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Chronic Migraine Defined (A Correction)

In All Migraineurs Are Different — So Stop Judging Me!, I wrote “…losing two days a week to migraine does not meet the clinical definition of chronic migraine, which is 15 or more migraine days a month.” Leora delicately pointed out that this is incorrect. Chronic migraine is actually defined as 15 or more headache days a month, eight of which are migraine. That’s my summary at least.

Verbatim, the current criteria for chronic migraine according to the International Headache Society follows. I’ve left out the footnotes; check the link for details.

A)    Headache (tension-type and/or migraine) on ≥15 days per month for at least 3 months*

B)     Occurring in a patient who has had at least five attacks fulfilling criteria for 1.1 Migraine without aura

C)    On ≥8 days per month for at least 3 months headache has fulfilled C1 and/or C2 below, that is, has fulfilled criteria for pain and associated symptoms of migraine without aura

1)     Has at least two of a-d

a)      unilateral location

b)     pulsating quality

c)      moderate or severe pain intensity

d)      aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)

and at least one of a or b

a)      nausea and/or vomiting

b)     photophobia and phonophobia

2)     Treated and relieved by triptan(s) or ergot before the expected development of C1 above

D)    No medication overuse† and not attributed to another causative disorder‡

I’m not sure if my initial statement was outdated or just outright wrong, but it doesn’t really matter. I appreciate readers who are willing to point out my mistakes without calling me an idiot! Thanks, Leora.

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Pain Receptors in the Bone, Skull & Scalp Pain, and Botox

Headache specialist Christina Peterson‘s comments on the news that a patient’s skin sensitivity may help predict Botox’s effectiveness for migraine explains the exciting research behind the story. Dr. Peterson attended the lecture on the topic at the International Headache Society’s annual conference. She wrote:

This was far and away the coolest lecture, although it was also given at the American Headache Society Meeting. Dr. Rami Burstein, who is a basic science researcher at Harvard, has done some ground-breaking research.

It has been conventional wisdom that there are no pain receptors within bone; the only pain receptors are on the periosteum–the lining on the bone. Dr. Burstein took it into his head to wonder if this were actually true of the skull, and set out to trace the pain pathways in rats. He showed amazing slides of fluorescent lime green nerve fibers shooting right through holes in the bone of the skull (so, yes, your skull can hurt), and terminating at the hair follicle.

So–when people say they have headaches that feel as if their hair hurts, it can be literally true. These nerve fibers were most dense at the sutures in the skull, where the bony plates of the skull come together. And now we know why craniosacral therapy works!

Dr. Burstein has also determined that there are three major types of headache pain:

  • Explosive pain (like you feel as if your brain is too big and will explode out of your head)
  • Implosive pain (as if your head will cave in the pressure is so great)
  • Orbital/eye pain (your eye hurts, or it hurts behind your eye, or it hurts to move your eye)

Unfortunately, you are permitted to have more than one of these in a given headache. He has found that it is the implosive type of pain that is most likely to respond to Botox. [all emphasis mine]

Dr. Peterson’s latest e-mail newsletter, which arrived in my inbox today, explains more about the research. If you aren’t subscribed to the newsletter, you’re missing out on an excellent, up-to-date resource. Take a look at previous newsletters and sign up for future issues.

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Migraine Treatment News

Here’s the roundup of migraine treatments. Other news posts I’m working on are about presentations at the International Headache Society’s conference (including cluster headache news), depression and chronic pain.

Migraine Patients Who Take Triptans Report Greater Satisfaction Than Patients Taking Barbiturates or Opioids
Survey: Migraine Patients Taking Potentially Addictive Barbiturate or Opioid
Medications Not Approved By FDA as Migraine Treatments

The survey found that patients taking triptans are significantly more likely than those taking barbiturates or opioids to report that their medication works well at relieving migraine symptoms, with sixty percent of triptan patients reporting that it describes their medication “extremely” or “very” well to say it relieves their migraines symptoms completely compared with 42 percent of patients taking barbiturates and opioids.

Patients taking opioids and barbiturates for their migraines also reported a lower quality of life than patients taking triptans, according to the survey. Patients taking these drugs were twice as likely as patients on triptans to say that migraines “always” limited their ability to exercise or play sports (35% vs. 14%), engage in sexual activity (33% vs. 17%), drive a car (28% vs. 14%), spend time with family and friends (28% vs. 8%) or simply get out of the house (33% vs. 15%).

Though many patients are prescribed barbiturates and opioids for their migraines, the majority indicated that they prefer their migraine medication to be FDA approved for the disease, not addictive and have few side effects. Seven out of ten patients (72%) surveyed said it’s “extremely” or “very” important that their prescription medications not be addictive, and eight out of ten patients (79%) said it’s “extremely”
or “very” important that their prescription medication have only minor side effects. Sixty-five percent said it’s important that their migraine medication be approved by the FDA to treat the disease.

Frova for Menstrual Migraine
Endo’s Menstrual Migraine Treatment Better Than Placebo in Study

Endo Pharmaceuticals said that its Frova 2.5mg tablets reduced the frequency and severity of difficult-to-treat menstrual migraine in women when used as a six-day preventative regimen.

Predicting Botox ‘s Effectiveness
Cutaneous Allodynia Predicts Response to Botulinum Toxin Type A in Migraine Patients

Botulinum toxin type A has been reported to be effective in preventing migraine attacks in some patients but not in others.

[R]esearchers found that patients with cutaneous allodynia had experienced significant reductions (P <.01) in migraine frequency and number of headache days in response to botulinum toxin type A, whereas patients without cutaneous allodynia had no such improvement in symptoms.

[I]nvestigators concluded that cutaneous allodynia could be used to predict which migraine patients are likely to respond to prophylactic therapy with botulinum toxin.

DHE Relieves Skin Sensitivity (Allodynia)
Migraine With Skin Sensitivity Eased By Older Drug

Dihydroergotamine or DHE, an established drug for migraine, works well even when the attack is accompanied by super-sensitivity to touch or heat and cold, according to researchers.

Many migraine sufferers get relief from the newer drugs known as triptans, but these are less effective when people also have heightened skin sensitivity. This condition, called cutaneous allodynia, makes even a light touch to the face or neck feel painful.

“Unlike triptans, DHE works in the presence of allodynia, any time in the migraine attack,” lead investigator Dr. Stephen D. Silberstein told Reuters Health.

Migraine Preventives
Migraines: Symptoms Disappear With The Right Prevention

According to Greek researchers, migraine sufferers can eliminate symptoms altogether if they take higher doses of anti-migraine medicine for a longer period of time than is now customary. Another team of researchers has found that certain psychopharmaceuticals could serve as a new therapy option for persistent chronic headaches.

“In treating migraines, optimizing the effect of already available agents is at least as important a task as developing new substances.”

I’m a little wary of this article, but wanted you to know about it. Take it with a grain of salt.