Understanding Episodic Migraines
By Deena Kuruvilla MD
Migraine affects a significant percentage of the world’s population and is often misdiagnosed as sinusitis or other sinus issues, muscle spasms, a primary eye problem, and so on.
Migraine is a disease characterised by pain, sensitivity to light, sensitivity to sound, nausea, vomiting, and disability.
We can define migraine based on the frequency of headaches; Episodic migraine is the likely diagnosis when a person experiences headaches less than 15 days a month, Chronic migraine is the likely diagnosis when a person experiences headaches 15 or more days a month for at least three months.
When will a doctor diagnose chronic migraine?
After other causes of headache have been excluded and a patient describes their headaches as consistent with a diagnosis of migraine, I narrow down how frequent the headaches are and how long they last.
According to the International Classification of Headache Disorders, a patient who has 15 or more headache days a month, of which at least eight days have migraine features, likely has chronic migraine.
Are chronic migraine symptoms more intense than episodic migraine symptoms?
People with chronic migraine are certainly more affected in their everyday lives. A study showed the rate of disability days per month was three times greater in people with chronic migraine than those with episodic migraine.
People with chronic migraine miss more workdays and leisurely activities. They also tend to have more co-existing conditions than people with episodic migraine.
For example, the same study found that depression is 205 per cent more likely in people with chronic migraine compared to episodic migraine. Anxiety is 140 per cent more likely in those with chronic migraine.
Do episodic migraine, chronic migraine, and headaches all have different causes?
Headache is too general of a term to assign it as a diagnosis for any person. Once we identify that a patient has headaches, we try to provide a very specific diagnosis, such as, migraine, cluster headache, tension-type headache and a medical condition that may be causing headaches.
Each of these conditions has different causes.
Migraine is thought to occur from several mechanisms, including family history, environmental factors, and mechanisms within the brain itself.
In people with migraine, we know that an area within the brain stem called the trigeminal nucleus caudalis becomes overactive and starts a storm of inflammation. In addition to inflammation, there are fluctuations in neurochemicals and changes in the blood vessels that take place.
Will my episodic migraine become chronic?
Migraine fluctuates throughout someone’s lifetime. There are times when migraine attacks may be less frequent and times when attacks may be more frequent. For example, in my female patients, I’ve found that the attack frequency increases—right around the first period, after giving birth to multiple children, during the perimenopausal period.
Risk factors for transforming from episodic migraine to chronic migraine are—obesity, overusing as-needed medications, sleep difficulties, such as sleep apnea and insomnia, depression and anxiety.
What are common treatments to manage migraine symptoms? Do they differ depending on whether I have episodic or chronic migraine?
Treatments definitely change when we differentiate between episodic and chronic migraine.
There are several categories of treatments—preventive treatments are meant to prevent attacks before they happen, rescue or abortive treatments are used when you have an attack, integrative medicine treatments are natural approaches that can be added to mainstream therapies.
If a person with migraine has four or more headache days a month or any number of days with disability, they qualify for preventive treatment, rescue treatment, and natural approach. I always discuss these three categories with my patients.
What are preventive treatments for migraine? How do they work?
Preventive treatments for migraine are meant to prevent and treat migraine in people who have four or more headache days a month. They can be daily medications in tablet form, or monthly or quarterly injections or devices.
Classically, beta-blockers, seizure medications, and antidepressants have been used for migraine prevention. While the mechanism by which these medications work for migraine is unknown.
When might my doctor recommend that I take a preventive treatment for migraine?
If you are experiencing four or more headache days a month or any number of headaches that cause disability, your doctor may recommend prevention.
Preventive approaches will also vary based on your coexisting medical conditions, whether you are pregnant, and what you do for a living. I always weigh the risks and benefits of treatments with my patients.
Are preventive treatments appropriate if I have episodic migraine?
It is ideal to prescribe preventive and acute treatments for migraine while a patient has episodic migraine, before they transform at some point to chronic migraine. Once a patient develops chronic migraine, it is much more difficult to treat.
In many cases, my patients may need more than one preventive treatment to get their headaches under control. There is evidence to suggest that different preventive treatments may work synergistically to provide an extra reduction in migraine days.
Once a patient is headache-free or close to headache-free for four to six months, I discuss tapering preventive medications with them.
What are the potential risks and side effects of taking a preventive medication for migraine?
This is variable depending on the treatment. Daily medications may have more side effects than a monthly or quarterly injection, device, or natural treatment.