Doctor on Call: What the heck is “transformed migraine”?
Sandra, a 37-year-old computer software engineer and mother of three from Colorado Springs, writes:
I am so confused. I’ve had migraine all my life, but in the past I always got by with Advil and a strong cup of coffee. Since my last pregnancy two years ago, however, I’m having migraine all the freaking time. My primary care doctor referred me to a neurologist, and she told me that I have “transformed migraine.” She also rattled off what seemed to be about 30 different choices I had for treatment, and when she was finally finished I left her office more confused than I was when I went in.
What is “transformed migraine,” and what should I do about it?
Perplexed in Colorado
The Doctor’s Reply:
Well, Sandra, there are the short answers, and there are the long answers. Before getting into that, however, let me assure you that you are far from alone. Every year many patients who for years have had only occasional episodes of migraine experience a “transformation” of their low frequency episodic migraine into what in the past was known as “transformed migraine” and now is characterized as chronic migraine. As many as 6 million Americans actively are stuck in the swamp of chronic migraine, and unfortunately only a small percentage ever seek medical attention, receive an accurate diagnosis and are prescribed an appropriate treatment plan. This is especially unfortunate given that we now have a large handful of evidence-based therapies for treating chronic migraine.
First step, pick a therapy for chronic migraine prevention/suppression and, along with it, a treatment plan for acute headaches that “break through” despite the prevention/suppression therapy. Evidence-based therapies for chronic migraine prevention/suppression now include onabotulinumtoxinA (BotoxA), any of the three currently available subcutaneously self-administered anti-CGRP monoclonal antibodies (mabs), an intravenously administered anti-CGRP mab (epitenzumab/Vyepti), and three orally administered drugs: rimegepant/Nurtec, atogepant/Qulipta and topiramate. Nurtec is to be administered orally every other day, while the other two are administered daily. The self-injected anti-CGRP mabs typically are injected once monthly, Vyepti is administered intravenously every three months and BotoxA is administered by a medical provider every 12 weeks. With the exception of topiramate, a medication the editor of this magazine tends to avoid due to problems with each tolerability, represents an equally good choice. We do not have data from head-to-head comparator research studies to tell us which one is of these options is “better” than the other, and there is no component of your headache history, no blood test, nor any imaging study that will predict which of these options is destined to be the best for you. Suffice it to say that with the notable exception of topiramate, all are safe, typically well tolerated and often effective in rapidly reducing your migraine burden.
In short, it boils down to a question of what you prefer. Do you favor an oral medication taking daily or every other day? Do you like the idea of a medication you inject yourself once monthly? How about the option of an intravenous medication administered every three months? And how about BotoxA? Again, for most patients with chronic migraine any of these is a good choice.
Don’t forget that optimal management of chronic migraine involves aggressive treatment of “breakthrough” headaches. Not only will effective treatment of those headaches help at the time you have them, but there is increasing evidence that elimination of prolonged, severe migraine episodes has a prevention effect which complements the prevention/suppression therapy you have chosen. As has been discussed at length in a previous issue of this magazine, it is best to have at hand several different therapies do use for the various levels of acute migraine headache. The therapies with the strongest evidence base for such use include “simple” analgesics (egs, aspirin and acetaminophen/Tylenol), nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium and ibuprofen, the various triptans (egs, sumatriptan/Imitrex, rizatriptan/Maxalt) and the newer designer drugs such as Nurtec, ubrogepant/Ubrelvy, lasmiditan/Reyvow and intranasal DHE/Trudhesa.
It is a pure shame that so few patients with chronic migraine receive appropriate treatment. There are a lot of options, but designing an appropriate treatment plan is really not all that complicated. Use this magazine to educate yourself as to the various options available, and give your choice a try. If it succeeds, great! If not, change course, and try another equally good option. Again, the bad news: we providers cannot predict prospectively what is the best option for you. The good news: in this process of educated trial of error, we now have a very nice selection of evidence-based options. Do not let your “transformed migraine” go untreated.