Migraine is a recurring disabling headache that can result in a progressive and chronic disease state. Despite the frequency with which headache patients present to their primary care physician's offices, less than 50% of them receive a specific headache diagnosis. Although the American Migraine Study II suggests that physicians have been doing much better at diagnosing and treating migraine over the past 10 years, we have to prove to our patients that we can lead them to a better land. Rather than have access to migraine-specific therapies that are highly effective in reducing the frequency, intensity, and duration of their headaches, migraineurs rely heavily on OTC medications to which they have easy access. These medications may transform intermittent migraine into chronic daily headaches by causing structural changes within the brain that result in central sensitization and self-propagation of pain. As pain progresses and becomes more intractable, patients become more disabled and develop comorbidities such as depression, anxiety, and sleep disorders. Their work productivity is reduced as their number of sick days increase. They may loose their jobs and health insurance due to high rates of absenteeism. When they cannot consult their primary care physician, the chronic daily headache patient may turn to the emergency department for acute treatment. Upon arrival in the ER, they may receive an image study (which is unlikely to yield any helpful information) followed by a narcotic injection. Relief is only temporary because the pain and suffering will re-occur as soon as the narcotic wears off. We have the knowledge and the tools to service our headache population better than we have in the past. We have headache therapies that can begin to alleviate acute headache in 5 minutes. Preventative medications and behavioral interventions are key to reducing the severity and frequency of attacks while preventing the downward spiral of this chronic illness. Let us not forget to involve our patients in their own headache management. They need to be aware of their treatment plan every step of the way. Medications, acute and preventative, are more effective if combined with lifestyle interventions. Patients must understand how to use preventative and acute medications and what to do in case rescue drugs are needed. Headache diaries are necessary for evaluation at each visit. Finally, as physicians, we must do our best as coaches to be there for our most difficult patients. If plan A does not work, we can try plan B. Hope should always be expressed, even for those who seem hopeless. © 2006 Mosby, Inc. All rights reserved.
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