Guest: Lindsey Plato-Johnson, DNP, FNP-BC, AQH, MSCP

View the recording from our Migraine Clinician Masterclass, developed in partnership with IVPN Neuropsychiatry. In this webinar, we hear from Lindsey Plato-Johnson, DNP, FNP-BC, AQH, MSCP, who talks about Acute, Preventive, and Behavioral Therapies for Migraine. Please note that this video is intended for healthcare providers.

TRANSCRIPT

Lindsey Plato-Johnson, DNP, FNP-BC, AQH, MSCP: Good evening, all. I am thrilled to be here. I’m Lindsey Plato-Johnson. I’m a family nurse practitioner with an added qualification in headache medicine. I live in Maryland in the USA, and I’m thrilled to be speaking with you tonight about the management of migraine using both abortive and preventive pharmacologic techniques as well as cognitive behavioral therapy.

I have no disclosures. 

During this presentation, the aim of this is to have an overview of the latest treatments and options for migraines encompassing both acute and preventive care, the pharmacologic treatment, as well as cognitive behavioral therapies. By the end of this session, you will be equipped with the knowledge and tools to optimize your migraine care, tailoring it to the individual patient needs.

To introduce a little bit more about migraines, migraine, as you know, is a complex neurological disorder characterized by recurrent throbbing headaches, often accompanied by other symptoms such as nausea, vomiting, and sensitivity to light and sound. 

The impact of migraines on patients’ quality of life and productivity cannot be understated. Chronic migraines can lead to significant disability, socioeconomic burden, and it makes it crucial for healthcare providers to be familiar with the latest approaches in migraine management.

Migraines affect over 1 in 10 individuals, more often females, with the most common age in the thirties, which are among the most productive years as it relates to career and family care. Migraine is ranked second after lower back pain worldwide among diseases with respect to years of life lived with a disability. 

Migraine pathophysiology. To effectively manage migraines, it’s essential to understand the underlying pathophysiology of this condition. Migraine headaches are thought to be neurovascular in nature, involving this complex interplay of neuronal and vascular mechanisms. We now know that migraines occur within the context of a predictable phase model involving a prodrome, a potential aura, the headache phase, and finally the postdromal phase. 

Migraines are a group of headache disorders with distinct clinical presentations. Proper classification is essential for an accurate diagnosis, appropriate treatment selection, and improved patient outcomes. The International Classification of Headache Disorders, ICHD, by the International Headache Society provides a standardized framework for categorizing migraines based on scientific criteria, and understanding the classification enables healthcare providers to differentiate migraines from other headache disorders and allows them to tailor the plans based on specific migraine subtypes. 

So here you’ll find the definition of a migraine disorder. This requires five headache episodes lasting 4 to 72 hours with the headache having at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and/or aggravation by or causing avoidance of routine physical activity. Additionally, during the headache, the patient typically experiences nausea, vomiting, and/or sensitivity to light or sound, and this is of course assuming the exclusion of a secondary headache disorder. 

The classification can be summarized using the POUND mnemonic. This could also be used as a clinical tool for diagnosing and screening for migraines. It includes a five-question screening tool. The first question is, is it a pulsating headache? Two is, does it last between 4 and 72 hours without medication? Three, is it unilateral? Four, is there nausea? And five, is the headache disabling, meaning that it is disrupting their typical activities? Each of those different questions get one point per positive response, and answering yes to four or more of the questions has a very high likelihood ratio of having a migraine disorder.

One of the challenges in diagnosing migraines is that there are currently no biomarkers that are diagnostic of migraines. Similarly, there are no labs or imaging studies that will diagnose migraines. The entire diagnosis is based on the patient history and their presentation. And I put a quote there at the bottom just as a reminder from Sir William Osler, who says, “Listen to your patient. He is telling you the diagnosis.” 

The approach to treatment then has to be individualized. So once the migraine disorder is diagnosed, the next challenge is how to approach it. This is not a one-size-fits-all situation, but rather the treatment needs to be individualized based on the patient’s characteristics.

With the model of a shared decision-making model, both the clinician and the patient are working together to develop a treatment plan that will be most effective and appropriate. This allows the patient to take into consideration factors that may be important to them, such as side effects, medication costs, and while still allowing the clinician to guide them based on the best practice. 

The first step in treatment is to effectively stop a migraine before it progresses and becomes disabling. To do this, it requires an early intervention with an effective abortive medication. For the sake of this presentation, I’m focusing on treatments that would be used within an outpatient setting. Within the inpatient or emergency department settings, other modalities may be commonly employed.

Here are the most commonly prescribed categories of medication for acute or abortive migraine medications. The first is NSAIDs, or nonsteroidal anti-inflammatory drugs. Next are triptans, followed by gepants, followed by the new ditan class, combination therapies, ergots, and devices.

Of course, if somebody is experiencing nausea or vomiting along with their migraine, it’s recommended to prescribe an antiemetic, such as ondansetron or metoclopramide. This is not only to alleviate their nausea, but it also enables them to take an oral medication that can be more effectively metabolized with the absence of vomiting. Let’s talk about each option individually.

The first one I want to speak about is typically available without a prescription or over the counter. The main action of nonsteroidal anti-inflammatory drugs or NSAIDs is blocking the production of prostaglandins via the inhibition of cyclooxygenase. This helps reduce inflammation and pain.

I will note that NSAIDs, as well as acetaminophen or paracetamol, are often used in combination treatments. Sometimes these combination treatments can contain butalbital, which may increase the risk of medication overuse headaches, and we’ll touch on that in just a few slides. 

Triptans are among the most commonly prescribed medications for migraines. They bind to serotonin receptors in the brain, which result in a decrease in intensity and the duration of migraine symptoms, such as headache, nausea, and sensitivity to light and sound. 

Gepants are more often used lately. They have a calcitonin gene-related peptide or a CGRP. It’s a protein that’s responsible for transmitting pain signals along the nerves, contributing to the generation of the headache pain linked to migraines. Gepants function by obstructing the binding of CGRP to its receptor, thereby preventing the initiation of these pain signals. This is a newer medication that has a lot of promise. Dr. Zachariah is going to be actually speaking a little bit more on this next. 

Ditans are a newer class of drug, and they work by blocking specific serotonin receptors, specifically the 5-HT1F receptor. This class offers an alternative for individuals that may not tolerate or respond well to triptans.

Ergots refer to a class of drugs that’s derived from the ergot fungus, with vasoconstrictive properties that could help alleviate migraines by narrowing blood vessels and reducing that blood flow. The historical use of ergot derivatives for migraines dates back many years, with ergotamine being one of the most early treatments known for migraines. However, advancements in medication have led to development of more targeted and effective migraine therapies that reduce the reliance on ergot-based medications due to some of the potential side effects and limitations.

There are also a variety of devices available that could be used for migraines that provide relief by interrupting the migraine processes through various mechanisms. This also includes cold packs, which I did not list up there, that could help by constricting the blood vessels, and a lot of patients find some good relief from those. 

When talking about as-needed treatments for migraines, it’s also important to mention the occurrence of medication overuse headaches. The definition is noted on the slide above. These headaches occur when a patient is consistently and excessively using acute migraine medications such as triptans, combination treatments, pain relievers, opioids, anything for an extended period of time. This overuse can lead to a paradoxical increase in headache frequency and severity, often turning into a chronic headache condition that’s more difficult to manage.

The prevalence in the general population is 0.5 to 2.6%, though it has been reported higher in Iran at 4.6%. The prevalence is substantially higher in those that have chronic daily headaches. It should be noted, though, and cautioned that not all individuals that frequently use as-needed medications develop medication overuse headaches and that there are some intrinsic factors that are associated with the risk of its development.

Beyond the obvious risk of overusing as-needed medications, smoking and sedentary lifestyle also increase this risk. It usually, but not invariably, resolves after the overuse has stopped. 

The use of preventive medication greatly reduces the need for as-needed medications and should be considered, particularly in patients that are at risk for medication overuse headaches, as well as those experiencing more than four to six migraines per month. 

Preventive medications for migraines are recommended for individuals who experience frequent and severe migraine attacks that significantly impair their quality of life and daily functioning. These medications are considered when acute treatment alone is no longer sufficient or when the use is limited due to frequent or potential side effects. 

Our previous toolbox consisted of drugs that were typically intended for other conditions, such as depression, high blood pressure, and seizure disorders. Recent research has shed light on the role of the trigeminovascular system and CGRP in migraine pathophysiology, leading to the development of very targeted therapies. 

Preventive medications vary from daily oral medications to injections to infusions. They may take several weeks to months to show the full effect, and so it really is important to have the patient on board and receiving adequate patient education about what to expect. Preventive medications, the goal of these is to reduce the frequency, severity, and duration of migraine attacks, ultimately improving the patient’s quality of life. 

The first one I want to speak with is about the tricyclic antidepressants or TCAs. These are a class of medications that have been used for migraine prevention. While not specifically designed for migraines, TCAs, like amitriptyline and nortriptyline, have demonstrated effectiveness at reducing the frequency and severity of migraine attacks. They work by affecting certain neurotransmitters in the brain and modulating the pain perception. Due to their effective sedation, one of their side effects is sedation, they’re sometimes helpful when disrupted sleep is a component of a trigger or an experience, a side effect of the patient’s migraines.

Selective serotonin reuptake inhibitors or SSRIs are another class of medications that have been explored for migraine prevention. Certain SSRIs, such as escitalopram and sertraline, can help in reducing the frequency and intensity of migraine attacks. Additionally, they help to address the comorbid depression anxiety, which we know can worsen migraines.

Beta-blockers are very commonly used for migraine prevention. These drugs, such as propranolol and metoprolol, were originally developed to treat cardiovascular conditions, but they have shown efficacy in reducing the frequency and severity of migraine attacks. Beta-blockers work by blocking the effects of adrenaline which can help prevent the blood vessel dilation and decrease the sensitivity of the pain pathways.

Angiotensin receptor blockers, or ARBs, are a class of medication primarily used to treat hypertension. However, some ARBs, such as candesartan and valsartan, have been investigated for their potential use in migraine treatment. These medications work by blocking the effect of angiotensin, which plays a role in regulating blood pressure and blood vessel constriction. While not a typical first-line option, it may be considered in somebody who has comorbid hypertension. 

And we’ll talk about this a few slides down, but one of the goals of treatment is to try to make sure that you are simplifying the treatment. So if somebody has hypertension, consider a beta-blocker or an ARB to treat that that will also treat their migraine because that would be less pill burden for them and it’ll be a little bit easier to increase adherence to the treatment plan.

Antiseizure medications, also known as antiepileptic drugs, or AEDs, have shown effectiveness at reducing frequency and severity of migraine attacks. Some AEDs that are commonly used include topiramate, valproate, and gabapentin. In general, these medications work by stabilizing abnormal electrical activity in the brain and modulating the neurotransmitters that are involved in pain transmission.

Calcitonin gene-related peptide monoclonal antibodies represent targeted migraine prevention, and this has medications specifically designed for migraine prevention. These work by blocking the effects of CGRP or its receptors, and by doing so, it helps reduce the frequency and severity of migraine attacks. These medications are generally well tolerated and have shown significant efficacy in individuals with chronic and episodic migraines who have not responded to other preventive treatments.

OnabotulinumtoxinA, originally known for its cosmetic applications, has been approved for migraine prevention, since 2010, in the US. This followed observations that individuals that were receiving these injections for cosmetic purposes actually experienced fewer migraines, and this is still quite often used. It requires an injection every three to six months, depending on how the patient is tolerating. 

Medical devices can also be part of the toolbox. It’s an innovative, nonpharmacologic alternative to manage migraines. As I mentioned previously, successful treatment of migraines is often not just a one-size-fits-all. You often have to use a combination of treatments to find what works best for the patient, and medical devices are really nice to include within a treatment plan.

Nutraceuticals are natural products that are used for potential health benefits, and several nutraceuticals have been explored for their potential in migraine prevention. Magnesium supplements show promise in reducing migraine frequency, as magnesium plays a role in regulating neurotransmitters and blood vessel tone. 

Coenzyme Q10, or CoQ10, is another nutraceutical that has been studied for its potential to decrease the frequency and severity of migraines due to its possible role in cellular energy production and antioxidant activity. Additionally, riboflavin, or vitamin B2, supplementation has demonstrated some effectiveness in reducing the frequency of migraines, and this may be due to its involvement in energy metabolism. 

There are also nonpharmacologic approaches, including trigger avoidance. Now, this could be a bit controversial, and we’ll talk a little bit about that in just a moment, but it may be effective for some individuals and empowers that individual to be more engaged in their care. To best evaluate and identify triggers, it’s recommended that the patient keeps a diary and identify anything that has preempted their migraine. 

Some examples of migraine triggers include increased stress, which may be related to a heightened sensitivity and changes in cortical excitability. This may also contribute to the transition of an episodic migraine to a chronic migraine.

The perception of migraine burden is also heightened during high-stress situations. With fluctuations in hormonal changes, specifically changes in estrogen during menstrual cycle and perimenopause, this could all increase the likelihood of migraine episodes. Most women who experience migraines typically will have a resolution within five years of their final menstrual period, so certainly something to look forward to after hot flashes.

There are some foods and beverages, such as alcohol, caffeine, aged cheeses, chocolates, that could trigger migraines in some. The big question remains whether the craving that preempted that person eating chocolate or consuming these substances was a premonitory symptom of a migraine, so perhaps something that cued that they were going to have a migraine made them want chocolate. They had chocolate and then had a migraine, but that migraine was potentially coming either way.

Similarly, though, skipping meals and dehydration could trigger migraines, but as I mentioned before, nausea and vomiting are a pretty common component of a premonitory symptom of a migraine, and so somebody may experience a decrease in their appetite leading up to that migraine. 

Nonpharmacologic therapies offer valuable alternatives for managing migraines. Acupuncture has gained attention for its potential to alleviate migraine symptoms and reduce their frequency, though some of the data is limited. Relaxation therapy, which includes techniques such as deep breathing and progressive muscle relaxation, can help manage stress and tension that often trigger migraines. 

Engaging in regular exercise has shown promise in managing migraines and preventing migraines by improving the overall health and reducing stress. It is, however, important that you find an exercise routine that best suits the patient and does not trigger migraines, as some exercise routines can trigger migraines.

Cognitive behavioral therapy is a psychological approach that helps individuals identify and manage triggers, thoughts, behaviors related to migraines. We’ll be covering CBT a bit more in depth. 

While medications play a significant role in managing migraines, a comprehensive approach to migraine management involves addressing the psychological factors as well. Altering negative thought patterns, emotions, and behaviors through cognitive behavior therapy, or CBT, can help migraines in multiple different ways. The primary aspect of CBT is identifying and addressing negative thought patterns and emotions, such as worry, fear, and anxiety, as this could contribute to onset and exacerbation of migraines. Throughout the program, stress management techniques and coping strategies are reinforced, and this helps to empower the patient and have them more engaged and involved in their therapy program.

It is known that negative emotions and belief about pain can amplify the perception of pain, particularly when some of the thoughts are catastrophic levels of thinking. CBT aims to reshape these beliefs and emotions by teaching individuals to reinterpret and reframe their pain experience. By altering how individuals perceive and react to pain, CBT can lead to reduction in perceived intensity of migraines and improve the overall pain tolerance.

This aspect has been found to reduce the disability associated with migraines. Negative thought patterns can also impact lifestyle choices, such as sleep patterns, diet, and exercise, which in turn influences migraine frequency and severity. So if somebody feels that being active or going outside is going to trigger their migraine, they are more likely to avoid that activity, or they may avoid going outside, and this may continue to add on to the level of disability they’re experiencing due to the migraine disorder. CBT helps to encourage these positive changes in their lifestyle, promoting all these physical activities and regular sleep, and those changes help with a better overall well-being and potentially lead to fewer headaches. 

And I did note there that this serves as a valuable complement to acute and preventive treatment. In many cases, this is not going to replace the treatment for the patient, but it does help as part of that toolbox. 

So, how does CBT work? CBT involves cognitive restructuring, behavioral activation, and relaxation techniques. And to put this simply, by changing our thought patterns about a situation, we’re able to alter our behaviors into a more healing pattern. 

So, the ABCs to work on the cognitive restructuring of migraines, the ABCs of cognitive behavioral therapy include the activating event, the belief that is assigned to that event, and the consequence of that belief. So allow me to explain this a little bit further using a typical type of scenario.

So, the patient may wake up with an impending migraine. Perhaps they’re having some of, maybe an aura, or perhaps they’re having some of the premonitory symptoms that they are familiar with that lead towards a migraine. And so this is their activating event. 

The belief about the experience, however, may take on a catastrophic tone. So they may think, well, now my whole day is going to be ruined. I’m not going to be able to take my son to sports tonight. It’s going to be a really rough day. I’m going to have to call out of work, etc., etc., and the consequence of this belief leads to increased stress and anxiety, because you have to start thinking of second plans and, oh, if I take off of work, it’s a busy day, perhaps even canceling plans for those days. And that shifted focus makes it harder for somebody to care for themselves and may not accurately reflect reality, since an effective abortive medication taken early in the process may be effective for them.

So while we are working on changing that activating event through using that abortive treatment, through using preventive care, the patient can meanwhile alter their belief about that experience, which changes the consequence, as noted here. 

And so in this situation, they have the same activating event, but instead they identify perhaps that they’re having a negative thought about it and change it. They reframe it. They tell themselves, I’ve experienced this before. I should take a medication now at the first sign of a migraine, and that’ll be most effective. I should be able to go on with the rest of my day. 

That consequence, that belief leads to them taking that medication, feeling confident in its efficacy and be able to recover quickly from a migraine while still experiencing fewer negative thoughts and, of course, less guilt. 

So there are many benefits of CBT for migraines as well as for other conditions. It provides patients with long-term coping strategies even long after the therapy has been completed. They feel empowered and have control over their condition and are better able to actively participate in migraine management. Prior to CBT, a patient may feel out of control. They feel that the migraine is controlling their life, and by having them take CBT and go through CBT, they’re better able to take charge of their life and know that they have options. And they’re able to be more actively engaged.

CBT could lead to a reduction in medication overuse and their reliance on acute pain medications, which can contribute to medication overuse headaches. CBT is generally well-tolerated, doesn’t have many side effects, and so it’s a valuable adjunct or alternative to pharmacologic therapy. I also noted that it helps to address any comorbid psychological conditions, such as anxiety or depression. 

So CBT for migraines typically involves a series of about eight to twelve structured sessions. CBT is unlike a typical therapy. They aren’t really exploring somebody’s childhood. They’re not really doing a psycho analysis of the patient. They’re talking more about the here and now, and it’s very structured and patient led. 

This is done by somebody who is either trained to deliver CBT and specializes in the treatment of headaches or chronic pain. Very often, this is going to be a therapist or a psychologist, but I do feel it’s important that it is somebody that typically manages chronic pain disorders. These sessions could be performed in person. It could be done via telehealth or in a group setting, really depending on the patient’s preference and of course the availability of those resources. 

So, the patient should expect that during the CBT sessions, it begins with an assessment of their headache history, their triggers, and their beliefs, and their emotional responses to pain. When I ran CBT sessions for patients for chronic pain related to pelvic pain, one of the first questions I asked was, what is pain to them? What does that word mean to them? It was very interesting to hear the different responses, and you get an idea, a glimpse into what sort of belief system is assigned to that experience. 

It should be noted that CBT requires full involvement and commitment on the patient’s part. This is not something that they could half-heartedly take part in, and it does require work. I let them know the first day there’s homework with this, and this will require a lot of active participation. 

They’re taught to identify and challenge negative thought patterns, develop problem-solving skills, and enhance stress management techniques, such as relaxation techniques. This could be very effective for migraines, and research studies have shown that CBT can be effective treatment, particularly for patients that have frequent chronic migraine attacks.

It is worth mentioning, though, that some of the studies have had mixed results in the efficacy, particularly when comparing it to other treatment modalities. Nonetheless, it can be a helpful part of the comprehensive management strategy for patients with medication overuse headaches, and CBT has been found to reduce the frequency, duration, and intensity of migraine attacks in some individuals. 

I do want to touch on, just take a brief moment to talk about migraines in special populations. It is important to note that the management may differ in these different special populations. While CBT is often used and can be fairly universal, medication selection and treatment modality selection may differ based on the patient’s age and the risk of side effects. 

For example, we might not consider, perhaps, a highly sedating medication in somebody that is elderly and at risk for a fall. Similarly, we don’t use many medications that are very sedating in children either. 

Menstrual migraines, in particular, require unique management strategy due to its association with hormonal fluctuations. So hormone therapy, including estrogen supplementation or birth control pills, may be considered for prevention, but caution must be used if the person experiences migraines with aura, such as visual changes, as this may increase the risk of stroke when combined with hormonal therapy. Tracking menstrual cycles and identifying triggers can help tailor these management strategies.

In some patients, I suggest that they take a medication prior to their menstrual cycle starting, if it’s a predictable cycle. In pregnancy and lactation, caution must be used in any medication that may spread to the fetus or through breast milk. In each of these specialized populations, personalized care is absolutely essential.

Like I mentioned earlier, I wanted to note that adherence plays a very major role in migraine management. Adherence refers to the extent to which patients follow the recommended treatment regimen, and consistent adherence ensures optimal effectiveness of acute and preventive medications. Things like skipping doses or disregarding instructions could compromise treatment outcomes and make it so that the patient may not be as successful in managing their migraines. 

So we want to talk about overcoming some of the barriers to adherence. So what are some of these barriers? Some of these are lifestyle factors. Perhaps transportation to get to the appointment is an issue. Perhaps they work a different shift or a split shift, and so taking their medication at the same time daily has been a challenge. It may just be forgetfulness, or maybe the side effects are intolerable, or they just didn’t have motivation. They’ve tried lots of medications so far. This is particularly true for my patients that have had migraines for most of their life, and they’ve kind of been treatment-fatigued at this point. Now we have lots of great new treatments, but they are a little fatigued by trying a lot of new things. 

Some of the strategies to overcome barriers include patient education, so educating them about adherence and potential benefits, assisting them in using alarms, calendars, and smartphone apps that may help with prompting the medication intake. As a provider, you want to make every attempt to simplify and streamline their treatment so it’s a little bit more manageable for them to take. And when it’s appropriate, particularly in the pediatric population, you want to incorporate family to offer some support in this process.

The benefits of regular follow-up are very essential, especially early on in the treatment process for migraines. Regularly scheduled follow-ups with a clinician allows for continuous monitoring of treatment progress and allows people to make necessary changes to tailor the treatment to the individual’s response and their evolving need. Regular follow-up prevents relapses by helping the person identify any potential relapse triggers and address them before they escalate. 

So even once somebody is doing well, they’re on a preventive medication, they’re having very few breakthrough headaches, it’s still important to follow up with them so that if you do see those headache frequencies starting to increase, you can kind of get ahead of it and treat it before it becomes out of control. This is why I still promote that a patient should keep a headache diary or keep track in some way of the headaches that they’re experiencing. There’s fantastic smartphone apps that they can use, and that helps to allow them to see what patterns are available. 

Much of the ensured follow-up and adherence is based on empowering the patient and provider relationship. This includes involving the patient in their care using a shared decision-making model, using open communication to express concerns, asking questions, and receiving guidance, and continuous patient education that helps empower the patients with knowledge about their condition, treatment options, and some self-management techniques. 

And one cannot talk about migraine management without acknowledging the significant psychological impact that occurs with migraine disorders. As I mentioned earlier, migraine disorders are among the most disabling conditions globally. Migraine experiences can be influenced by psychological factors such as stress, anxiety, and depression, and this starts to become a self-fulfilling prophecy, a self-filling machine, because the more stress the experience related to the condition, the more likely they are to experience migraine triggers, and it can be a very stressful experience.

Looking at the migraine phase model, there are multiple days involved. It’s not just the headache. It involves this prodromal phase, the premonitory symptoms. It involves an aura that could be disruptive to their life, and then after that, it has the migraine hangover that they’re experiencing for possibly days afterwards as they recover from having the headache experience. 

CBT helps to equip individuals with strategies to manage pain perception and cope with triggers, potentially reducing the intensity of migraines, thus breaking this pain cycle. It also teaches them adaptive coping mechanisms, enhancing the ability to manage pain and stress effectively.

Ultimately, the most effective treatment for migraine disorders is not going to be that one-size-fits-all, but combining approaches will lead to the most effective treatment overall. Treatment plans should be individualized and created with the patient’s input on their preferences and their needs. Acute treatments provide immediate relief, while preventive medications aim for long-term management.

CBT complements medical interventions by addressing some of the psychological factors that contribute to the migraines. And a collaborative care approach will help involve the patient. It improves patient outcomes and improves their quality of life. 

There is no greater time than now to be engaged in migraine therapy. There’s new targeted therapies that are coming out regularly, and it allows for greater customization of treatment for the patient. It’s so nice to be able to go in to see a patient and now have the confidence that you’re going to be able to help them because there’s so many options available, and you know that you could talk to the patient about these options and find something that works best for them.  With the use of a collaborative approach incorporating acute and preventive strategies, patient education, along with cognitive behavioral therapy, you have a comprehensive toolkit to successfully manage the patient’s migraine and allow them to gain back their life.

Thank you. Here’s my references, and this is a migraine resource kit that is available for healthcare providers.

*The contents of this video are intended for general informational purposes only and does not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. AMD and the speaker do not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.