HJAR Jan/Feb 2023

HEALTHCARE JOURNAL OF ARKANSAS I  JAN / FEB 2023 57 Julio Olaya, MD President Pain Medicine Specialists of Arkansas economic burden. Little evidence exists spe- cifically on treatments for chronic migraine, as studies to date have primarily focused on prevention of episodic migraine. New treatments for chronic migraine have become available since 2018. Those with the most robust evidence include ona- botulinum toxinA, erenumab, fremanezum- ab, galcanezumab, and eptinezumab. 7 Treatment decisions should remain pa- tient-centered, focusing on goals, prefer- ences, reduction of disability, and improved quality of life. Unfortunately, when there are multiple alternatives and explanations for a particu- lar pathology, that tells us that we are still in the stage of trying to find solid evidence to control a very incapacitating disease such as chronic migraine. Getting to the bottom of it will require more research because one thing is for sure: chronic migraines are caused by multiple factors, and there is high variability in this field. 7 Research questions • What are the new targets for the treat- ment of refractory chronic migraine? • What is the effect of COVID-19 on the progression and treatment of chronic migraines? • What are the long-term safety and effi- cacy of calcitonin gene-related peptide (CGRP) receptor antagonists? • What biomarkers predict treatment re- sponse to chronic migraine treatments and facilitate personalized medicine? • Which treatments for prevention of episodic migraine, not thoroughly studied, are effective for chronic mi- graine? 7 n I want to thank Jorge Villarreal, MD, for sharing his knowledge and experience in the treatment of migraine and for providing me with access to the most updated information. Villarreal practices neurology in Culiacan, Sinaloa, Mexico. He completed a residency in neurology at The National Institute of Neu- rology and Neurosurgery in Mexico City with a postgraduate in cerebrovascular diseases in Canada. He is amember of theMexicanAsso- ciation for the Study of Headache andMigraine and also of the International Headache Soci- ety, the AmericanAcademy of Neurology, and the Mexican Academy of Neurology. He also contributes his knowledge of neurology and headachemedicine throughmultiple scientific publications. REFERENCES 1 GBD 2015 Neurological Disorders Collabora- tor Group. “Global, regional, and national bur- den of neurological disorders during 1990- 2015: a systematic analysis for Global Burden of Disease Study 2015.” The Lancet: Neurology (Sept. 17, 2017):877-97. https://doi.org/10.1016/ S1474-4422(17)30299-5 2 Headache Classification Subcommittee of the International Headache Society. “The Interna- tional Classification of Headache Disorders 2nd Edition. Cephalalgia 24, supplemental 1 (2004):9- 160. doi: 10.1111/j.1468-2982.2003.00824.x 3 Ha, H.; Gonzalez, A. “Migraine Headache Pro- phylaxis.” American Family Physician 99, no. 1 (2019):17-24. PMID: 30600979 4 Dodick, D.W. “A Phase-by-Phase Review of Mi- graine Pathophysiology.” Headache 58, supple- mental 1(May 2018):4-16. doi: 10.1111/head 13300 5 Headache Classification Committee of the In- ternational Headache Society (IHS). “The Interna- tional Classification of Headache Disorders, 3rd edition (beta version).” Cephalalgia 33, no. 9 (July 2013:629-808. doi: 10.1177/0333102413485658 6 Robblee, J.; Starling, A.J. “SEEDS for success: Lifestyle management in migraine.” Cleveland Clinic Journal of Medicine 86, issue 11 (November 2019):741-9. doi: 10.3949/ccjm.86a.19009 7 Hovaguimian, A.; Roth, J. “Management of chronic migraine.” The BMJ 379 (2022): e067670. doi: 10.1136/bmj-2021-067670 Treatment The goal of chronic migraine treatment is to reduce the frequency and severity of migraine, improving health-related qual- ity of life. Treatable risk factors for chronic mi- graine include the following: • Caffeine intake. • Obesity. • Depression. • Sleep disorders such as insomnia, snor- ing, sleep apnea. • Chronic pain conditions such as low back pain, neck pain, arthritis. • Analgesic overuse. • Stressors. • Ineffective acute migraine treatment. Lifestyle interventions are a mainstay of migraine counseling. Disruptions of routines can frequently result in migraine attacks. A helpful mnemonic is SEEDS, which stands for “Sleep, Exercise, Eat, Diary, Stress.” 6 Lifestyle factors and mood symptoms that contribute to migraine frequency/ severity include: • Abnormal sleep patterns caused by insomnia or obstructive sleep apnea. • Skipping meals and fluids. • Exercise frequency, or lack of exercise. • Analgesic/medication overuse. • Caffeine use. • Depression screening. The relation between exercise and mi- graine can be complicated; regular exercise has beneficial effects for chronic migraine, but exercise can often trigger migraine attacks. Summary Chronic migraine is a neurologic condi- tion associated with individual, societal, and