We talk to Dr. Ewa Czapińska-Ciepiela, MD, a neurologist specializing in migraine treatment and a board member of the Polish Headache Society, about migraine and modern methods of treating this most common neurological disease in the 21st century.
Pain is a signal that something disturbing is happening in the body. Is a headache a sign that something is not working properly?
Ewa Czapińska - Ciepiela:Not necessarily. Headaches, the so-called secondary, or symptomatic, i.e. indicative of pathological changes, e.g. intracerebral hemorrhage or a brain tumor, constitute only a fraction of a percent of all headaches. The most common are the so-called primary headaches, including the so-called psychogenic or stress-related tension headache. About 60 percent of them experience it. Europeans.
And which category does migraine head fall into?
E.C.-C.:Migraine headaches are among the primary headaches. Increasingly, scientific studies indicate the genetic determinants of migraine. We know that there are certain genes that can predispose you to migraine, but we don't know which one or how many there are. Probably, these genes are responsible for the malfunction of ion channels and neurotransmitters in the brain, which leads to the phenomenon of hyper-excitation, i.e. over-stimulation of nerve cells. This phenomenon in turn causes the release of inflammatory substances such as CGRP at the peripheral endings of the trigeminal nerve, which has its nucleus in the brainstem. The action of inflammatory substances causes the dilation of the meningeal arterioles, i.e. the branches of the carotid artery, and because they are richly innervated, their relaxation causes pain.
This means that if my grandmother suffered from a migraine, she would also "catch up" with me one day …?
E.Ch.-C.:Relax. Not everyone with a family history of migraine must have it. Whether you will suffer from migraines, it depends on whether you have what we call "migraine pacemaker" in your head, i.e. whether your brain has a certain predisposition to generate abnormal impulses or not.
Since "ordinary" headache and migraine pain are so-called primary headaches how do you tell them apart?
E.C.-C.:By diagnostic criteria. Typical migraine pain is one that lasts from 4 to 72 hours. This is the most important criterion. Additionally: this pain is usuallyit covers half of the head (the so-called half pain), is a pulsating pain (it is the effect of pulsating blood vessels), and also has medium or high intensity, or even slight physical exertion, e.g. climbing stairs makes this pain even worse. Migraine pain may also be accompanied by nausea, vomiting and hypersensitivity to certain stimuli, such as light or noise. If you had migraine pain, you would immediately distinguish it from "ordinary".
And if I already know it's migraine pain, should I see a doctor with him?
E.Ch.-C.:That would be for the best. Unfortunately, this is not always the case. I see patients - because it is women who suffer from migraines most often - who have been suffering from migraine headaches for up to 30 years. Why didn't they apply earlier? Because the pains had different severity, took different forms, because the patients de alt with them with over-the-counter painkillers, or, unfortunately, often happens, they heard from their doctors that " their beauty "that"have to get used to the pain"etc. And only when migraine headaches became so strong or frequent that they caused suffering and prevented them from leading a normal personal and professional life, then the patients started looking for a specialist and treatment.
Who will help us treat migraines?
E.Ch.-C.:I know a family doctor whose hobby is treating headaches, and he knows it very well. Unfortunately - this is rather an exception. Many doctors downplay migraine and discourage patients from taking treatment. So I suggest: let's go to a neurologist who will check if a neuroimaging examination of the brain is needed to rule out secondary causes of headaches, and then whether the patient should be looked after by a neurologist specializing in migraine treatment. Because not every neurologist specializes in it.
And if I do not have the results of such specialized tests, what should I bring to the "migraine doctor"?
E.Ch.-C.:Even without the test results, you don't come to him "empty-handed", because no test will tell you as much as the patient himself and his experience. Have you heard about the migraine diary? They are even available in a handy and easy-to-use electronic form as applications for mobile devices. These are notebooks in which the patient writes down information about headaches, e.g. when they appeared, under what circumstances, how long did they last, what were the symptoms.
How else can I help my doctor diagnose and treat migraines?
E.Ch.-C.:Be honest and admit what and how many medications you take for headaches. Recently I hada patient who told me on the 4th visit that he was taking some medication. Because those from the pharmacy without a prescription, he did not count at all. And it came to me when these stopped working.
Exactly - if painkillers do not work, what …?
E.Ch.-C.:Migraine treatment is based on two types of therapy. The first is the so-called emergency treatment. As the name suggests, its purpose is to quickly stop the pain. It uses the already mentioned painkillers and the so-called triptans. And there are 2 schools here. Some specialists start with painkillers and then recommend triptans. And others, and I am one of them, immediately introduce triptans, because they are safer and stop the pain faster. The thing is that triptans and complex painkillers that contain more than one ingredient can be used up to 8 times a month, because when taken more often they cause the so-called. rebound headaches, i.e. aches and pains caused by an excess of painkillers.
And the second therapeutic method is …?
E.Ch.-C.:This is a preventive treatment. They are activated when the patient feels the migraine headaches are so severe or frequent that they cause exclusion from everyday life and cannot be stopped. Taking preventive drugs, i.e. beta-blockers, calcium channel blockers, antihypertensive drugs, antiepileptic drugs and antidepressants must always be supported by the patient's decision. These drugs are taken constantly, every day, regardless of whether there is pain or not. These medications help to reduce the duration and frequency of migraine attacks and the symptoms that accompany it.
Therefore, preventive drugs reduce migraine pain, but are not only dedicated to treating migraines. Are there any medications that have been invented specifically for migraines?
E.Ch.-C.:Yes - they are here. This is called biological drugs. This is a complete novelty and a breakthrough in the treatment of migraine, although clinical trials have been carried out for several years. Biological drugs are antibodies that act on these inflammatory substances in the meningeal vessels in the final stages of migraine pain. For now, only erenumab is available from biological medicines, and the registration process of the next three: fremanezumab, galcanezumab and eptinezumab is still ongoing.
So you only need one tablet …?
E.C.-C.:Not a tablet. Biological medications for migraine are taken as an injection under the skin in the arm or the thigh. And such an injection is given once a month. As indicated - in those patients who experience migraine pain for 4 or more days a month. Important - currently they cannot be taken by patients with systemic diseasescirculation after a heart attack or stroke, as well as pregnant and breastfeeding women.
Is it true that … botox is also used to treat migraines?
E.Ch.-C.:It's true, botulinum toxin is used, but let's be precise: only for the treatment of chronic migraine, i.e. the one in which headaches appear for at least 15 days a month, and for at least 8 days have the features of migraine. Botulinum toxin is injected into strictly defined places on the head (forehead, temples, occiput), neck and shoulders. The number of injections per treatment is 31 to 39. The treatment is repeated every 12 weeks until migraine remission is achieved.
Doctor, you say and write: a person with migraine or a migraine sufferer?
E.C.-C.:Definitely: suffering from migraine. Because migraine is a disease. Its curse is that both about her and the patients themselves are said so lightly:your head hurts - so what, take the powder, take a walk in the fresh air, sit for a while and it will be over. And the pain doesn't go away. Do you know that according to the World He alth Organization, the first neurological cause of disability among people under 50 is not such diseases as multiple sclerosis or stroke, but migraine? In my office, I listen to various stories of patients who live with migraine for many years. Some of them have long since lost their jobs, their families, stopped dreaming, loving, going out to people, having any plans. They live with the pain of migraines, and when it goes away fear it will come again. And believe me, I will never forget a patient with genetically determined muscular atrophy, who entered my office in a wheelchair and asked for help, saying that it is not the paresis of arms and legs, but that migraine is ruining her life.
Ewa Czapińska-Ciepiela, MD, PhD She graduated from the Faculty of Medicine at the Jagiellonian University. She obtained the title of a specialist in neurology, and then a doctor of medical sciences at the University of Warsaw. He works at the Epilepsy and Migraine Treatment Center in Krakow. In his clinical practice, he deals with, inter alia, diagnosis and treatment of various types of headaches and epilepsy. She completed a course of diagnosis and treatment of migraine in Rome under the scholarship of the European Federation of Headaches and a clinical internship at the Christian Doppler Clinic in Salzburg. She received a certificate of an expert in the treatment of chronic migraine with botulinum toxin in Istanbul, and since then she has been training doctors in Poland in the use of this method. He is a member of the Board of the Polish Headache Society. Co-organizes the annual conferencededicated to doctors and psychologists "Psychosocial Aspects of Epilepsy" in Krakow.