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Optimal Management of Acute and Preventive Migraine - Episode 2

Reducing Clinical Burden of Migraine

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Andrew C. Charles, MD; Jessica Ailani, MD; and Sait Ashina, MD, discuss the impact of migraine on a patient’s quality of life and share strategies for reducing the clinical burden of disease.

Jessica Ailani, MD: Andy, what is episodic migraine? What is chronic migraine? When is a patient episodic or chronic, what’s the magic behind 15 days? Talk about how the disease could progress between episodic vs chronic and how that’s taken in the clinical practice.

Andrew C. Charles, MD: As you alluded to, the definitions are evolving. There’s some push to change the definition of episodic vs chronic migraine. The key point there is that the cutoff is 15 headache days per month. There’s some push to make that more nuanced because 15 days is an arbitrary cutoff. To your point about disability, your migraine has a spectrum of severity, clinical symptoms, and disability associated with it. At the very mildest end, people may have 1 attack every month or every few months that they’re able to manage. But in our practice, it’s much more common for people to be profoundly disabled by migraine. That disability includes inability to function socially with family and friends.

Of course, there’s a tremendous associated inefficiency and lack of productivity at work associated with migraine attacks. As Dr Ashina mentioned, it’s not just the headache that can create this disability for some. It’s the fatigue, the cognitive dysfunction, the inability to function normally. That’s important in terms of producing, either home or work, disability. On the positive side, what’s striking with some of our newer therapies when we achieve success is that people had no idea how much the migraine was affecting their life until they have some attack-free days. They’re in wonder because they haven’t experienced this sense of wellness for such a long time.

Jessica Ailani, MD: I find it interesting when someone you think is well controlled gets on a therapy that’s effective for them. Suddenly, it’s not just about migraine pain. All their associated symptoms start to get better. They tell you that they’re feeling, for the first time, really clear of mind. It’s this sense of well-being and feeling normal…that makes you realize that burden of disease is so high. It’s more than pain. Interictal symptoms, as Sait was mentioning, that in-between fear of attack, but the cognitive slowing, the burden of the postdrome that patients will often have can disable the patient.

Sait, we’re talking a lot about episodes of migraine attacks, interictal burden, and developing disease that’s frequent. How would you suggest patients try to reduce this risk of chronification? Do you try to prevent this disease burden from becoming high? What things do you suggest to patients?

Sait Ashina, MD:This is an important and great question. Thank you for asking. Just to add to Andy’s explanation about the burden, we have a study showing that patients with even 4-plus migraine days per month are as disabled as patients with so-called chronic migraine, which is 15 or more days per month. In our practice we tell patients to keep a diary with all the information about the headaches to visualize this, to see how many days they experience per month. It gives them an opportunity to see not only the number of days but also the triggers—for example, what triggers their migraine attacks, what’s it associated with? In this way, the patients can find out about their triggers and go back and try to control them.

Among the top 10 triggers for migraine are dehydration, lack of sleep, stress, etc. They’re all associated with progression of migraine. In a given year, 2.5% of people with migraine can progress from episodic to chronic. How can we prevent that? There are some risk factors, and some of them are modifiable. Some of them are nonmodifiable. For example, nonmodifiable is the female sex. We know that migrane is more common in women than in men. That’s another burden. Younger age is also a risk factor. Then we the modifiable risk factors—for example, anxiety, depression, or allodynia, which is increased sensitivity to touch on the head or face experienced during an attack. If we try to control these risk factors and explain them to patients, we may be able to prevent progression from episodic to chronic state.

Jessica Ailani, MD: These are great points. Nowadays female sex might be a modifiable risk factor. I’m not saying that as a joke. There are some new studies, very few, about people transitioning gender. Unfortunately, for male-to-female transition, they pick up the risk of female gender when it comes to migraine. It seems you can change your risk factor, but it’s unclear if you transition from a woman to a man. We don’t have enough data to know if you can reverse your risk. I’m not saying that’s a good reason to transition genders. That’s a personal choice.

Sait Ashina, MD:I agree with you. With my transgender patients, I see estrogen as a trigger, which is challenging. Of course, we try to overcome it with prevention, aggressive treatment of migraine. It’s an interesting area to investigate in the future studies.

Jessica Ailani, MD: This is something we need to learn much more about, and there are some young investigators looking into this. It’s an exciting area.

Transcript Edited for Clarity