What to do When Migraine Treatment Fails

Richard Lipton, MD, FAHS offers advice to clinicians treating persistent migraine.

The persistence of chronic migraine can be quite disheartening, causing patients who have tried multiple treatments with no results to feel that they are out of options. Richard B. Lipton, MD, FAHS, Director of the Montefiore Headache Center, Professor of Neurology at the Albert Einstein College of Medicine, and past president of the American Headache Society has treated numerous patients with this concern. Over the years, he has developed a strong grasp on when to move forward with a possibly effective treatment plan and when to change course. In an interview with the American Headache Society, Dr. Lipton explains how he chooses his treatment methods and offers advice to others treating persistent migraine.

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What’s the biggest challenge physicians face when treating persistent migraine?
By the time many patients see a headache specialist, they believe that they have tried everything. Then the challenge is to figure out why none of the treatments they’ve tried in the past have worked. There are a number of common reasons treatments may fail. I would say the most common and most important, is that the diagnosis is either incorrect or incomplete. Many patients I see who have tried multiple therapies with little to no results come in with a diagnosis of migraine when really they have another head pain disorder.

Sometimes patients have more than one disorder, meaning after you successfully treat one disorder, they’re left with the second undiagnosed disorder. The first step to finding a treatment that works is making sure that you have a correct and a complete diagnosis before proceeding.

Can you tell us about some of the reasons migraine treatments may fail?
A fairly common one is that the patient has triggers that are either unaddressed or unidentified. Triggers initiate or increase the probability of getting a headache after exposure. The most common trigger that makes patients difficult to treat is medication overuse. A patient who is taking an over-the-counter medication that contains caffeine on a daily basis, may not get better. The very medicine they take to relieve their pain triggers their next headache as it wears off.

Inadequate use of preventive medications also may cause treatments to go wrong. It’s not unusual for patients to say that they’ve tried every single preventive drug and that none of them have worked. To them, that may mean they’ve taken a drug like Topiramate for three days and then stopped when the didn’t see any difference in headache days. Unfortunately, that’s not long enough for that treatment to work. It’s important to stress that preventive drugs need time to work because the word ‘prevention’ itself creates unrealistic expectations for patients. They may assume that as soon as they take the drug, they’ll never have another headache. The reality is that for oral preventives, benefits develop slowly. The definition of success is reducing headache frequency by 50%.

Do you have any advice for bridging that communication gap?
It’s a bit sad, but it’s important to bring patient expectations in line with therapeutic realities. Sometimes patients feel that the goal of treatment should be the complete elimination of headache. Or they may feel, that when you take an acute treatment, they should be pain-free in 10 minutes and then able to get back to work. The reality is that headache therapy is now really wonderful, better than it’s ever been, but may fall short of patient expectation. The reality is that migraine is a chronic disease. Like all chronic diseases, we can’t cure migraine. We can make it a lot easier to live with. If the doctor and patient are aligned on what success looks like, it becomes much easier to achieve success and make the patient satisfied with the treatment that’s available.

That being said, how do you know when it’s time to change course?
There are course changes that occur at multiple levels. It’s important to consider if a patient isn’t getting the benefits they’re looking for after a few months. Before making any concrete decisions, it’s important to run down the checklist – Is the diagnosis complete and correct? Have I identified all the triggers? Am I using the tools that I have in my quiver appropriately to relieve pain?

Then examine the other possibilities. Sometimes, when a patient says their medicine isn’t working, what they mean is that they have side effects they can’t tolerate. If the problem is side effects, then you definitely need to change treatments, perhaps to a more tolerable drug. Other times, the issue is recurrence, meaning they take their medication and their headache returns after a few hours. As a rule of thumb, if the patient has a partial response and no side effects, I like to see patients on a drug for at least six to eight weeks before we give it up.

Richard Lipton, MD, FAHS, is a member of the American Headache Society, a professional society for doctors and other healthcare 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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