These are the powerpoint slides, with Dr. Robbins voiceover, that accompany the Difficult to Treat(Refractory) headache talk.
Well welcome back and today we’re going to just show the written slides that accompany our talk on refractory chronic migraine i’m going to run through these fairly quickly and you can watch the attached video that’s on this channel that is our talk on refractory chronic migraine a chronic migraine is a few percent of the population which is millions of people and
We’ve gone through different definitions for refractory chronic migraine over the years but basically prevention medicines cannot have helped and we base refractory based on how well prevention medicines help or don’t help there’s a lot of questions and challenges with refractory chronic migraine the definition which we’ve been working on for decades how much
Does disability in the person matter are there biomarkers or chemicals in the blood stream or spinal fluid that we can tell or scans such as types of mri or pet scans and does it help to separate into mild moderate and severe refractory migraine refractory migraine can change where it goes back to episodic headache and all of a sudden is not so refractory where
Medications are working and of course we treat headaches differently at different ages medication overuse complicates everything and the diagnosis of medication of use is very debatable one question is how the headaches come about does it matter how we treat them new daily persistent headache where they come about over 24 hours or so or people are hit on the head
And it’s post-traumatic headache does this change our treatment versus what we call transform migraine where it happens slowly over years pathophysiology means what’s really causing the headache in the brain and it comes down to genetics mostly we get what we call central sensitization where the brain is just firing on its own and there are changes in the brain
With refractory chronic migraine where you can see on certain scans changes in the white matter in the brain does medication overuse headache change the brain and how much do psychiatric comorbidities such as anxiety depression bipolar personality disorders how much do you see in the brain as far as changes in gray and white matter with those one question is is it
Useful to have a scale of mild moderate and severe i published on this in the journal of headache and pain several years ago and that’s actually an open access journal if you google journal of headache and pain from europe it’s actually from italy it’s the european headache society their journal and we published on separating into mild and more moderate or severe
Refractory categories to see i think that for research this helps but clinically it also can help medication overuse headache as i mentioned is complicated it does contribute and the official definition of the international headache society is not all that accurate you just need a certain number of days of taking painkillers or over the counters but i think it’s
More complicated than this that would be medication overuse mo but to diagnose medication overuse headache we really need to tell if the medication and the overuse of it is causing the headache which is much more complicated now outside of medicine we do want to minimize medicine so it takes a village to raise a pain patient it also takes a village to help somebody
With severe psychiatric problems and so we get other villagers will use physical therapy or psychotherapy whichever is appropriate massage acupuncture we always encourage exercise people get the most extra exercise benefits in the first 20 minutes a day so 20 minutes a day on average people get eighty ninety percent of the benefits of exercise we’re going for at
Least 15 or 20 minutes a day walking treadmill bike anything the core work pilates and yoga can help meditation is always a mainstay and they teach it easier these days instead of an hour or two hours you can do ten minutes of meditation it can help and biofeedback which is more of a formal program catastrophizing is where people are always thinking it’s a 12 on
A scale of 1 to 10 everything is horrible the world is ending and we try to dial down the catastrophizing dial sometimes we see what we call catastrophizing by proxy where a parent says how can a sixteen-year-old possibly have headaches like this and we try to calm things down resilience is very complicated and i go into resilience more on our formal lecture on
This channel but it involves genetics the short arm versus the long arm of the serotonin transporter gene there was a wonderful article on resilience in the new york times a number of years ago called a question of resilience but you can go on the new york times website and google it and search for it and it was just a terrific article on resilience in people a lot
Goes into being resilient but we’re always trying to improve resilience which is not easy to do acceptance people generally will not accept chronic pain or chronic headaches when they just start so they may go to a hundred different clinics looking for the aha moment which rarely comes and sometimes we see lack of acceptance by parents by proxy coping we’re always
Trying to promote active coping which is not just sitting around saying doctor doctor give me an drugs and when you do i’ll get out of bed and go back to work we need people to volunteer work exercise do things a second about the caretakers it’s very difficult for spouses or parents or kids of something with severe pain or severe headaches and there’s a certain
Amount of depression sometimes it’s a tough position we do see some all-star spouses and parents but more often people around the person don’t want to hear it after a while unfortunately people with headaches tend to be shunted aside and at work nobody wants to hear it so the best we can do is try to help their headaches headaches actors also have a high rate of
Burnout and i coach residents and doctors in a number of ways to try to reduce burnout now there’s a number of good out there outpatient therapy options there’s no good algorithm because every patient is unique if you have a hundred different headache patients that are refractory or difficult to treat you go a hundred different ways we look at the headache history
And the medication history we look at all the comorbidities psych medical they’re sleeping and their gi system do they have diarrhea or constipation or ibs gerd weight gain is a big problem so is that an issue fatigue do they have neck and back in arthritis pain what’s their job or school requirements for instance if people have heavy duty job requirements our
Accountant or a physicist or a chemistry teacher we don’t want to push topamax to higher doses because it can make them very spacy addiction histories are important if we’re thinking of using anything that could possibly be addicting and finances i don’t want to push a therapy on somebody that i know can’t afford it the family history of responses and family history
Of psychiatric and medical comorbidities is also very important in the end we run this all through our brain our computer brain and using our gestalt hopefully we come up with a good plan so the top ten medicines for one person is much different than for the next person botox is a very good treatment for many people it works for sixty percent of people long-term
And there’s new studies that show that the more botox people get if they get a three four or five six seven eight times they’re more likely to revert to episodic headaches or not chronic anymore it’s fda indicated in fact it’s the only thing that’s fda indicated is a prevention for chronic migraine and there’s several ways to do it either the fda protocol which is
31 shots around the head or lower amounts chase in the pain we’ve done botox for about 20 years and we do it all kinds of different ways off-label we’ve used botox for cluster tmj many people have used it in adolescence we’ve had some good success and it probably works through the neuro immune response i started looking at the immune system and headache in 1987
We did some studies on helper suppressor cells and i was convinced that it was a key and headache we actually found the opposite to aids we’re instead of lower helper to suppressors we found higher helper to suppressors and headache patients and indeed when people do get aids it changes their headaches now they get headaches for other reasons when they get the
Clinical syndrome of age which thankfully is much less these days because of the successful medicines polypharmacy is another way to go and that means using two or more preventives comorbidities like the medical psychiatric and somnia drive where we go with these medicines weight gain and fatigue our big concerns sometimes we use botox with another preventive or
Even a natural preventive such as potato lex spg blocks for frontal pain they’ve been around since nineteen fourteen but they’re much easier to use now because of these newer devices and it we squirt some novocaine basically up the nose and it blocks the spg which is a collection of nerve cells in the front and sometimes it really helps chronic migraine were nothing
Else has it’s very safe so it’s always a consideration now back at the head blocks occipital nerve blocks and trigger point injections are useful they do hurt they do only last a week or two or three if they do help sometimes they can stop a cycle occasionally adding in steroids will help but usually we just used the marcaine a novocaine type medication frequent
Ripped hands many people lapse into daily tripped hands or frequent triptans years ago i did a study of 118 people where we use daily trip tans or frequent and while medication overuse is a concern over the 25 years these looks safer and safer and sometimes they are the only remedy that helps what we try to do is minimize the medicine we use the kinder gentler
Triptans such as naratriptan or provo which is now generic and we can always use preventives with these opioids are a huge controversial area and treating chronic pain and chronic headaches for a tiny subset of refractory patients they may help long-term there are a lot of concerns with them and now with the media exposure slamming opioids and the opioid epidemic
It’s tougher and tougher for patients to find doctors to prescribe but there is a small group who does very well my general rules for success no personality disorders not addictive personalities not using them in younger patients we don’t want to be the first to put people on opioids but once they’re on them for six months or a year their brain is sensitized and
It’s tough to get off sometimes if they do well on short-acting opioids we can switch to the long-acting the key is no tolerance to the pain killing analgesic effects most people do get tolerant and recently and i believe this week the journal nature or science there was a groundbreaking study on who gets tolerant and it may have been a study in animals but they
Believe that they’ve been able to identify a protein or substance in the brain and blood stream that will identify who’s tolerant and why they’re tolerant versus not and i think this may lead to using better drugs it is amazing that in two thousand years we are still using the same morphine based drugs we need better painkillers that have less side effects less
Tiredness less constipation are not addicting the companies have tried there’s been billion-dollar labs merck & glaxo working on better pain medicines and they just did not work out stimulants occasionally help which are used for a dd adhd sometimes they help tiredness and fatigue and weight and sometimes they help the headache in the right person simulants can
Be remarkably helpful without causing the usual tiredness and weight gain the idea is to use low doses as we want to use with opioids and there’s basically two classes the riddle n type and the adderall type so some people do better with one versus another but again in younger patients were very careful with these mao inhibitors used to be used quite a bit there
It’s a class of depression medicine that was used in the 1980s a lot the medication phenelzine or mera dil we used and now we’re using more of the patch the em sam patch but they’re probably under used for some patients mao inhibitors are the only medication that helps their headaches or depression i still use the older one the phenyl zine but the end sam patch
This alleged lien is actually safer and easier we’ve had some good success with it you do have to watch your diet with you somewhat but they are actually much safer than what was always talked about there are a number of other miscellaneous approaches methergine is difficult to obtain and it’s expensive but occasionally it will help for a month or two there’s an
Alzheimer’s mild dementia medicine called my man teen or namenda that occasionally helps it’s called an nmda antagonists which has a number of properties and it can also help memory muscle relaxant sometimes our will help and we’ll use the non addicting ones and they’re now is out this tms transcranial magnetic stimulation device there’s a unit for home use the big
Unit that r is in office as it is for depression the home unit is for headaches we don’t know the true statistics of how many people will be helped but i guess to made thirty to forty two percent of the more refractory patients probably will be helped long-term with tms it costs about a hundred and seventy dollars to 250 per month you can get the cost down and i
Think that it’s relatively safe we don’t absolutely no long-term side effects but the bigger tms machine gives thousands of pulses and this only gives a single one so i don’t think that we’re going to encounter long-term side effects but i will be recommending stopping it here and there because of that ketamine has been used intravenously more for depression but
Sometimes for pain and i think it can be helpful but there’s a lot of side effects the nasal spray which we do in the office is milder we’ve had some good success for refractory difficult depression a little less for headaches but i think ketamine if you use it judiciously and low doses is fairly safe and there is neuromodulation neural stimulation where they
Implant leads and wires under skin and there’s a battery pack some people do well with this long-term more often people needed taken out or it doesn’t work or they have some complication but for some people it has been useful another one coming along is the ati spg implant which doesn’t have any leads and wires i think that’s more promising they’ve had over 400
Patients in europe and had reasonably good success migraine surgery where they cut into muscles in the front or back is still early there’s no studies that i believe have been very well done we can’t recommend it at this time and what’s coming is cgrp antagonists which are called monoclonal antibodies where people have a shot once a month or every two months or
So and it prevents headaches i think that the effect will be reasonable in some people but people are getting their hopes up about these drugs and in the studies the effect is better than placebo but it’s not a miracle i think i’ll wrap it up here and we’re going to have other lectures including soon we’ll put one on on bipolar and personality disorders thank you
Transcribed from video
Refractory "Difficult to Treat" Chronic Migraine Powerpoint Slides By Headache Migraine Cluster
