Migraine Uncovered – Interview with Dr. Cady, Headache Expertby Shaheen E Lakhan, MD, PhD, MEd, MS, FAAN | May 16, 2009
It is estimated that 18% of women and 6% of men experience migraines. In fact, most medical visits for headache are due to migraine. Over a year ago, Dr. Larry Mccleary, former acting Chief of Pediatric Neurosurgery at Denver Children’s Hospital, shed light on the neural theory of migraine causation. In response to this article, numerous readers showed interest in knowing more about migraines basics and how to deal with it from a biopsychosocial perspective. So, we at Brain Blogger sought answers from the premier headache expert, Dr. Roger K. Cady, from the Headache Care Center in Springfield, Missouri.
Dr. Cady received his MD degree from the Mayo Medical School in Rochester, MN. He completed his residency in family practice at St. Francis Mayo in LaCrosse, WI, and is certified by the American Board of Family Practice. He is a fellow of the American Headache Society and a member of the American Medical Association, the American Academy of Pain Management and the American Academy of Family Physicians. Dr. Cady is vice president of the board of directors for the National Headache Foundation.
To start off, what sets a migraine apart from a tension-type headache?
Tension type headache is the most common headache in the general population but rarely produces much disability for the sufferer and is generally easily treated with lifestyle adjustment of over the counter medications. It is uncommon to see a healthcare professional about tension headache.
As the name suggests, tension headache is a headache without the presence of other symptoms. The headache is generally mild to moderate in intensity, more likely to be on both sides of the head and with a steady and pressure quality to the pain. It is not associated with nausea or sensitivity to light or sound.
Migraine is the most common headache causing people to seek medical attention. Migraine is always more than just a headache. The headache can be on one or both sides of the head and more likely to have a throbbing quality or to be made worse by daily activity or things like bending over. Associated with the headache are symptoms like nausea and sensitivity to light, sound, and other sensory stimuli.
Migraine affects approximately 28 million Americans and affects 3 times as many women as men. Migraine extracts a high personal toll from those inflicted and impacts families and social spheres as well. It causes a very significant pharmacoeconomic impact in the workplace and for society in general. It is one of the most common reasons for work absenteeism and even a greater cause of workplace presenteeism i.e. at work but unable to function to capacity.
Both headaches can be episodic or intermittent or chronic, meaning occurring 15 or more days a month. In people with migraine, many experts suggest that migraine and tension headaches exist on the same spectrum and arise out of the same pathophysiological process (big and little migraines).
I recall the vascular theory of migraine from decades past which held that migraine symptoms were a function of ischemia and hyperemia. How far have we advanced in understanding the pathogenesis of migraine?
The pathophysiology of migraine has changed dramatically over the last 2 decades. Today migraine is understood as a neurological disease with a genetic predisposition. Sufferers inherit a nervous system that is more vigilant of its surroundings than the brain of a non-migraineur, and this nervous system has an enduring predisposition to recurrent attacks of migraine triggered by events that do not produce migraine in the general population. This tendency spans decades of life for most migraineurs. Migraine is the quintessential example of how the genetic makeup of the individual and their environment can interact to produce an attack of migraine and over time the disease of migraine.
An attack of migraine occurs when the nervous system encounters triggering events that overwhelm the brain’s capacity to adjust. The first phase of a migraine is called the premonitory period or prodrome. This period is characterized by non-headache symptoms such as fatigue, cognitive change, sensory sensitivity, nasal congestion, muscle pain, yawning. This can be a warning for many people that an attack of disabling migraine is inevitable.
The second phase is called the aura and occurs in approximately 30% of attacks. This represents an electrical event in the brain called spreading cortical depression and produces a period of neurological changes that can last up to one hour but the symptoms are fully reversible. Symptoms generally are visual such as flashing lights or sensory such as numbness in the face or upper extremity.
The third phase is the headache phase. It usually begins with a mild headache that progresses sometimes very rapidly into a moderate to severe headache that is associated with nausea, sometimes vomiting and sensory sensitivity to light, sound, touch, and smell. Also there is frequently muscle pain in the head, neck, and shoulders and nasal congestion or “sinus” symptoms. However, large studies consistently show that what most physicians or patients consider sinus headache is actually migraine. This generally causes a person to seek refuge in a dark quiet place and generally lasts from 4-72 hours.
The final phase is called the postdrome. Sometimes it is referred to as the migraine hangover and consists of muscle aches and pain, slowed cognition, fatigue, and general malaise that can last up to another 24 hours. More rarely, some people experience a boost in energy and elation.
In general, what treatment options are current available for migraineurs for acute attacks and prophylaxis?
Treatment is divided in acute and preventive. Acute treatment is used to reverse an attack of migraine after it has begun. Preventive medications are used to prevent an attack from occurring.
Acute medicines include simple analgesic like non-steroidals, Excedrin, and triptans. Triptans have the largest evidence base of efficacy and are considered the gold standard. More infrequently, pain medications are used such as codeine; but in general these are avoided and migraine specific medications such as the triptans are preferred. Ideally, acute medications can rapidly reverse migraine and return patients to normal function within 2 hours for most migraine sufferers. This is certainly not true for all patients.
Acute medications used too frequently can cause headaches to increase in frequency. This is called medication overuse headache or sometimes rebound headache.
Preventive medications are generally taken on a daily basis to protect the nervous system from migraine. The common classes of preventive medications are beta blockers like propanolol, tricyclic antidepressants like amitriptyline, and antiepileptic drugs like topiramate or divalproate sodium. Propanolol (Inderal), topiramate (Topamax), and divalproate sodium (Depakote) all have FDA approval. Success is considered a >50% reduction in migraine attacks. In most instances these drugs are effective approximately 50% of the time.
Your group has been involved in several clinical trials including early intervention using rizatriptan (MAXALT-MLT). Based on your research, is it more efficacious for clinicians to treat patients when migraine pain is mild?
I actually published the first paper on early intervention in 2000. Early intervention means taking an acute medication at the onset of headache when the pain is mild and before migraine become fully developed. The clinical trial model of migraine required patients to hold treatment until the headache was moderate to severe and other symptoms supporting the diagnosis were present. Early intervention almost doubles the pain free efficacy of triptan medications, reduces the chances that the migraine will return, and decreases side effects. Also since people do not wait for disability, it obviously limits the impact of a migraine.
What is the value of patient education in the management of migraine?
Patient education is the cornerstone of effective medical care of migraine. The goal of medical care should ultimately be to assist the patient become an effective manger of their migraine. In the TEEM study rizatriptan was very effective when used to treat migraine over placebo. However, in the group that received face-to-face education with the study investigators, the efficacy of rizatriptan increased 11% and satisfaction of the subjects increased by 21%. Obviously, education posed no risk to the patient. Most interesting is the fact that this type of collaborate education did not change placebo rates; only the efficacy of the medication. It is the first drug study to look at education as a research variable, and I hope it becomes a model of migraine research in the future.
In your opinion, when should the care of migraineurs migrate from primary care providers to specialists (i.e. neurologists or other physicians with board certification in headache medicine)?
There is a wide range of therapeutic need in the population of migraine sufferers. For some, migraine occurs infrequently while for others it is a near-daily event. We now consider migraine to be a potentially progressive chronic disease. Migraine sufferers with progressive migraine or migraine not responding to treatment should ask for a referral to a headache specialist. When migraine is poorly controlled, it becomes a very disabling disease and is associated with many co-morbid diseases such as depression, irritable bowel disease, fibromyalgia, hypertension and heart disease, etc.
Can you give us a glimpse into the future of treating migraine?
[You can find a] copy of an editorial I wrote on this subject for Mayo Clinic Proceedings that came out last Friday.
Thanks again for participating in this interview for Brain Blogger and shedding light on migraine pathophysiology and management. I wish you the best with your research endeavors and professional pursuits.
Cady RK. The future of migraine: beyond just another pill. Mayo Clin Proc. 2009 May;84(5):397-9.
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