The case study

A 39-year-old woman with a long history of migraine who was referred for ‘worsening headache’. She experienced daily, constant headache attacks with migraine on 20 days/month. The patient was taking frequent acute treatment for migraine, along with two oral preventives and daily painkillers. She had insomnia, couldn’t exercise due to headaches, often skipped meals, and consumed a high intake of caffeine daily. She had controlled hypertension and untreated depression (due to frequent headache days).

Demonstrate empathy

“Chronic migraine with medication overuse headache is a common problem that is often very challenging to manage” – Dr Christine Lay, University of Toronto

The expert faculty considered that the initial approach should be to demonstrate empathy with the patient’s circumstances and an understanding of how the patient has arrived at the situation of medication overuse behavior without apportioning any blame to the patient.

Establish patient-physician partnership

Professor Todd Schwedt, Mayo Clinic recognized that it is important to work in partnership with the patient, emphasizing to them that there will be no quick fix but that there are steps that can be taken to improve the situation and reduce the number of migraine/headache days over time.

“By engaging the patient as a partner, the majority of patients are reassured in knowing that the physician is educating and guiding them along the treatment path”– Dr Christine Lay, University of Toronto

Incorporate patient’s goals

Professor Kathleen Digre, University of Utah advised physicians to be clear on the patient’s goals and expectations before setting out a management pathway. The biggest mistake of the initial consultation would be if the patient were advised to stop caffeine, painkillers, and acute migraine medication, and they went away overwhelmed and did nothing, cautioned Professor Schwedt.

A step by step, holistic approach

“It is important to have a good exit strategy for some of the prescribed treatments, including preventives, that are failing the patient” – Dr Matthew Robbins, Weill Cornell Medicine

Professor Schwedt outlined his approach which would be to start the patient on a new preventive and aim for a slow, gradual reduction in the overused acute medications (including caffeine), with close follow up. Transitional therapy is appropriate while tapering off reliance on overused medications. The expert panel also discussed the use of alternative acute medications and preventives, neuromodulation devices, biobehavioral interventions and healthy lifestyle changes.

Professor Kathleen Digre emphasized that although local mental health resources may be limited, the patient may be directed to good content online on mindfulness and relaxation training (e.g. videos available at dawnbuse.com).

The resolution

“Education on medication overuse is the most important thing we as physicians can do, helping patients to understand what is going on” – Professor Kathleen Digre, University of Utah

Dr Christine Lay, University of Toronto advised that in practice, management of this patient case involved a 25-minute educational discussion about migraine and medication overuse. All over-the-counter painkillers were stopped, and a bridging therapy added. The acute migraine medication was switched. Oral preventives were tapered off and a calcitonin gene-related peptide monoclonal antibody preventive prescribed. A significant reduction in caffeine intake was recommended and dietary changes including vitamin D and magnesium supplements were added. The patient was given cognitive behavioral therapy (CBT) and directed to mindfulness apps.

After 4 months, the patient’s migraine frequency had reduced to 13 days/month. The patient was walking daily, had lost 15lbs in weight, had reduced hypertension, was doing mindfulness and CBT, and was sleeping and feeling better.