Doctor on Call: Giving up too soon vs sticking with a loser
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Keisha, a 38-year-old elementary school teacher who lives in Baltimore writes:
I am so incredibly frustrated. My doctor treats me like a guinea pig, prescribing one migraine treatment after another. I start a medicine, and it doesn’t work. When I tell him that it’s not helping, he just prescribes something else.
I’ve had migraines for as long as I can remember, but they were just an occasional aggravation. Then about two years ago I went through a lot of work-related stress, and my migraine just keeps getting worse. Now I have a headache of some sort every day, and for the first time in my life I’ve been calling in sick. In the last few months I’ve tried at least a half dozen therapies that were supposed to prevent my headaches, and none of them has worked. Now this doctor wants me to try yet another one. This is getting ridiculous!
The Doctor’s Reply:
First, Keisha, please know that I sympathize. The trial and error process of trying to find a migraine prevention medication that is both effective and well-tolerated can indeed be an incredibly frustrating experience for the patient. And, trust me on this, it’s not so great for the healthcare provider either. While it would be nice to have a blood test, a brain MRI finding or some other indicator which would predict in advance how well or poorly a given patient will respond to a given migraine prevention therapy, that indicator simply does not exist.
So if for now we must continue this process of educated trial and error, it would be at least of some help if the therapy prescribed would either work or not work within a relatively short period of time. Alas, of the many therapies which possess a decent scientific evidence base for use in migraine prevention, even those which have the potential to exert a positive therapeutic effect within the first weeks after beginning treatment do not always “work” that quickly.
In the research investigations that earned the drug its FDA approval, the newest of the migraine prevention medications, intravenously administered epitenzumab (Vyepti), was observed to exert a beneficial effect as early as the first 24 hours following the initial infusion. Even so, even with epitenzumab, some patients may require months before a positive treatment response becomes evident.
Why? If a therapy is destined to be effective for migraine prevention, why may it take so long for improvement to begin? The wide variation in the time required for patients to begin experiencing a positive treatment response may largely reflect the patient’s particular migraine biology. If migraine typically results from a genetically sensitized biologic circuit within the nervous system, patients whose migraine circuitry has been chronically sensitized for a long time may require a longer period of treatment before enough “desensitization” occurs to produce the beginnings of a positive treatment response.
In your case, Keisha, your previously episodic migraine progressively “transformed” from low frequency to high frequency to chronic migraine and, eventually, to chronic daily headache/chronic migraine. In parallel with that clinical “transformation” there has been progressively increasing sensitization of the biologic circuit that generates your headaches, and at this point that circuit is so sensitized that you are always either on the verge of headache or have a headache. When the circuit really gets going, you experience a clinically severe and functionally incapacitating migraine episode.
It took time for your circuitry to become so sensitized, and even with an appropriate therapy it is likely to take time to reverse that process. One or two months of treatment with a given prevention therapy just may not be enough. Even a therapy that “fits” your migraine biology and eventually will produce an acceptably positive clinical outcome is destined to fail if discontinued too early.
In short, don’t stick with a loser, but at the same time don’t give up too soon. A knowledgeable headache subspecialist will be able to give you a pretty good idea of how long you should continue with a given headache prevention treatment before moving on to another.
