D. Michael Ready, MD
Director, Headache Clinic
Baylor Scott & White Health
Temple, Texas
O
ver 36 million Americans suffer from migraine.
At last count, only 416 physicians were certified
in headache medicine in the U.S. Although headache
providers do not need to be certified in the subspecialty
of headache medicine, these figures indicate a provider
shortage for those experiencing migraine and chronic
headaches. It is extremely likely that many of those
suffering from headaches will not be seen by a headache
specialist. The challenge then becomes what can a patient
do to gain control of their headaches and their lives. The
French scientist Louis Pasteur once said that “Chance
favors only the prepared mind.” During the initial history
and physical examination (and at all follow-up visits), I
ask every migraine patient two questions; “Why do you
have migraine?” and “What do you want to do about
it?” In other words, how are you going to “prepare your
mind” to achieve a different outcome than what you’ve
had before? As a headache specialist, I do have more experience in treating headache, but I possess the same tools
as any other health care provider. The difference is only
my skill and experience in using them. In this equation,
provider + patient = outcome. What will make the biggest
difference in the outcome is what the patient contributes.
The preparation for migraine treatment success involves
understanding three things:
• how you arrived where you are (why you have
migraine)
• what is keeping you there (why you are having them
as often as you are)
• and, how to reverse the process.
When an individual seeks care for their headaches, the
diagnosis will almost always be migraine. In its simplest
terms, migraine is an inherited hypersensitive nervous
system that is poorly tolerant of change (stress). The genetic
predisposition to migraine is what determines whether or
not you are susceptible for an attack. The attack frequency
is a product of an individual’s past experiences and their
current environment. Migraine pain is not intuitive.
Patients frequently obsess about “why” they hurt, and do
not accept migraine as a sufficient explanation for their
pain. For these individuals, it can be challenging to believe
that one can be in that much pain without having anything
“broken.”The failure to recongnize migraine as a legitimate
explanation for their pain demonsrates a lack of knowledge
and understanding of migraine.
The World Health Organization ranks the acute disability
of a severe migraine attack at its highest level, equivalent to
the disability associated with dementia, quadriplegia, and
an acute psychotic attack. Migraine is the fourth leading
cause of disability in women and the seventh leading cause
overall. It is responsible for half of all disability associated
with neurological conditions. If migraine is not accepted
as a sufficient explanation for a patient’s pain, it is unlikely
that any significant improvement will occur as the patient
will likely search for some undiscoverable pathological
pain generator.
Chronic migraine – the most disabling form – does not
develop de novo. Rather, the attacks evolve from episodic
to chronic. This progression has been divided into stages
(Cady, Lipton et al):
• Stage I is infrequent episodic migraine (1 to 2
headache days a month). In this stage, an emphasis
is placed on resolving the attack as soon as possible.
• Stage II is frequent episodic migraine (3 to 8
headac H^\