What to Try When Nothing’s Working
When migraines fail to respond to the usual therapies, we can believe that we are either cursed or that we have missed something. Only one of these thoughts allows us to move forward. When we believe that we have missed something, we go back to the beginning. We repeat a history and physical looking for missed clues. We consider intervention previously tried and those untried. We adopt new approaches and mindsets that allow patients to become comfortable with being uncomfortable. When people say that they have done everything, it should be pointed out that it is unlikely that they have “done everything” because they have not found out what the next thing to do is. There are multiple interventions that have demonstrated benefit in refractory cases, and if these interventions fail to improve the condition, then it is always appropriate to adopt new perceptions and behaviors regarding pain. It is always too early to quit.
KeywordsPerpetuating factors Precipitating factors Modifiable risk factors Migraine progression Medication overuse Stratified care Polypharmacy Pharmacological treatment Nonpharmacological treatment Herbal therapies Occipital nerve decompression Cytochrome P4 50 testing IgG/IgE testing Wearable technologies Migraine comorbidities Anxiety Self-calming skills Fight or flight response Progressive muscle relaxation Relaxation response Visualization Thermal biofeedback Mindfulness meditation Guided imagery Yoga Distraction Ignition failure Reframing Spirit animal Stress response Behavioral sleep Hypothalamic dysregulation Sleep efficiency Stimulus control Sleep hygiene Sleep restriction Autogenic training Adult abuse Trauma Dietary therapies Migraine diet IgG elimination diet Omega-3 fatty acids Oxidative stress Local anesthetic Occipital nerve block Sphenopalatine ganglion block Pericranial bupivacaine injections Onabotulinumtoxin A Collaborative care model SWOT Commitment Adherence Catastrophizing MOAI Serotonin syndrome Hypertensive crisis Tyramine diet Ketamine Stimulants Steroids Pain perception Pain management techniques Central sensitization Neuroplastic changes Sensory discriminative Affective motivational Descending inhibition Long-term potentiation Long-term depression Descending inhibition Tonically active neuron Peripheral stimulation Limitedly augmented pain Cognitive reprogramming Cognitive therapy Benefit finding Resilience Gratitude Affective balance Negative affect Positive affect EMDR Coping skills
Occipital nerve block (MP4 20313 kb)
Sphenopalatine ganglion block (MP4 300435 kb)
- 1.Perry CJ, Blake P, Goadsby PJ. Surgical intervention altering the natural history of chronic migraine headache: a harbinger of peripheral afferent nerve involvement? Cephalalgia. 2009;29S:40.Google Scholar
- 2.Tennant F. Cytochrome P450 testing in high-dose opioid patients. Practical Pain Man 2012;12(7). Available at http://www.practicalpainmanagement.com/treatments/pharmacological/opioids/cytochrome-p450-testing-high-dose-opioid-patients.
- 13.Tang KY, Goodchild CE, Webster LR. Sleep and chronic pain. In: Deer T, editor. Comprehensive treatment of chronic pain by medical, interventional, and integrative approaches: the American academy of pain medicine textbook on patient management. New York: Springer; 2013. p. 947–62.CrossRefGoogle Scholar
- 24.Loukas M, El-Sedfy A, Tubbs RS, Louis Jr RG, Wartmann CH, Curry B, et al. Identification of greater occipital nerve landmarks for the treatment of occipital neuralgia. Folia Morphol. 2006;65:337–42.Google Scholar
- 28.Hepp Z, Rosen N, Varon SF, Gillard P, Mathew N, Dodick DW. The real-world impact of onabotulinumtoxin a on headache-related ER visits and hospitalizations in the management of chronic migraine. Presented at the American Academy of Neurology annual meeting, 22 Apr 2015.Google Scholar
- 31.Niesters M, Khalili-Mahani N, Martini C, Aarts L, van Gerven J, van Buchem MA, et al. Effect of subanesthetic ketamine on intrinsic functional brain connectivity: a placebo controlled functional magnetic resonance imaging study in healthy volunteers. Anesthesiology. 2012;117:868–77.CrossRefPubMedGoogle Scholar
- 41.Robbins L, Maides J. Stimulant use in migraineurs with comorbidities. Pract Pain Manag. 2009;9(7):58–9.Google Scholar
- 46.Ray A, Zbik A. Cognitive behavioral therapies and beyond. In: Tollison CD, editor. Practical pain management. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2002. p. 189–208.Google Scholar
- 48.Schwartz J, Begley S. The mind and the brain neuroplasticity and the power of mental force. New York: Harper Perennial; 2002. p. 372–7.Google Scholar
- 50.Satinover J. The quantum brain. New York: Wiley; 2001.Google Scholar
- 52.Ray A, Ullmann R, Francis M. Pain as a perceptual experience. In: Deer T, editor. Comprehensive treatment of chronic pain by medical, interventional, and integrative approaches. The American academy of pain medicine textbook on patient management. New York: Springer; 2013. p. 745–58.CrossRefGoogle Scholar
- 53.Price D. Psychological mechanisms of pain and analgesia. Seattle: IASP Press; 1999.Google Scholar
- 57.Schwartz J, Begley S. The mind and the brain neuroplasticity and the power of mental force. New York: Harper Perennial; 2002. p. 372–7.Google Scholar
- 64.Levy A. A brain wider than the sky. New York: Simon & Schuster; 2009.Google Scholar
- 69.Wiesel’s headache. Headache 2010;50(6):1087–8. [no authors listed].Google Scholar
- 70.Norman Vincent Peale. (n.d.). BrainyQuote.com. Retrieved 1 Nov 2015. From BrainyQuote.com Web site: http://www.brainyquote.com/quotes/quotes/n/normanvinc100962.html.