The Roller Coaster of Fluctuating Migraine Frequency

Have you ever felt like you were on a migraine roller coaster, where your migraine frequency seems to be going up and down, up and down? You’re not alone! This is a very common pattern in migraine that has long been a pattern in patient diaries, but is hidden in plain sight in research, according to headache specialist Richard B. Lipton, MD. Dr. Lipton examined the cyclical nature of migraine and how it presents in patients and in research in “Riding the Migraine Roller Coaster,” a talk he gave at the American Headache Society’s scientific meeting in June.

When people with migraine record their attacks, highs and lows of migraine frequency are usually evident. A person may have no attacks for a few weeks, then have a spate of them over the next few weeks, then back to no attacks for a few weeks, and so on. The variation in frequency can happen from year to year, month to month, week to week, or day to day. It’s even possible for a person to cycle through meeting the diagnostic criteria for chronic migraine (15 headache or more headache days a month, at least eight of which are migraine) one month, then episodic migraine the next, and back again. Why migraine attacks are cyclical remains unknown, but it has implications for both patient care and research.

Despite the obviousness of migraine frequency cycles in patient’s diaries, the cyclces often get hidden in migraine treatment research. Dr. Lipton explained that these cycles are hidden when migraine frequency for multiple patients is averaged, which is a standard practice in research. This happens because patients in the same study can be at different points in their cycles of migraine attack frequency and, when averaged, the variations cancel each other out.

In a hypothetical study of 10 patients, if half have no migraine days in a month and half have 10, the average is 5 migraine days per patient that month. In the same study three months later, the half that had no migraine days the first month could have 10 three months later and those who had 10 attacks the first month could have none. Again, the average shows 5 migraine days a month for all patients.

The cyclical nature of migraine could be why there appears to be such a high placebo response to migraine drugs in research – when people are given a placebo and do have an improvement in their migraine frequency, it might be due to their natural frequency cycle, completely independent of whether or not they took the placebo.

It could also explain why so many preventive medications appear to be effective in clinical use, but have lackluster results in research. Some portion of patients might benefit significantly, but averaging the results without adjusting for the complication of migraine frequency cycles could hide those improvements.

Developing a better understanding of the cyclical nature of migraine attacks could lead to major changes in the way migraine is viewed, researched and treated. And, of course, it validates all the people with migraine who swear their migraine attacks come in spurts.1

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