The difficulties patients face and possible strategies to break the cycle were explored by three experts during interviews at the Migraine World Summit 2023: Stephanie J. Nahas, Associate Professor at Thomas Jefferson University, Philadelphia, USA; Gisela Terwindt, Professor of Neurology at Leiden University Medical Center, Netherlands; and Judith Owens, Professor of Neurology at Harvard Medical School, Boston, USA.

It is an unfortunate reality that no single migraine treatment is effective for everyone.¹ This presents additional challenges for the management of migraine and can provoke a vicious cycle of increasing use of acute medications that become less and less effective.²

Patients with migraine may start to believe that they have tried everything and nothing will work. In reality, even though patients have often used many pharmacological and non-pharmacological approaches, there is always another option available.¹

The contribution of disturbed sleep

Migraine has many complex risk factors. Interestingly, Professor Owens highlighted that altered circadian rhythm may feed directly into the vicious cycle: migraines are more common in the early morning and patients with migraine are more tired than controls after a change in sleep pattern.³

Migraine pain makes it harder not only to fall asleep but also to stay asleep. Sleep disorders such as insomnia are 2- to 8-fold more common in people with migraine.^4,5 The result of persistent sleep disturbance is that sensitivity to pain and the perception, intensity, and tolerance of pain are all made worse.⁴

Sleep disturbance worsens pain intensity and reduces pain tolerance

And so it can be very easy for patients to slip into a vicious cycle. Professor Terwindt² asked us to consider a scenario: a patient wakes up with a mild headache. Will it remain a mild headache or is it the start of a migraine attack? The patient has commitments that day, so they don’t want to take the risk and decide to use an acute treatment. The next day starts the same way.

It is easy to see how this could quickly become a habit for the patient. Before long, it can be impossible for them to tell whether their headache is a migraine attack or a result of the medication they are using frequently.²

Strategies for dealing with patients’ struggles

Maintaining good ‘sleep hygiene’ can be helpful where poor sleep is a contributor. Patients should try to keep to a regular bedtime and wake time, not use electronic devices before going to bed, use a quiet, dark, cool bedroom, and limit daytime naps to 30 minutes in the late afternoon.⁴

More generally, for many patients with chronic migraine, their migraine has no distinct start or end.¹ According to Professor Nahas, one of the problems patients struggle with most is how to choose which days to use acute medication, knowing that using too much might make their migraine worse.¹

Patients struggle to choose when to use acute medication, knowing that too much might make their migraine worse

Diaries can help, but patients easily become fatigued with keeping track of every detail of their attacks.¹ Professor Nahas asks her patients that if they only document one thing, it is when they need additional medication to treat an attack. On top of this, she generally advises restricting acute medications to 2 or 3 days a week.¹

Another strategy is listing together with the patient the approaches they have tried, separating them into those that did not make any difference and those that had potential but did not help enough or no longer gave the same benefit that they used to. This may reveal new possibilities, such as adding a preventive treatment or behavioural therapy to one of the previous approaches that had potential.¹

Breaking an established cycle

Once a frequency of 4 to 7 headache days per month is reached, acute treatments may not be enough and preventive medication should be considered.¹ If not addressed early enough, the vicious cycle may lead to medication overuse headache (MOH), where the acute medication itself is causing headache.² Preventive medication can be a vital part of breaking the vicious cycle both before a patient reaches MOH and after successful treatment of MOH.²  

Clinicians can offer preventive treatments to act as “cycle breakers”, giving patients a break from acute medications they take at home and helping them to manage further attacks more effectively.¹ Patients with early morning migraines may benefit in particular from preventive treatments with longer half-lives.⁴

Use preventive “cycle breakers” to give patients a break from acute medications

A study in the Netherlands suggested that acute withdrawal of the offending medications without additional treatment could also be effective.⁶ According to Dr Terwindt, the key is to find out the patient’s ‘natural’ migraine attack frequency (ie, without MOH) towards the end of this withdrawal and then assess whether preventive treatment is needed.²

Whatever strategies are used, it is critical that the patient and clinician work together to find the best solution for them as an individual. The journey should be a collaborative one.^1,2