Difficult to Treat (Refractory) Chronic Migraine: Outpatient Approaches

Key Words Headache ◽

Refractory Migraine ◽

The Many ◽

Long Acting ◽

This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. This review contains 8 highly rendered figures, 4 tables, and 25 references. Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

Difficult to Treat (Refractory) Chronic Migraine: Outpatient Approaches

10.2310/fm.6809 ◽

2020 ◽

Author(s):

Lawrence Robbins

Keyword(s):

Medication Overuse ◽

Trigger Point ◽

Key Words Headache ◽

Refractory Migraine ◽

The Many ◽

Long Acting ◽

This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. This review contains 8 highly rendered figures, 4 tables, and 25 references. Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

Difficult to Treat (Refractory) Chronic Migraine: Outpatient Approaches

10.2310/neuro.6809 ◽

2020 ◽

Author(s):

Lawrence Robbins

Keyword(s):

Medication Overuse ◽

Trigger Point ◽

Key Words Headache ◽

Refractory Migraine ◽

The Many ◽

Long Acting ◽

This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. This review contains 8 highly rendered figures, 4 tables, and 25 references. Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

Difficult to Treat (Refractory) Chronic Migraine: Outpatient Approaches

10.2310/im.6809 ◽

2020 ◽

Author(s):

Lawrence Robbins

Keyword(s):

Medication Overuse ◽

Trigger Point ◽

Key Words Headache ◽

Refractory Migraine ◽

The Many ◽

Long Acting ◽

This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. This review contains 8 highly rendered figures, 4 tables, and 25 references. Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

The Many Faces of Medication‐Overuse Headache in Clinical Practice

Headache The Journal of Head and Face Pain ◽

10.1111/head.13785 ◽

2020 ◽

Vol 60 (5) ◽

pp. 1021-1036

Author(s):

Nicolas Vandenbussche ◽

Koen Paemeleire ◽

Zaza Katsarava

Keyword(s):

Clinical Practice ◽

Medication Overuse ◽

The Many

Involvement of Corticotrophin-Releasing Factor and Orexin-A in Chronic Migraine and Medication-Overuse Headache: Findings From Cerebrospinal Fluid

Cephalalgia ◽

10.1111/j.1468-2982.2008.01566.x ◽

2008 ◽

Vol 28 (7) ◽

pp. 714-722 ◽

Cited By ~ 60

Author(s):

P Sarchielli ◽

I Rainero ◽

F Coppola ◽

C Rossi ◽

ML Mancini ◽

...

Keyword(s):

Chronic Migraine ◽

Potential Role ◽

Medication Overuse ◽

Orexin A ◽

Compensatory Response ◽

Corticotrophin Releasing Factor ◽

Response To Stress ◽

The Brain

The study set out to investigate the role of corticotrophin-releasing factor (CRF) and orexin-A in chronic migraine (CM) and medication-overuse headache (MOH). Twenty-seven patients affected by CM and 30 with MOH were enrolled. Control CSF specimens were obtained from 20 age-matched subjects who underwent lumbar puncture for diagnostic purposes, and in all of them CSF and blood tests excluded central nervous system or systemic diseases. Orexin-A and CRF were determined by radioimmunoassay methods. Significantly higher levels of orexin-A and CRF were found in the CSF of MOH and to a lesser extent in patients with CM compared with control subjects (orexin-A: P < 0.001 and P < 0.02; CRF: P < 0.002 and P < 0.0003). A significant positive correlation was also found between CSF orexin-A values and those of CRF ( R = 0.71; P < 0.0008), monthly drug intake group ( R = 0.39; P < 0.03) and scores of a self-completion 10-item instrument to measure dependence upon a variety of substances, the Leeds Dependence Questionnaire (LDQ) in the MOH group ( R = 0.68; P < 0.0003). The significantly higher orexin-A levels found in CM and MOH can be interpreted as a compensatory response to chronic head pain or, alternatively, as an expression of hypothalamic response to stress due to chronic pain. A potential role for orexin-A in driving drug seeking in MOH patients through activation of stress pathways in the brain can also be hypothesized.

Psychiatric Comorbidity in the Evolution From Migraine to Medication Overuse Headache

Cephalalgia ◽

10.1111/j.1468-2982.2005.00910.x ◽

2005 ◽

Vol 25 (7) ◽

pp. 519-522 ◽

Cited By ~ 123

Author(s):

F Radat ◽

C Creac'h ◽

JD Swendsen ◽

M Lafittau ◽

S Irachabal ◽

...

Keyword(s):

Psychiatric Disorders ◽

Odds Ratio ◽

Psychiatric Comorbidity ◽

Medication Overuse ◽

Anxiety And Depression ◽

Psychoactive Substances ◽

Addictive Disorders ◽

Substance Related Disorders

We set out to study the role of psychiatric comorbidity in the evolution of migraine to medication overuse headache (MOH) by a comparative study of 41 migraineurs (MIG) and 41 patients suffering from MOH deriving from migraine. There was an excess risk of suffering from mood disorders [odds ratio (OR) = 4.5, 95% confidence interval (CI) 1.5, 13.5], anxiety (OR = 5, 95% CI 1.2, 10.7) and disorders associated with the use of psychoactive substances other than analgesics (OR = 7.6, 95% CI 2.2, 26.0) in MOH compared with MIG. Retrospective study of the order of occurrence of disorders showed that in the MOH group, psychiatric disorders occurred significantly more often before the transformation from migraine into MOH than after. There was no crossed-family transmission between MOH and psychiatric disorders, except for substance-related disorders. MOH patients have a greater risk of suffering from anxiety and depression, and these disorders may be a risk factor for the evolution of migraine into MOH. Moreover, MOH patients have a greater risk of suffering from substance-related disorders than MIG sufferers. This could be due to the fact that MOH is part of the spectrum of addictive disorders.