Don't Let Yesterday Take Up Too Much Of TodayIt is important to minimize medication. While pharmacothreapy may be the cornerstone of treatment, we don’t want to rely solely on medication. Addressing triggers may help (particularly stress and sleep). It “takes a village” to help a severe pain patient, and we must recruit other “villagers”. A multidisciplinary approach is vital. For those with posterior (occipital, cervical) pain, physical therapy may be of benefit. With moderate or severe structural cervical pathology, various cervical injections (facet blocks, epidurals) may help. Refractory Chronic Migraine (RCM) is frequently comorbid with anxiety, depression, bipolar, or ADHD. A good psychotherapist is often invaluable. Aberrant “pill taking” behavior may also be addressed through therapy. Acupuncture occasionally is useful, as is massage. We encourage at least 20 minutes per day of any type of exercise, and core work (yoga/pilates) may be of benefit. Even 5 minutes of exercise at a time is encouraged.

We must encourage active coping. Many RCM patients are passive copers, relying on their next pill for any relief. The psychotherapists and physical therapists are vital in improving self efficacy and fostering active coping. Passive coping is a major predictor of disability.

Improving functioning is one goal of therapy. Resilience is a key construct when dealing with chronic pain. Resilience has a strong genetic basis via the serotonin transporter gene. Two long arms of the gene are good, while 2 short arms predict a possible lack of resilience. Abuse as a child contributes to chronic pain as an adult, and many with RCM have had sexual, physical, or emotional abuse. Improving a patient’s functioning requires a concerted multidisciplinary effort, which usually includes an excellent psychotherapist.

Acceptance is important when dealing with RCM. Without acceptance, patients have a higher level of angst, and are constantly seeking a magic cure from various clinics. Acceptance does not mean being resigned to having severe daily headaches; we work on increasing acceptance without resignation.

Catastrophizing leads to a low level of function, increased anxiety and depression, and disability. Psychotherapists and the provider should work with the patient on minimizing the histrionics.

No algorithm works for RCM patients. Treatment choices depend upon a number of variables including: headache severity, sleep, age, medical comorbidities, psychiatric comorbidities, addictive tendencies, and others. The medication list at age 18 is quite different than for those at age 75. The presence of fatigue, commonly encountered in migraineurs, steers us away from certain treatments. Irritable bowel syndrome (IBS) often accompanies RCM, and with constipation many medications are best avoided.

The following outlines a number of outpatient approaches to RCM. These include Botox, polypharmacy with multiple preventives, sphenopalatine ganglion blocks (SPG), occipital nerve blocks and trigger point injections, daily or frequent triptans, opioids, stimulants, monamine oxidase inhibitors (MAOI) and miscellaneous approaches. Some of these treatments may be combined.


By Dr. Lawrence Robbins, M.D.

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