Consider the following clinical scenarios.
Ellen, a 42-year-old married woman, presents to Dr. H’s office with a recent increase in her migraines. She looks sad and worried.
Dr. H. walks into the room, introduces himself, and immediately opens the electronic record to review her medical history forms. Her migraine episodes have increased from once biweekly to 1 to 2 times weekly; with additional less intense headaches on many other days. She uses both a triptan and an over-the-counter medication to control the pain–she gets a limited number of sumatriptan each month and is beginning to escalate her OTC usage. Dr. H. asks her about the intensity and duration of her headaches, reviews her medication use, and questions her about associated symptoms such as nausea or light and sound sensitivity ? Ellen responds with yes and no answers. Dr. H. reviews different medication options, prescribes an older preventative medication and renews her sumatriptan.
In the second scenario, Ellen is in Dr. J’s office. When Dr. J enters the doorway to her office, she introduces herself and is welcoming and seated in a less formal manner. Dr. J is making eye contact with Ellen and not looking at her computer.
Instead of asking her questions that require a yes or no reply, she asks Ellen to walk her through her migraine experiences. She learns that the patient has been under much stress with work, and hears about troubling family issues, and that she is worried about her increased number of headaches and decreased functionality. Dr. J says, let’s talk about options. She tells her the first thing is to optimize acute care in order treat the acute attacks effectively. Simply “taking” a medication is insufficient to know whether a patient is taking that medication optimally. She asks Ellen to take her through her process in treating a migraine.
Ellen, Dr. J surmises, has a penchant for treating any sensation associated with a possible approaching headache with OTCs, which needs to be curtailed. Her use of OTCs could be at medication overuse levels thereby contributing to her headaches. Dr. J explains and shows Ellen a simple headache diary. Dr. J then discusses the future: the two of them will develop a plan to control the migraine frequency for the long term. The plan will include ways to control the stressors in Ellen’s life. Dr. J provides Ellen with names of psychologists with expertise in cognitive behavior therapies and relaxation-based treatments; they can help Ellen manage stressors that could be impacting her headaches. Dr. J communicates that migraine management requires a comprehensive approach that can involve behavioral as well as pharmacological therapies to maximize both headache relief and reduce disability.
Migraine is a brain disease that can often be fueled by behavioral issues. Psychological stress, sleep problems, mood and anxiety issues can transform migraine from episodic to chronic. The operative word here is can. Patients with migraine who learn to better manage stress, employ simple relaxation strategies, and identify and treat comorbid psychiatric issues may show significant improvement. Migraine treatment can require more than one health care professional asheadache specialists, psychologists, perhaps psychiatrists, and sleep specialists may all be involved
Getting migraine under control often cannot be accomplished in just one visit; it can take time, as medications might need to be added or adjusted, sleep, diet, and physical activity modified along with stressors identified and managed. Helping patients optimize their acute treatment regimen is critical so they get quick relief while limiting overuse. Overuse of either prescription or OTC medications can lead to medication overuse headache (MOH). MOH can increase headache frequency and reduce the effectiveness of some preventive medications as well as other therapies.
All these steps require good communication strategies by the physician and an understanding of the benefit of comprehensive treatment strategies that include behavioral therapies.
Helping motivation to change
Readiness to change will vary with different patients. Some people will be open to treating stress-related issues in an initial session while others will require many sessions in which the physician gently explores these concerns. It is helpful for the physician to ask open-ended questions, helping patients to “tell their stories.” The clinician needs to actively listen and accurately reflect patient’s thoughts and feelings (“it sounds like you…”) Avoiding overinterpretation and occasionally summarizing ensures clear communication. Both patients and physicians have identified high quality communication in the patient-physician relationship to be a key factor in adherence with acute headache medications.
Anxiety is common in migraine sufferers and predicts long-term migraine persistence. Some individuals with high levels of anxiety may overuse immediate relief medications because of worry about getting a migraine. Many migraineurs have a significant amount of fear about any sensation that may herald a migraine. Consequently, some medicate fear, preemptively. Patients also can fear side effects to new medications, thereby reducing their willingness to change existing therapy for a potentially more effective treatment.
Biological rhythms, sleep and coping skills
Managing migraine also includes managing consistent biological rhythms. The literature has shown that chronobiological issues can be a driver of headache frequency and may also contribute to mood and anxiety disorders. Studies have shown that a simple cognitive-behavioral treatment for insomnia has transformed many migraineurs from chronic migraine to episodic migraine.
Studies have demonstrated that a combination of optimal medication and cognitive behavioral therapy can be very effective. Behavioral therapies increase self-efficacy, a belief that patients have the requisite skills to manage a complicated disorder like migraine. A few sessions of stress management training combined with preventive medications and maximizing acute care options may have significant added value—reducing migraine frequency and related disability and ensuring better disease-coping mechanisms.
Final notes
Migraine is a biobehavioral disorder and it is important for the clinician to evaluate a diverse set of factors and come up with a comprehensive plan. This is particularly important for the patient with high frequency migraine who exhibits stress-related factors and possible psychiatric comorbidities. There are numerous cognitive behavioral therapies incorporating relaxation strategies and stress management techniques that can be very effective in caring for these complicated patients.