HJAR Jan/Feb 2023

56 JAN / FEB 2023 I  HEALTHCARE JOURNAL OF ARKANSAS PAIN MEDICINE COLUMN PAIN MEDICINE MIGRAINE is the leading cause of disability in young women worldwide. 1 Migraine is a common primary headache disorder, typi- cally characterized by disabling attacks of severe throbbing unilateral headache, ac- companied by nausea and by hypersensitiv- ity to sound, light, and headmovement, last- ing about a day. In effect, migraine attacks may repeatedly incapacitate patients physi- cally, mentally, and socially for many days. In one-third of patients, there is a preceding aura that typically lasts 20-60minutes. 2 Ac- cording to Jorge Villarreal, MD, a neurologist expert in the field, treating this incapacitat- ing disease is very challenging. Some pa- tients take multiple analgesics, hoping that this will stop or control the pain without knowing that medication overuse can make matters worse, and some wait until the epi- sode is present in a full-blown fashion, not knowing that, in many instances, a preven- tive therapy could diminish the frequency of the episodes and/or the severity. Migraines impose significant health and financial burdens. Approximately 38% of pa- tients with episodic migraines would benefit from preventive therapy, but less than 13% take prophylactic medications. Preventive medication therapy reduces migraine fre- quency, severity, and headache-related dis- tress. Preventive therapy may also improve quality of life and prevent the progression to chronic migraines. Some indications for preventive therapy include four or more headaches a month, eight or more head- ache days a month, debilitating headaches, and medication overuse headaches. Identifying andmanaging environmental, dietary, and behavioral triggers are useful strategies for preventing migraines. First- line medications established as effective based on clinical evidence include dival- proex, topiramate, metoprolol, propranolol, and timolol. Medications such as amitripty- line, venlafaxine, atenolol, and nadolol are probably effective but should be second- line therapy. There is limited evidence for nebivolol, bisoprolol, pindolol, carbamaze- pine, gabapentin, fluoxetine, nicardipine, verapamil, nimodipine, nifedipine, lisinopril, and candesartan. Acebutolol, oxcarbazepine, lamotrigine, and telmisartan are ineffective. Newer agents target calcitonin gene-related peptide pain transmission in the migraine pain pathway and have recently received approval from the U.S. Food and Drug Ad- ministration; however, more studies of long- term effectiveness and adverse effects are needed. The complementary treatments Pet- asites, feverfew, magnesium, and riboflavin are probably effective. The emergence of new treatment targets and therapies illustrates the bright future for migraine management. Nonpharmacologic therapies such as relaxation training, ther- mal biofeedback combined with relaxation training, electromyographic feedback, and cognitive behavior therapy also have good evidence to support their use in migraine prevention. 3 Pathophysiology is complex, with clini- cal and laboratory evidence suggesting that vulnerability to migraine can be genetic or acquired. 4 Diagnosis Chronic migraine is a clinical diagnosis based on a patient’s history and examina- tion, excluding other causes of headache and identifying comorbid disorders, e.g., polypharmacy with analgesics, as treatment success is reliant on an accurate diagnosis. Chronic migraine must be distinguished from other headache conditions including medication overuse headache. The International Classification of Head- ache Disorders sets out the most used di- agnostic criteria for chronic migraine. It defines chronic migraine as a “headache occurring on 15 or more days/month for more than three months, which, on at least eight days/month, has the features of mi- graines headache.” 5 MIGRANE More Than Just a Headache . .