The Mindful Migraine

The Migraine World Summit is almost over, but there’s a few more hours left of their good information. I’ll definitely be back next year to listen again.

Yesterday’s presentation was by headache specialist, neurologist and founder of Migraine Quebec, Dr Elizabeth Leroux.  The contents of her interview are simplified, and slightly reordered, below.  As always, please remember I’m not a doctor, so don’t take my notes at face value, and speak to your health care provider if they raise questions you’re curious to pursue.

First off for discussion was ‘acute medications’ which are used to treat individual attacks. [I’ve also heard these called ‘attack’ or ‘abortive’ medications].  What is available is different in different countries.  Usually, however, patients start with anti-inflammatory medications, then move to triptans, and medications that assist with nausea.  More recently, there are treatments called ‘gepants’ which are designed to intercept the message between the CGRP proteins and their receptors, thus blocking the pain signals.  These are exciting, she notes, because if they are taken often enough, then the acute treatment ends up acting as a preventative.

On top of these, there are several ‘self-care’ options which she listed as pet therapy, meditation, eye masks and ear-plugs, which all bring relief during the attack.

In terms of ‘preventative medication’, Dr Leroux noted we now have a lot of medication choices.  The first line of defense includes ‘old’ oral preventatives such as beta-blockers for blood pressure, drugs for epilepsy, and drugs for depression or pain management.  After that, around 2011, Botox arrived for chronic migraine which is generally very well tolerated.  In the last two years there has been a ‘tornado’ of CGRPs treatments that have arrived, both as injectables or intravenous.  Most recently, are gepant-CGRP medications that can be taken in oral form. 

She noted that we should not be concerned about taking medication that was designed for an alternate patient, such as epilepsy, because they act on the brain in a way that (“by serendipity”) still aligns with your neurological system.  Blood pressure tablets were also raised as an example [and Botox might be added here too].  She said the harm in trying medications was generally low, and if something doesn’t work; move on.

The two lessons she has learnt over the years: there is no ‘one size fits all’ approach to migraine treatment, and, if a doctor tells you “there’s nothing left to try” – do some research, because there’s (almost) always something else to try. 

In terms of additional assistance, she mentioned aromatherapy, and using oils such as mint, eucalyptus, lavender, citrus, and ginger.  Mint, especially, she said has been rubbed on the temples for centuries.  Dr Leroux also raised supplements as being helpful, including; magnesium, B2, Q10, but also potentially melatonin, vitamin D and feverfew-camomile.  She reiterated that in this area as per most, there is no one thing that works for everyone.  She suggested for example, that whilst some patients enjoy the oils, others “won’t go near scent with a 10 foot pole” during an episode.

Caffeine was raised as a treatment option, and Dr Leroux said that it does help, and can boost the efficacy of some medications.  However, she also noted that we now tend to consume so much caffeine throughout the day that we’re more likely to cause headaches through excessive use and/or withdrawal.

Nausea tablets were raised as yet another treatment option, to which Dr Leroux again agreed, suggesting it can act as a pain-blocker when given intravenously in hospital, but is less likely to be effective when taken as an oral medication.  Although, she did acknowledge they might assist indirectly by making you drowsy and relaxed.

There were a few other medications which she said are not internationally available, including ‘ditans’ and ‘DHE’ medications, both cousins of triptans, but which had mixed value to migraines due to the number of side effects.

Therapy was also raised, with various options listed, including: CBT (cognitive behavior therapy), ACT (acceptance and commitment therapy) and PRT (pain reprocessing therapy) – all of which, in their various ways, help you to focus on mindfulness, identify potential triggers, and learn how to see pain as less threatening.

[This has been BIG for me.  I haven’t followed any official courses, or gone to specific therapy for this, but it’s what I mean when I say “separate pain from suffering” – pain is painful, but suffering is truly miserable.]

Past trauma was briefly considered, and Dr Leroux noted that mental health can definitely have an ongoing impact on your physical health.  She also reminded patients that she, and other neurologists and headache specialists, are not trained in psychology, so they are often reluctant to ‘go there’ in case they do more harm than good.  If you need to talk about your issues, however, she always recommended you reach out and ask for help so your doctor can point you in the right direction.

Physical movement was emphasized, both in terms of physio (physical therapy) and personal trainers.  She reiterated the need to get others to motivate you and train you how to best move your body, so that you don’t just see benefits now, but into the future.  Choose people that are interested in seeing you again, help you set goals, and follow up on your progress. She laughed that when she was young, she was a ‘library rat’ who liked sitting still and reading, but now she recognizes that flexibility, strength, and persistence, are vital to her mental health.  She suggested experimenting with different options until you ‘find your thing’.  She also recommended that you can still exercise ‘restfully’, but suggested you get out of bed, out of your room, and meditate, stretch or do yin yoga, somewhere separate to your bedroom.

Contraceptives were mentioned, but they did not go into details as Dr Leroux explained hormonal issues were very patient specific and it was hard to make generic recommendations.  She suggested keeping records on menstruation and migraines to assist you look for patterns that could help your doctor treat the issue.

There were brief discussions about her frustration with the quantification of chronic migraine; she felt that 15 days a month was too many, and really 8-10 was already having a significant impact on people’s lives.  Again, she said the diary was your best friend in terms of helping provide evidence to doctors about patterns, frequency and severity.  She tried to reassure viewers that for the majority of people, migraines will be episodic and stay that way.

In terms of medication ’overuse’, she noted that she preferred not to call it that as it implied blame.  Sometimes persistent headaches can be caused by withdrawal [or rebound] but sometimes there’s other issues at play, and it’s very hard to predict who might be susceptible to this.

Adult-onset hemiplegic migraine, where you suffer from stroke-like symptoms, (but also tremor, seizures, paralysis aura), was also mentioned briefly. It was noted that this is a genetic disorder that can be hard to treat.  She recommended the website that looks at FND (functional neurological disorders) for more information: www.neurosymptoms.org

Finally, she ended by saying something to the effect of “I’m learning every day from my patients – from their persistence and courage – I see great stories – so don’t lose hope – there are potential allies out there who can help you – keep trying to get better.”

Thanks Dr Leroux, I couldn’t have said it better myself!

Take care, Linda.