migraines around their menstrual cycle. Many women will notice a reduction in migraine attacks after menopause, but that is not always true. Many women also have a reduction in migraine attacks during pregnancy, but that is not always true as well. We think this has to do with fluctuations in estrogen levels. As to manipulating hormones, we definitely do this much more often now and in the last several decades. While we used to think this was a big trigger for most women with migraine, the way we use hormones now is different. We have different formulations, lower doses of estrogen, IUDs are mostly progesterone-based, and we do not find that many of these medications necessarily trigger migraine attacks for most women, but it is also a possibility. We do pay attention, when a woman comes in and they are starting to have migraines, to what age in their life are they in, their hormonal status, the quality of their periods, and how often they are having migraines. We note how intense the migraine attacks are—are they more or less often, has the patient experiencing migraines started a new type of birth control, or do they have an IUD? Sometimes, if there is a strong hormonal link, we might actually treat migraines with a hormonal type of treatment, with the idea that reducing the frequency of hormonal shift can actually improve migraine as well.

Philippa Cheetham, MD: Thank you for watching Neurology Live® Cure Connections®. If you enjoyed the program, please subscribe to our e-newsletter to receive upcoming programs and other great content right in your in-box. Thank you so much.

Transcript Edited for Clarity