Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And here today to highlight chronic migraines is Dr. Moises Dominguez. He's an Assistant Attending Neurologist at New York-Presbyterian Hospital, Weill Cornell Medical Center, and an Assistant Professor of Clinical Neurology at Weill Cornell Medical College Cornell University.

Dr. Dominguez, thank you so much for joining us again. So, I'd like to talk about chronic migraines. But first, can you tell us what they are? What are migraines actually, and when are they defined as chronic?

Dr. Moises Dominguez: Thank you so much for having me, Melanie, and such an excellent question. So, you know, migraine is a complex, disabling neurological disorder that affects over one billion people in the world. And this neurological disorder presents with episodes of moderate to severe headache attacks that's associated with light and noise sensitivity and/or nausea. And this speaks to why this condition is more than just a headache. You can think of it as like a sensory information processing issue that leads to head pain, sensitivities to light, sound, smell, touch, and even motion. And that's why lots of folks can experience dizziness with migraine and, additionally, even brain fog during these episodes. So, it's really considered this complex condition.

Then, when you say, okay, this person is likely to have migraine, you can divide it based on how many days of headache they get per month. So, in an individual who has less than 15 days of headache a month, they're said to have episodic migraine. However, there are individuals that if they have 15 or more headache attacks per month. With at least eight of those attacks having the sensory processing issues that we previously talked about, then they're said to have chronic migraine. And that has an additional layer of disability associated with it.

Melanie Cole, MS: Well, I've heard from people that suffer from chronic migraines and you've used the word disability a few times. They are absolutely debilitating and really affect the quality of the life of the patient. So, are there risk factors for developing chronic migraines? Are there certain people that predisposed to getting headaches in general and migraines?

Dr. Moises Dominguez: So, that's an excellent question, especially because we have to ask ourselves, why did someone transition from having episodic migraine to chronic migraine? The evidence suggests that risk factors for transforming from episodic to chronic migraine include just having more headaches at baseline. So, that's one of the biggest things. Secondly, is frequently using or overusing as-needed headache treatments, such as overly treating with acetaminophen or ibuprofen, because the person is experiencing a lot of headache attacks. Another thing includes depression. And lastly, a phenomena called cutaneous allodynia, which is where if a person just simply touches their head, or if they put their hair up, or if they wear glasses, or if they even lay on a pillow, they can experience pain. And these are sort of thought to be the risk factors for this transformation.

The reality is, is that migraine is very complex. It's something that's commonly inherited, and perhaps environmental factors play also a role in a person transitioning to having these migraine attacks. But that's currently the thought as to why people transition from episodic migraine to chronic migraine.

Melanie Cole, MS: This is such an informative episode. So many people probably have questions now as we're talking about that. And before we get into treatments, Dr. Dominguez, how important is shared decision-making when treating and dealing with chronic migraines? Can you speak a little bit about how patients can really partner with their neurologist and why that's so important for treatment?

Dr. Moises Dominguez: Yeah, I completely agree. It's extremely important, especially because having an alliance with your healthcare provider is therapeutic in and of itself. And we want people to understand their condition and hear what is it that they value and prioritize in their treatment plan. Because the reality is, is that individuals have a unique migraine experience and we have to tailor their treatments to their specific needs.

So, it's important also to let people understand with chronic migraine that having treatments that reduce the overall burden of migraine called migraine prevention is key in this case. And the choice of migraine preventive treatment that we choose is also influenced by what the person may value.

Melanie Cole, MS: Yeah. That's how that shared decision-making is so important for treatments because as we said, it affects the quality of life so much. Now, for people that are suffering an acute migraine, and I know we're talking about chronic, but for acute flareup, what do you tell people as we get into the treatment options that are available at that moment to help? Is it a dark room? Is it shutting your eyes or a cool compress or medications?

Dr. Moises Dominguez: That is a very, very good point, especially because migraine is considered an episodic disorder. And although we may try to reduce the overall burden of migraine, there will be attacks that slip through the cracks. So, I think, first and foremost, is actually having as-needed medications with them, such as over-the-counter analgesics, triptans like sumatriptan, gepants like rimegepant and ubrogepant. And generally speaking, once a person is experiencing that a migraine attack may come, it's better to treat early, because you're more likely to control that headache attack when that happens. And in addition to medication, other things that a person may find useful to them, such as wearing a cold compress or an ice cap, or laying in a quiet dark room for a bit while that abortive treatment kicks in to hopefully stop the migraine attack in its tracks.

Melanie Cole, MS: And now, let's talk about some of the novel approaches to treat chronic migraines. Speak about some of the emerging therapies that are used and are there any game-changers, doctor, that really excite you?

Dr. Moises Dominguez: You know, in cases of chronic migraine, botulinum toxin injections are very effective. This is one of our procedural treatment modalities in headache medicine. And basically, it involves performing 31 injections in the person's head. And although it sounds like a lot, this procedure actually takes a few minutes. And it's something that you do once every three months.

Now, when it comes to novel treatments, these treatments target a molecule that plays an important role in migraine called calcitonin gene-related peptide, or CGRP. And these treatments that target this molecule comes in three different modalities. So, one is an infusion that a person can get once every three months. The other is a monthly injectable with one of those injectables that you can get once every three months. And lastly, is in the version of a pill that a person can take daily in the case of chronic migraine or every other day in the cases of episodic migraine as well. And these are especially interesting and great treatment additions to the field of headache medicine because these CGRP-targeted preventive treatments are specifically designed to treat migraines, and that's huge.

Melanie Cole, MS: That is huge. What an exciting time in your field. Now, where in the treatment continuum do other complementary therapies come in, doctor, like relaxation or yoga, meditation, these other forms? How do they fit into treatment plans?

Dr. Moises Dominguez: Behavioral therapies are also used in the comprehensive management of migraines. And these behavioral therapies include biofeedback, progressive muscle relaxation, and even cognitive behavioral therapy for migraine. Also, when it comes to yoga, which I think is great, it's also beneficial in individuals with migraine. And thus, we should consider that as part of our comprehensive treatment plan. Some studies have suggested that with doing yoga, it can reduce how often, how severe, and disabling migraine attacks are.

Melanie Cole, MS: Wow, that's so interesting to note. And before we wrap up, is there any way to prevent these, doctor? Is there anything that people can do to stop the triggers from happening or to prevent them in the first place?

Dr. Moises Dominguez: I would say that one of the most important means of preventing a person from transitioning from having episodic migraine to chronic migraine is, first, properly diagnosing the headache disorder. Because once you identify it, then you can immediately implement appropriate treatment. The second thing is implementing effective, preventive, and acute treatments for migraine, evaluating the why. Like, why is it that this person is experiencing headaches so often? And then, addressing any potential risk factors that can cause the person to transform from having episodic migraine to chronic migraine.

When it comes to preventing migraine in general, I would say that that can be pretty challenging, especially because it's sort of like inherent to the person. I think the best thing that we can do is, in addition to therapy, is also making sure that we maintain an active lifestyle, that we're having at least seven to nine hours of sleep, that we're being at least physically active for about three days a week, finding ways to reduce stress. And in addition, you know, these things can even improve other aspects of our lives too outside of migraine. But I would say those are the major things.

Melanie Cole, MS: Well, thank you so much, Dr. Dominguez, for joining us again. What a great guest you are, and these are so educational, and I know that they're helping so many people that have questions about chronic migraines. Thank you again. And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, iHeart, and Pandora. For more health tips, please visit weillcornell.org and search podcasts and parents don't forget to check out our Kids Health Cast. There's so many great podcasts there. I'm Melanie Cole. Thanks so much for joining us today.

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