Will My Chronic Migraine Ever Become Episodic Again?
Please note, since the publication of this article, the guidelines for migraine diagnosis have been updated. For information on the most current, ICHD-III, guidelines please click here.
Chronic Migraineurs often mistakenly believe that they’ll always suffer debilitating Migraine and headache pain more days than not for the rest of their lives, yet this is very often untrue. With good treatment, time and work, chronic Migraineurs will often be able to revert back to episodic status again.
Migraine is a genetic neurologic disease. Chronic Migraine is a complication of Migraine disease that is often misunderstood by patients, usually because the doctors who diagnose and treat them don’t understand the process themselves.
What is chronic Migraine?
Chronic Migraine is not a variant of Migraine disease. A variant (a specific type, often with specific genes guiding them) cannot be changed, however a complication sometimes can be changed. Just as a chronic Migraineur didn’t start out life in a chronic state, they may not necessarily stay chronic. This is good news for chronic Migraineurs!
Sometimes Migraineurs are surprised at exactly what chronic Migraine is. In a nutshell:
- When the Migraineur has fewer painful days (or days with an attack, which may be without pain) than days spent feeling *normal*, we label that person as an episodic Migraineur. Their heads are free of attacks and pain more days than not.
- When a Migraineur has more painful days (or days with an attack, which may be without pain) than days spent feeling *normal*, the ICHD-II says that they have transformed or become chronic. They experience head pain and attacks more days than they feel good.
Doctors are aware that there’s a single day that separates a diagnosis of episodic Migraine vs. chronic Migraine, and they’re currently working on a better way to diagnose patients. We suspect chronification has physiological effects in the brain, but we can’t test yet to see if chronification has occurred. Doctors use the ICHD-II definition and criteria to *best guess* which patients are in this situation. It’s certainly not a perfect scenario, but right now it’s the best we have.
How did transformation occur?
Transformation from episodic Migraine to chronic Migraine is so easy, it occurs before the patient and often their doctor is even aware it’s happened. Often it is by journaling their Migraines that patients and their doctors discover how serious the situation has become.
There are many avoidable and unavoidable things that may lead to the transformation of episodic Migraine to a chronic status, but it’s thought that one of the most frequent, avoidable contributors to transformation is the result of unknowledgeable physicians prescribing pain medicines for their patients instead of abortives which stop the Migraine process itself: Medication Overuse Headache (MOH).
Because pain and pain medicines can actually physiologically change how our central nervous systems are wired and function, it is important to treat the root of the problem — Migraine attacks – not just the symptom. Comorbidities which are not well understood or frequently misdiagnosed such as thyroid dysfunction, blood sugar problems, fluctuating hormones or traumatic brain injury can exacerbate Migraines and lead toward chronification. Missing the identification of a frequent trigger may even result in transformation, because the patient is unable to avoid the Migraine process for so long that it causes brain changes that result in chronification.
There are many reasons why an episodic Migraineur may become chronic, but our goal is always to turn that around and help the chronic patient become episodic again, so they can once again become active participants in their lives.
How do I become episodic again?
The transformation from chronic to episodic actually happens with reasonably frequency. Fortunately, one of the reasons we don’t hear about it is that when a patient gets their life back, they often choose to celebrate it by getting involved in the things they love again and choose to try to forget their chronic experience.
- For those who aren’t taking an oral preventive that helps them, that’s almost always one of the first courses of action and are used in concert with abortive and rescue medicines. Some of these therapies are FDA approved, however most of them are not approved for Migraine prevention. That doesn’t mean they don’t work, but it does mean that the research wasn’t done to prove their effectiveness in Migraineurs. Migraine prevention is a “happy side effect” of these drugs approved for other uses.
- Fortunately we now have another preventive therapy that seems to work reasonably well for patients who have tried other preventives. OnabotulinumtoxinA (Botox) injections are a more precise, targeted therapy and have been reported to help chronic Migraineurs revert to episodic Migraine patterns again… when done by a trained and skilled physician. Some patients on onabotulinumtoxinA are eventually able to stop or reduce their injections, while others will stay on them indefinitely. Many patients utilize onabotulinumtoxinA in concert with other preventives for optimized Migraine management.
- Nerve blocks can be useful to help *reset* the central nervous system and revert some chronics to episodic patterns again. These often need to be done repeatedly and multiple injections into multiple locations simultaneously to be effective, but they are worth a try for many patients. The addition of steroids into the anesthetic has not been shown to be helpful for Migraineurs and is discouraged because of potential side effects which may range from mild to serious.
- There are surgeries that are not FDA approved, but may be helpful for a specific subset of patients when performed by skilled and trained surgeons. Even on their best day, these surgeries do not eliminate or *cure* Migraine despite some claims. They may help with some triggers and symptoms however.
- Transcranial Magnetic Stimulation is another option we may have up our sleeves, when the FDA gets around to approval. Until then, it is available in Europe, but not here in the United States.
I’ve reverted to episodic again — now what?
If you are on a preventive regimen and you get better, DO NOT STOP IT. This mistake happens frequently and the Migraineurs who try it unsuccessfully are horrified to learn that once stopped, a preventive may not work as well — or at all — when tried again. Sometimes these therapies can eventually be slowly reduced with positive results, but this is better done with the help of your physician and only after a relatively long stretch out of the chronic category. Remember that the brain physically changed when you became chronic. That didn’t happen overnight, and changing it back again will take real time and perseverance.
Sometimes some of the physiologic central nervous system changes that have occurred are permanent. Chronics may never be able to successfully get off their medicines and treatments, even after they have reverted back to an episodic pattern. Their health care partners, management, medicines and treatments are their lifelines.
We know that chronic Migraineurs are more likely to be disabled, suffer comorbid conditions that are difficult to treat, and choose to end their lives. The most important thing I hope chronics will get from this article is that there is hope for them. For us. Being chronic today doesn’t have to be the end of our story…
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