Thursday, March 16, 2023

What Is An Intractable Migraine

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How I Cope Through The Storm

Intractable Migraine

Ive learned over the years to navigate intractable migraine attacks with less panic and more presence. I know that mindfully calming my nervous system and shifting my body out of a state of fight or flight is one of the most powerful tools in my arsenal to weather high pain with more ease. Every small comfort I can reach forfrom blackout curtains to cozy clothing to breathing exercisesis a way I can signal safety to my body, even while an attack rages on.

When I worry the waves of harsh pain might swallow me whole, I remind myself I do not have to feel brave to be brave. I think of all the times I have made it to the other side of impossible pain before, and gently remind myself that courage rides on my inhales and exhales, whether I feel it there or not. I reassure myself that by simply continuing to breathe, I can and will reach calmer waters again.

The debilitating nature, both physically and emotionally, of these cycles of continuous pain is difficult to describe to one who has not lived it. For those of us who have, please know that although your battle might often feel invisible, it is very real, and you are so very brave.

Options For Drug Therapy

Antiemetics. Dopamine receptor antagonists are assumed to merely treat nausea in patients with migraine however, they act independently to abort migraine and thus should be considered irrespective of the presence of nausea.

The two most commonly used agents are prochlorperazine and metoclopramide. The American Academy of Neurology guidelines recommend prochlorperazine as first-line therapy for acute migraine. Metoclopramide is rated slightly lower and is considered to have moderate benefit.4 The Canadian Headache Society cites a high level of evidence supporting prochlorperazine and a moderate level of evidence supporting metoclopramide.5 The American Headache Society assessment of parenteral pharmacotherapies gives prochlorperazine and metoclopramide a level B recommendation of should offer .3 Hence, either agent can be used.

To reduce the risk of post-treatment akathisia, diphenhydramine or benztropine may be given before starting a dopamine receptor antagonist. Diphenhydramine may be independently effective in migraine treatment,6,7 but data on this are limited.

Oral naproxen sodium is a possible alternative in patients with cardiovascular disease, as it has been shown to carry a lower cardiovascular risk than other NSAIDs.8

The same concerns in patients with renal dysfunction apply to any NSAID, as the enzyme cyclooxygenase plays a constitutive role in glomerular function.

Ilf Brain Training To Remediate Primary Headache Disorders

In our neurology practice ILF brain training has provided relief to primary headache sufferers refractory to standard medical management , including those who have failed advanced pharmacological interventions . We speculate that refractory primary headache syndromes reflect a dysregulated state or chronic instability of hypothalamic-trigeminal connections , and that ILF brain training effects the re-regulation of hypothalamic networks.

Also Check: Why Do I Get Headaches

Dealing With Intractable Migraine

The migraine is still here and I do not know when or if it will go away. If things start to progress and worsen, I will just go through my steps again. It is an ongoing process, one that may repeat itself a few times a year. This is what having chronic intractable migraine looks like for me. I wish it wasn’t my normal, but it is. Here’s hoping one day a new normal comes my way.

Causes And Diagnosis Of Status Migraine

Intractable Pain

Status migraines are believed to share the same causes as regular migraines. The World Health Organization believes that migraines have a genetic basis, and some studies have revealed that 70 percent of migraine sufferers have a family history of migraines.

Migraines have been found to be triggered deep in the brain, releasing inflammatory substances around the nerve and blood vessels of the brain. Why this occurs is still unclear.

Through the use of imaging studies such as MRIs, it has been revealed that changes in cerebral blood flow to the brain occur during ocular migraines and visual auras. But it is still uncertain if this is the cause, and not simply an association.

Migraines commonly affect adults in their 30s and 40s but can start in children during the puberty phase. Women are more commonly affected by migraine headaches compared to men. Approximately 15 to 18 percent of women and six percent of men in the United States are estimated to suffer from migraine headaches.

The diagnosis of status migraines is determined by its severe unremitting intensity, lasting more than 72 hours.

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What Inpatient Treatments Do We Have For Acute Intractable Migraine

We recommend the following combination treatment:

Normal saline 1 to 2 L by intravenous infusion over 2 to 4 hours. This can be repeated every 6 to 12 hours.

Ketorolac 30-mg IV bolus, which can be repeated every 6 hours. However, patients with coronary artery disease, uncontrolled hypertension, acute renal failure, or cerebrovascular disease should instead receive acetaminophen 1,000 mg, naproxen sodium 550 mg, or aspirin 325 mg by mouth.

Prochlorperazine or metoclopramide 10-mg IV infusion. This can be repeated every 6 hours. However, to reduce the extrapyramidal adverse effects of these drugs, patients should first receive diphenhydramine 25- to 50-mg IV bolus, which can be repeated every 6 to 8 hours.

Sodium valproate 500 to 1,000 mg by IV infusion over 20 minutes. This can be repeated after 8 hours.

Dexamethasone 4-mg IV bolus every 6 hours, or 10-mg IV bolus once in 24 hours.

Magnesium sulfate 500 to 1,000 mg by IV infusion over 1 hour. This can be repeated every 6 to 12 hours.

If the migraine has not improved after 3 cycles of this regimen, a neurologic consultation should be considered. Other options include dihydroergotamine and occipital nerve blocks performed at the bedside.

What Should I Do If My Migraine Lasts More Than 72 Hours

When it comes to status migrainosus, diligence is key. If a person has a migraine for over 72 hours, this individual has status migrainosus and must receive immediate medical attention. After an emergency room or hospital visit, a status migrainosus patient should follow up with their neurologist to ensure they are receiving the best medical treatment to prevent future attacks. Patients who have experienced status migrainosus generally suffer from chronic migraines, and should visit The Migraine Institute to find out if they qualify for long-lasting Botox or surgery treatment..

Dr. Jonathan Cabin of The Migraine Institute is committed to helping patients identify long-term solutions to migraines, like status migrainosus. As a board-certified head and neck surgeon with dual-subspecialty training in facial plastic and reconstructive surgery, Dr. Cabin provides two interventional treatments to help migraine patients achieve long-lasting relief:

  • Botox for migraines involves the use of Botox injections to reduce or eliminate nerve irritability that can trigger painful migraines.
  • Minimally Invasive Migraine Surgery helps remove faulty nerve signals that can cause migraines.
  • During a consultation, Dr. Cabin will learn about an individuals migraine symptoms and gather critical information about the patients migraine history. Then, Dr. Cabin will provide personalized interventional migraine treatment recommendations.

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    When Does A Migraine Start To Become Be Dangerous

    Migraines are typically benign, or non-life threatening, but this is not the case with status migrainosus. Due to its relentless and never ending nature , status migrainosus has the potential to become and is considered, in most instances, an emergency medical situation. The longer the condition persist, the more serious it can become. Indeed, status migrainosus can be life threatening, inducing conditions such as dehydration, stroke, aneurysm, permanent vision loss, serious dental problems, coma and even death. In the long-term, it can lead to psychological problems such as anxiety and depression, which increases the risk of suicide.

    How Is Status Migrainosus Diagnosed

    Managing Intractable Migraine

    To diagnose someone with status migrainosus, doctors will examine the patients previous diagnoses, medical history and symptoms to rule out the possibility of other types of headache, such as:

    They will also check for red flag symptoms to ensure that the patient isnt experiencing a more serious condition than migraine, such as a stroke. Some signs theyll look for include:

    • Sudden vision changes or double vision
    • Sudden numbness or weakness

    Once the diagnosis is confirmed, doctors can develop a treatment plan.

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    Prevention And Tips For Status Migrainosus

    Due to the unrelenting presentation of status migraines and treatment difficulty, the best course of action is to prevent status migraine development from occurring in the first place. This will typically come in the form of prescribed medication that will reduce migraines from occurring, and if they do still occur, they will likely be less severe and shorter in duration. These medications include:

    • Antidepressants medication such as amitriptyline
    • Antiseizure medication such as topiramate or valproate
    • Blood pressure medication such as metoprolol tartrate and propranolol

    Preventing status migraine development will also require the avoidance of various triggers and lifestyle habits. The following are some helpful suggestions that may prove beneficial:

    • Preventing hunger by eating several small meals throughout the day
    • Preventing dehydration by drinking eight or more glasses of water per day
    • Good sleep hygiene practices
    • Deep breathing and meditation to relieve stress
    • Not over using migraine pain relievers

    If you are a known sufferer of status migraines, it may be worth your time to see a neurologist to get a detailed evaluation of your own unique situation. They are the best equipped to diagnose status migraines and to look deeper for any potential causes. Lastly, by adhering to your doctors prescribed treatments and the avoidance of triggers, you can be certain you are doing all you can to avoid this severe form of headache

    Regular Migraine Vs Status Migrainosus

    The difference is in the duration and the response to treatment. A regular migraine attack usually lasts between 4 and 72 hours. Treatments like triptan drugs and pain relievers can often relieve migraine pain and other symptoms.

    Status migraine symptoms last for longer than 72 hours, even with treatment. The headache might go away for a few hours, but it keeps coming back.

    Symptoms of a status migraine can be severe enough to disrupt your life. Vomiting can also lead to dehydration and an electrolyte imbalance.

    People with status migraines should see a primary care doctor or neurologist for treatment. The doctor will look for any health issues or lifestyle factors that might trigger your headaches. Theyll recommend treatments based on this information.

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    What Can I Do To Make My Migraine Go Away

    There is no one-size-fits-all cure for all migraines, at all times. However, both over-the-counter and prescription medications are available to treat migraines, including rescue medications that can be taken to alleviate active migraine symptoms. Preventative and abortive OTC and prescription migraine medications are also available. Preventative medications are taken on a regular basis to limit migraine frequency, duration or intensity, while abortive medications are taken during the early stages of a migraine to help prevent a migraine attack from escalating.

    What Triggers Status Migrainosus

    The Ins and Outs of Intractable Migraine

    Status migrainosus is a migraine attack that spins out of control and becomes difficult to treat. The reason why an individual attack of migraine develops into this is not exactly known. A triggeror a combination of triggerscould cause a migraine attack to develop into status migrainosus, including:

    • Changes in medication
    • Lack of sleep

    The best way to reduce the chance of a migraine attack developing into status migrainosus is by beginning treatment at the first signs of an attack. Recognizing your prodrome, or preheadache, symptoms can help alert you to take your prescribed acute treatment. The earlier you treat your attack, the more likely you are to stop it in its tracks or prevent it from getting out of control.

    Its important to remember that migraine attacks are not anyones fault. Migraine attacks can be spontaneous, meaning they can still occur even if youve carefully followed every step of your treatment and management plan.

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    Resources For Intractable Migraine Patients

    Intractable migraines usually evolve from regular migraines, although it is not unheard-of for a patient to begin their migraine journey experiencing them. However, the same way it typically takes time for a persons migraines to become intractable , it usually is a process, one that takes time, to return to normal and be migraine free. Very seldom will a new pill or treatment be the magic solution that takes it all away. Because of this long, often painful and difficult process, emotional support is absolutely vital.

    Having people who understand your condition and support you is one of the most effective coping mechanisms migraineurs can have. These websites offer support and help to people who have migraines and intractable migraines.

    Intractable migraines, as well as other types of migraines, are often a chronic illness. It is easy to withdraw from others as the pain makes it difficult to be social or even maintain relationships. You may not want to burden others with your persistent pain, or you may simply not have the energy to foster a relationship. Whatever the case, getting support in any capacity is helpful. The resources listed here will connect you to other people who have intractable migraine just like you. They also offer valuable information and, most of all, hope for a future without migraines, without pain.

    Management Of Refractory Migraine

    There are several reasons why standard headache treatments fail . These reasons include incomplete or inaccurate diagnosis, important exacerbating factors and comorbidities have been missed, non-pharmacological treatment has been inadequate, pharmacotherapy has been inadequate, neuromodulation has not been considered and unrealistic expectations by patients. These factors should be systematically considered in the clinical evaluation of patients with refractory migraine.

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    Typical Migraine Attack Vs Status Migrainosus

    They are both neurological conditions characterized by intense, debilitating symptoms. A typical Migraine attack can range from moderate to severe and can last anywhere from 4 to 72 hours.

    Katsarava, Z., Buse, D. C., Manack, A. N., & Lipton, R. B. . Defining the differences between episodic migraine and chronic migraine. Current pain and headache reports, 16, 8692

    Treatment Of Status Migrainosus

    Managing Intractable Migraine & Status Migrainosus with Dr. Berk

    Considering that stratus migraines do not respond to commonly used migraine medications and treatment, treating this severe form of a headache can be complicated. However, traditional migraine medications will still be used. This includes the use of triptans, ergots, and non-steroidal anti-inflammatory drugs.

    If proven unsuccessful, stronger pain relievers will be used. The use of suppository anti-nausea medication may also be utilized.

    Because of the intensity of this severe form of a migraine, treatment often takes place in a hospital setting. This allows for the delivery of fluids and medication intravenously, the fastest methods for receiving treatment.

    Types of medications that may be used include:

    • Dihydroergotamine: Used to treat intractable headaches
    • Ondansetron or metoclopramide : Anti-nausea medication
    • Depakote: Anti-seizure medication
    • Dexamethasone : A steroid medication that may help improve status migraine symptoms

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    Intractable Migraine: A Definitive Guide

    Intractable migraine is a persistent or chronic, debilitating migraine without aura that significantly affects a persons ability to function. Even when affected individuals take steps to control triggers and make deliberate lifestyle changes, it still has a major impact on their quality of life.

    They typically do not respond to the most common preventative medications , such as beta-blockers, tricyclics, anticonvulsants, and calcium channel blockers.

    These migraines do not usually respond to abortive medications either. Triptans, a class of prescription medications that induce vasoconstriction, and nonsteroidal anti-inflammatory drugs usually fail as well. The trials to find a treatment that actually brings relief are usually quite long and arduous. All too often relief is never found.

    Also known as refractory migraines, they are often described as relentless and never ending. It is a fact of life for so many people. They go to bed with it, wake up with it, and struggle to function through the day despite the pain, nausea, vertigo, and vision disturbances that often accompany these incapacitating migraines. They can be dangerous and should be taken seriously treated as a medical emergency.

    Axon optics caught up with Dr. Jonathan Cabin of The Migraine Institute in Beverly Hills, California to get some insight into intractable migraine.

    • Difficulty focusing or inability to think clearly
    • Sleep deprivation or sleep loss
    • Dehydration
    • Hypoglycemia

    Identify Important Exacerbating Factors And Comorbidities

    Important exacerbating factors include medication overuse, dietary or lifestyle triggers, hormonal triggers, psychosocial factors, or the use of other medications that trigger headaches and may lead to refractoriness. In the search for exacerbating factors, ask about factors the patient may have identified and then probe for common and uncommon exacerbating factors, especially those that are subject to modification or intervention.

    In headache subspecialty practices, medication overuse and withdrawal is a common cause of refractoriness . It is therefore important to specifically establish the patients pattern of medication use, including both prescription and over-the counter medication. Patients are often embarrassed about medication misuse and fear that the physician will make harsh judgments. It is therefore important to ask about medication use in an open, non-judgmental manner.

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    Complications Of Intractable Pain

    Unlike chronic pain associated with arthritis, intractable pain can affect hormones, such as cortisol, because intractable pain also raises levels of stress and inflammation in your body. This can contribute to problems, such as high blood pressure and a high pulse rate. Intractable pain can also result in sexual dysfunction.

    Intractable pain often interferes with sleep, making you more likely to feel fatigued. Insufficient sleep and constant pain can also combine to make it difficult to concentrate and make decisions. Along with interfering with your thinking skills, intractable pain can also affect your physical performance.

    The Ins And Outs Of Intractable Migraine

    Understanding Status Migrainosus with Intractable Migraine
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    What It Is:Intractable migraine, also called refractory migraine and/or status migrainosus, is the medical term used to describe a persistent migraine that is either 1) difficult to treat or b) fails to respond to standard and/or aggressive treatments. In general, its a migraine that simply doesnt go away, regardless of treatment.

    What It Feels Like: Intractable migraine is relentless and seems to never end. You wake up with it. You go to sleep with it. Its there all day. The pain levels associated with it, however, may not be constant. The symptoms generally are not either.

    When I had my last intractable migraine, some days would be full of vertigo, nausea, and vision disturbances. Other days would be relatively symptom-free . In general, my pain tended to lessen over night , and increase over the day . When I was blessed with a lesser-pain day , I tended to get sharp ice-pick stabs throughout the day that were significantly more painful than the underlying pain. My disability level ranged from mild to severe, depending on the number of symptoms present and the magnitude of the pain.

    As with any other migraine attack, an intractable one will be different for everyone who experiences it. This is one of the reasons they are so difficult to treat. If you have an intractable period, it will likely look very different from mine.

    Who Gets It: Any migraineur can theoretically get an intractable attack

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