April 30, 2018

Touch Sensitivity During Migraine Episodes: Q&A With Dr. Rami Burstein

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Originally posted on March 30, 2018

Touch sensitivity can develop years after migraine symptoms first appear. Dr. Rami Burstein explains its causes and treatment

Dr. Rami Burstein is a professor of anesthesia and neuroscience at Harvard Medical School and vice chair of Anesthesia, Critical Care and Pain Medicine Research at Beth Israel Deaconess Medical Center in Boston. He has specialized in headache since the 1990’s, and currently studies allodynia, or migraine-related sensitivity to touch.

Why do some people develop sensitivity to touch after years of migraine?
The reason why touch hurts is because the repeated and recurrent experience of migraine eventually changes the properties of certain neurons. It makes them more sensitive than they should be. When these neurons become more sensitive than they should be, instead of being activated only by pain, they begin to respond to touch. On its own, the sensitivity to touch is hardly ever seen in children. Usually, it takes seven, eight, nine, 10 years of having migraine before a patient begin to feel what we call allodynia, more sensitive to touch. It’s not age; it is the total number of migraine attacks that you have been exposed to during your lifetime.

What are you doing to help migraine patients who are living with the symptom of sensitivity to touch?
We don’t have medication to just reverse the sensitivity to touch. Emails that we got from patients once we started publishing the fact that migraine patients do feel touch as pain showed us that the most important part of our work was to send them the message that they’re not crazy, that they don’t make it up, that it is something real. Patients didn’t share these symptoms with doctors until our papers started coming out, which told them, it’s OK for you to tell your doctor, and when you do, the doctors will know that you belong to the group of patients that should be treated early.

What questions should a general practitioner ask a migraine patient to diagnose touch sensitivity?
Have you ever noticed that your scalp becomes more sensitive during migraine? Have you ever noticed a tendency to untie your hair from a bun or ponytail when you have a migraine, because it needs to be loose and not pull on or apply pressure to your scalp? At an academic center, there are questionnaires that were developed in several places, called allodynia questionnaire, that are used quite successfully in a large number of studies.

How can that diagnosis make a difference for a patient with allodynia?
It will allow doctors to explain what’s happening to them, provide them the rationale for why treating early is so critical, and explain why delaying treatment is going to extend their migraine and make it more difficult to abort. I think it’s the most important part. There is a whole host of reasons why patients would not treat early, and unless we educate them aggressively on the importance of treating early, we’re not going to get there.

What kind of treatment options do you find are most effective in catching a migraine or stopping it before it starts?
The answer differs between episodic and chronic patients. Patients who have at least five days pain-free between two migraine attacks usually will respond to the classical migraine medication, the triptans, very well if they treat early, because it takes about four to five days for the central nervous system to return to baseline activity, and now they’re responsive to triptans. If we couldn’t give them four or five days pain-free, and their central nervous system is not returning to baseline, and they continue to be sensitive to touch. These are usually the patients who become less responsive to triptans.

We don’t have a magic bullet that will take what we call long-term memory that these cells have and stop it, because they share a common mechanism with memory that we need for everyday life. So we don’t have a magic bullet to target the neurons that get hypersensitive and mediate the sensitivity to touch.

Dr. Burstein is a member of the American Headache Society, a professional society for doctors and other health care workers who specialize in studying and treating headache and migraine. The Society’s objectives are to promote the exchange of information and ideas concerning the causes and treatments of headache and related painful disorders, and to share and advance the work of its members. Learn more about the American Headache Society’s work and find out how you can become a member today.

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