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Treating Chronic Migraine: Remember the Fundamentals



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well the fundamentals are what you want

to do you nearly need to make a specific

headache diagnosis headache by itself is

just a symptom it's like saying someone

has arm pain there are many causes of

arm pain there are over 300 different

causes of headaches some of them are

threatening secondary headaches some of

them are not threatening but problematic

those are primary headaches once you

know that your patient has a primary

headache then you want to find out with

as much specificity as possible what

kind of a headache is it is it in fact a

migraine and if so is ADD episodic

migraine meaning less than half the

month or chronic migraine meaning 15 or

more days a month or is it some other

kind of headache as well and is it

confounded by something so you have to

take a careful history examine your

patient find out what they've done in

the past

find out what's worked what hasn't it

worked and then after you've made a

diagnosis give them a plan an action

plan

well secondary headaches are due to

something else there you often

threatening headaches that can be due to

a variety of things many patients have

come to the clinic think they have a

brain tumor fortunately most dot don't

but occasionally sometimes they do and

they might have a history of a different

kind of headache a change in their

pattern a worsening pattern or when you

examine them you might find some

abnormality on their examination that

would tell you there's something wrong

until you needed to do in evaluations

and testing such as imaging

the International classification of

headache actually makes it relatively

easy to diagnose specific headache types

headaches may have certain

characteristics their nature may be

pounding or they may be pressure they

may be on one side of the head they may

have associated symptoms like nausea

vomiting lighter sound sensitivity and

that will help you get into the butch

category of headache that you have then

based on frequency if it's more than

half the month headaches are typically

called chronic this confuses people

because when most people think of

chronic they think about how long the

patients had the problem for in the case

of the International classification of

headache disorders chronic really refers

to frequency so if it's 15 or more days

a month its chronic migraine or chronic

tension type headache if it's less than

15 days a month its episodic when you're

choosing a treatment for a patient with

headache and acute treatment you really

need to know the characteristics of the

patients attack does it wake them up at

night full-blown so there's very little

time to treat do they have nausea or

vomiting which suggests that giving a

pill isn't a great plan and you really

need to know is this a mild moderate or

severe headache so that you match the

treatment or treatments because patients

may have more than one kind of attack

they may need to have more than one

trick up their sleeve when it comes to

treating you want to match the choices

they have with the type of headache or

headache attacks that they have and then

patients are able to say if they have a

terrible headache that wakes them up

with vomiting they're not going to take

a pill they're going to use a nasal

spray or an injection or maybe a

suppository whereas the person whose

headache comes on leisurely over several

hours during the daytime and they have

some time might use an oral medication

if they can catch the headache fast

enough but some patients need more than

one option

these are questions that you ask the

patient they're yes/no questions is

their treatment reliable can they count

on it does it work quickly can they go

ahead and plan their life those are the

sorts of questions there are five

questions but they're your Snowe

questions and each question should be a

yes it really addresses unmet needs so

if your patient says no they can't count

on their acute treatment to relieve an

attack that's an unmet need and you need

to address that or they can't make plans

you know for a family event on the

weekend because they don't know if

they're going to be able to control

their headaches or you know does their

medication the formulation works some of

the time or some of the time not any

time on those five questions you get and

no it means it's an unmet treatment need

whereas if they're all yeses that's fine

it means their acute treatment is given

the reliability they can go without

planning their life

their medication is well tolerated

that's another problem if their

medication works but isn't well

tolerated or doesn't restore them to

normal then you need to consider

stepping it up giving them a different

treatment