S3:Ep19 – The Evolution of Migraine Disease



Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

Molly O’Brien: Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today, we’re diving into the topic of how migraine can turn chronic, and to dive into this topic with us is VP of neurology at Lundbeck Pharmaceutical Dr. Roger Cady. Dr. Cady, thanks so much for joining us today.

Dr. Roger Cady: Well, I’m glad to be here, Molly, and thank you for inviting me.

Molly: We’re very excited to have you here, and you’ve been involved in the migraine and headache world for quite some time, so we’re looking forward to getting your insight.

Dr. Cady: Yeah, well, you can see with all the gray hair, I’ve been around for a while, yes.


Molly: You’re an expert. We’ll say it like that. 

All right, so I’m super interested in this topic. I personally have migraine. I’ve had it my whole life but turned chronic in my 20s, and I didn’t really know that you turn chronic and why it happens. So I think a lot of people out there are curious about this issues.

So we’ll start off with a very basic question. Why do some people transition from occasional or acute migraine into chronic migraine?

Dr. Cady: Well, the bottom line for this is that migraine is a very dynamic disease. And I’m sure in your own experience, you realize that there are good months and bad months, and depending on what’s going on in your life and other things, you can have more frequent or less frequent migraine. So I think that’s a big part of that answer.

And then the other thing is that people who have migraine sort of inherit a nervous system that is unique to people that don’t have migraine. And you see that in the fact that family histories are very common. Many people have another family member with migraine, or if you have two parents with migraine, odds are you’re going to have migraine more than if you have one or have no parents with it.

So there’s this sort of genetic predisposition that makes certain people susceptible to changes in their environment, and a major part of the reason that people go back and forth and transition from episodic to chronic is that they’re responding to different changes in their life at different times.

Molly: It’s always interesting to note that — some people will ask, “Well, why do have migraine right now? Why do you have an attack?” Well, I don’t know, and it’s nothing I did. A lot of the time, that’s the case.

Dr. Cady: Yeah, Molly, that is so, so important. Migraine is not a disease people should be blamed for, and unfortunately in the past, that sometimes happened. But this is a very biologic disorder, and we understand it that way today, healthcare professionals and people who work in the field of migraine. And this is as biologic as is diabetes or hypertension or any other chronic disorder.

Molly: Our next question is, “If someone is living with chronic migraine, is there any hope or chance or — chance, I guess, would be a good way to put it — any chance that they could transition back into having occasional or acute migraine?

Dr. Cady: Absolutely. I mean, I talked about this a moment ago, that in life, even with and without treatment, people transition from more frequent migraine to less frequent migraine. And there’s actually a pretty large population of people who kind of are on that threshold between episodic and chronic migraine and move back and forth quite commonly. 

But I think you’re also asking another important question. If people get in and sort of stuck in that chronic migraine, can they get back into a much more manageable pattern of migraine. And here, again, the answer is yes. There are lots of causes or things that relate to people getting caught in chronic migraine. There’s lots of solutions that we can provide. 

And the most important solution, in my mind, is to make this transition from seeing migraine as a disease that you treat attack by attack with acute medicine to one that you manage on a day-to-day basis by protecting the nervous system and preventing migraine from occurring as frequently as it does maybe today. So when people start with migraine, they’re often thinking about, “Well, I need medicine when I have an attack.” But when it starts to become frequent, you need to think about protecting that nervous system and preventing migraine, so preventative therapies start to take the forefront.

Molly: And you mentioned medication just now. I’m wondering, is there any role that medication has from someone transitioning from episodic migraine to chronic migraine?

Dr. Cady: Yes. It’s a very important thing for all people with migraine to understand because medication is one of the most frequent reasons that people do get trapped and stuck in this cycle of chronic migraine. And it kind of works two ways. One of them is when people are over-reliant on their acute medicine to treat frequent migraine, it’s easy to want to take more medicine because you’re having more migraine. And so, in doing that, very often people start to find that their medication isn’t working quite as well as it used to, and again they’re taking more and more of that medication.

And so, in the end, when they’re using very frequent medication, the medication itself can actually transform the headache and a new headache can emerge and coexist with migraine, especially chronic migraine, and that’s called the medication overuse headache, or MOH. It’s a name I don’t really like, by the way, but it’s what we’re stuck with in our nomenclature today. Anyway, it’s really where the medication is actually starting to maintain the headache.

So the big thing with medicine is you need medicine that is effective and actually doing what it’s expected to do and what you as a patient would be expecting it to do. And then the other is to provide medication that transitions from this “treat the attack” to “prevent the attack,” so the preventive medications.

Molly: And thank you for that. Yeah, sometimes it’s tough to keep up with all the vernacular, making sure we have the right terms, but you seem like you know. It’s tough for me to keep up sometimes. “Oh, that changed.” 

So we talked a little bit about medication just now. I’m wondering, is there anything that people can do to mitigate their chronic migraine? I know you said kind of having those medications that we need, but what else can people do to mitigate chronic migraine?

Dr. Cady: Well, I think in migraine and to manage migraine well, you really need to be proactive and you really need to be an advocate for yourself. And so I’m a big proponent of that, and that starts with probably education, learning about not only the disease and what you find in the textbooks and articles and things like that, but understanding yourself and how your unique biology fits into the world in which you live, and starting to make and be part of the decision-making process around this. 

I think it’s very important that you forge a relationship with a healthcare professional and, actually, probably a larger team of headache allies. That could be best friends, spouses, people who also share this disease and maybe have ideas on how they’ve managed it successfully. So you create kind of a team around all of that.

And the other thing about this is I think it’s important to keep track of your migraine. Keep a diary. Look not only for the things that seem to cause or associate with migraine, but also about those days where things go well. What happened on those days that made you successful with the environment? And I think you can learn a lot around that.

And I think the other important thing is to frequently do an inventory with yourself and literally say, “Am I getting the results that I really am looking for?” and honestly not settle for this idea that good enough is good enough, that you’re not really good but you’re able to survive and get by. And I think one of the most important questions that people can ask themselves is, “How many days a month am I actually free from migraine? Do I have good days?” And if you’re not happy with that answer, well, then I think it’s time to kind of reflect and reevaluate your migraine management program.

Molly: It’s such a good way to look at that, to take inventory, right? We are our own best advocates, like you mention, but to take inventory of what’s going well, what’s not going well. But I think sometimes when you’re in such a loop of pain, it gets hard to remember those days that are good. So I think taking inventory is good.

Another point you mentioned was having a team of people on your side, not just your providers, but other people. And I kind of liken that to — we talk about migraine toolbox a lot, right? What are the tools we need? So it’s like a toolbox of people, and I love that concept. You need people around you to lift you up and to build you up and be on your side.

Dr. Cady: Yeah, absolutely, and it’s so important. And these are partnering relationships. We all participate in that. And, of course, at the center is the person with the migraine. But, as you know, migraine has so many facets and spokes that work out, so I think family members can be part of this, your social circles can be part of this, and, of course, your healthcare team can be part of this.

Molly: So, going back to how chronic migraine works, is there a reason that only some people transition to chronic migraine, or does it kind of tie into those environmental factors and genetic factors that we just — we can’t pinpoint it yet?

Dr. Cady: Yeah, well, I think ultimately it does tie into those genetic factors and the environment, and we can’t all avoid all of the things in life that can provoke migraine, and I think that’s an important thing to understand. But we’re just learning about this, and what we are learning is that this process of chronification or going from a more episodic pattern of migraine where migraine has a beginning and an end to one where migraine just begins to merge together and the headaches are always there to some degree or the effects of those headaches are always there. 

And one of the things that we’re learning is that the nerves that are activated and cause migraine, when repeatedly activated over and over again, the threshold to activate on the next time gets lower and lower and lower and eventually can reach a point where it almost takes nothing to cause your next migraine. A change in the weather — boom, I got a migraine. And, yeah, you’ve probably experienced that. And it’s this type of sensitization — or neuronal sensitization, as it’s called — that is probably at the heart of the physiology of chronic migraine.

And so I kind of liken this with patients — talking about putting the insulation back on the nerves, and that comes with a lot of different ways. I mean, you can do it with certain things in your lifestyle and managing your environment, not as a saint or perfectly, but more acceptable to you and more successful for you. And it can happen by getting your acute medications tuned up so you’re taking them at a proper time, ones that actually work well for you. 

And, importantly, we’re learning this early addition of prevention, and it’s not all of medicine. That can be things with lifestyle and biofeedback, relaxation techniques, and, I always point out to my patients, making sure you have time for recreation every day. That’s how the nervous system gets its balance. So that’s an important thing to consider and track in your diaries and in your records.

Molly: I love that. I’m curious if, in your years working within the industry and being a doctor, if you’ve seen an emergence of more chronic migraine and what you might attribute that to. Is it just simply we’re knowing more about it or if more people are transitioning?

Dr. Cady: Yeah, well, that’s a superb question, to be honest. As you’re probably well aware, there’s about 39 million people in the United States alone with migraine, and of that population, about 4 million are estimated to have chronic migraine. So that’s 10 percent of people at any one point in time. If you kind of looked at this over a lifetime, it’s going to be a much larger percent that at some point would evolve into chronic migraine. 

I think, to get back to your question, though, the reason that we probably see chronic migraine is, first of all, we’re looking for it. It’s being diagnosed. People don’t realize that we didn’t have a diagnosis of chronic migraine until 2004 —

Molly: Oh, wow.

Dr. Cady: — and I would argue that we probably didn’t have a really good definition of it until maybe 2016 or the most recent, 2018. So this is a relatively new concept for physicians to understand. When I started in migraine, it was looked at as a self-limited disorder that would go away no matter what you did, and people returned back to normal. And now we find when migraine’s frequent enough, that is definitely not true, that the effects of migraine can linger between migraines and worsen over time if migraine is not well controlled or well managed.

So I think those are probably important reasons. And then one could argue — and we saw this during the COVID pandemic — when we have major stress in our lives, permeating our lives, it’s more likely for migraine to transform from that episodic into a more chronic form.

Molly: Fascinating to learn this and to learn a little bit about the history and how our knowledge has grown and changed over the years.

Dr. Cady: Oh, that’s so true, just so absolutely true.

Molly: And, Dr. Cady, as we wrap up here, I’m wondering if there’s anything else you want to share with our audience about migraine in general or about chronic migraine, stuff that you just want people to make sure they know.

Dr. Cady: Yeah, well, I’m always kind of careful to call migraine a disorder, a condition, when it’s infrequent, when people are having one or two migraine. And, of course, those attacks can be very disabling, but people do recover, and there’s plenty of time to recover between attacks. But it has this curious ability, if you will, to really transform into a disease. And that’s an important thing for people who have this sensitivity, if you will, or the genetic influences that lead to migraine, for them to understand, that when migraine becomes frequent, it permeates every aspect of your life. And it’s not just your personal life. It’s family. It’s friends. It’s your work environment. And we really need to understand that this is, in fact, or has the potential to be a chronic disease.

And the other most important thing that I want to leave everybody with is this is treatable. In fact, I would argue that migraine is one of the most treatable chronic diseases, and people aren’t broken who have migraine. They kind of need a tune-up, I think, very often, but they’re certainly not broken.

Molly: I love that analogy, and I think just by saying that, you offer some hope, right? 

And that is wrapping up this episode of Spotlight on Migraine. I’d like to say thank you to our guest today, Dr. Roger Cady. Thank you for helping us get a little bit more insight on how chronic migraine goes on. We appreciate your time.

Dr. Cady: Well, Molly, it was enjoyable, and I really appreciate the opportunity to have this. And for all your listeners who live with migraine or know someone who lives with migraine, I wish them all the success in the world. Thank you.

Molly: We really do appreciate that, and we appreciate you watching or listening out there. A big thank you to all of our followers. That wraps up this episode of Spotlight on Migraine. For the Association of Migraine Disorders, I’m your host, Molly O’Brien.


Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

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