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4 Not-So-Obvious Differences Between Episodic and Chronic Migraine

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I’ve often wished that chronic migraine (CM) had a different name. I have lived with this diagnosis for six years and have found this description consistently misleading and confusing both for myself and others.

When most people hear the word “chronic,” the first thing that comes to mind is either a) something that has been going on for a long time or b) something that happens frequently or regularly.

Although these are both often true in the case of an individual living with chronic migraine, they are not the defining factors which lead to a chronic migraine diagnosis.

Chronic migraine is defined by the American Migraine Association as: headache occurring on 15 or more days per month for more than three months, which, on at least eight days per month, has the features of migraine headache.”

Episodic migraine is separated into two categories and defined as: “low-frequency episodic migraine (less than 10 headache days per month) and high-frequency episodic migraine (10-14 headache days per month).”

CM occurs in approximately 1% of the population, and studies estimate that approximately 2.5% of people with episodic migraine will transition to chronic migraine each year. For this portion of the population, CM typically progresses over the course of a few months until it completely dominates the person’s life. Migraines that once consisted of debilitating attacks that came and went become an almost daily battle.

Living with chronic migraine is very different from living with episodic migraine. Sometimes, these differences are not even clear to migraineurs in general. I often think about severe presentations of other chronic illnesses, and how that differentiation does not exist in the migraine world when talking about the spectrum of disease.

Unfortunately, because migraines are so invisible and the battles are fought behind closed doors and blackout curtains, those suffering with the most severe presentations of this disease can be accused of exaggerating (often, painfully, from others who experience migraine themselves). It’s incomprehensible to many who experience episodic migraines that every day can be migraine-impacted. But the very diagnosis of CM dictates that as part of the disease presentation.

Below I am sharing four things about living with CM that I have found to be the most challenging to explain to others in the hope that it will shine a light on this condition and encourage better understanding.

1. The line between “having a migraine” and “not having a migraine” becomes inexplicably blurred.

My heart aches just typing that out, because it rings so true to my experience and has been one of the hardest things to explain to others. Often I am asked, “did you have a migraine yesterday?” or “do you feel better today?” It seems like an easy question, but is actually difficult to answer. Because my migraine attacks are so frequent, their “pre-pain” and “post-pain” aspects blur the lines between attacks. My experience of CM is that I live in a state of constant head pain, the only real change being the degree of that pain.

Most of my pain presents behind my eyes, and they are sensitive every single day to the world around me (driving, going to the grocery store, interacting, screen time, light sensitivity, etc…). My head pain can ramp up within a matter of minutes to a full-blown migraine, leaving me nearly constantly teetering on the edge and having to severely monitor and limit my activities. Canceling plans is a challenge I struggle with almost daily. Some days it is because I am actively experiencing an attack, and at other times it is because I know my threshold is so low that doing anything at all will tip me over the edge.

2. Triggers become less straightforward when living with CM.

“Do you know what your triggers are?” This question used to make me cringe when I was first diagnosed with CM. I often wanted to shout (in a quiet voice) at the person asking me, “um yes, it seems like life is my trigger!” When you experience migraine attacks on over half the days in a month, and the line becomes blurred between having a migraine and not having one; another thing that can become blurred is the clarity of your triggers.

On my hardest CM days (sometimes weeks), simply existing in the world is like walking through a booby-trapped minefield. One wrong step, and my head will explode in pain. Sometimes it is from a well-known trigger (traveling, bright lights, large groups of people, lack of sleep), but often, it is unclear exactly which specific trigger or combination of them has triggered a painful episode.

For those experiencing episodic migraine, identifying and avoiding triggers is often a very straightforward and effective way to manage their condition. I find that for many CM patients, it often feels like the onus is put on us to understand the minefield we are walking through, even when it’s impossible to do so and any step could set off a bomb. Please be sensitive when asking this question, and know that it is possible to experience CM even if you “know your triggers” and work diligently to avoid them.

Natalie at the doctor managing chronic migraine.

3. Treating acute CM pain can be a complex balancing act.

Almost every migraineur has their particular “favorite” rescue medication. There are a myriad of choices, and each person must find, through trial and error, the ones that work best for them. The complication with CM is that most rescue meds require monthly rationing to avoid medication overuse headache (MOH). Although this is a dilemma many with episodic migraine face also, it is often a daily struggle and extreme stressor when living with chronic migraine. By its very definition, every CM patient experiences more migraine days per month than “non-migraine days.” This means that even when you are in extreme pain, with the potential to escalate to downright debilitating, you cannot treat it with rescue meds each time.

There are multiple reasons for this — but the most important is that by treating your pain too frequently, you can create a MOH, which is likely to prolong and worsen the pain cycle. In my case, the only thing that helps relieve my most excruciating migraine pain is a class of medications called triptans. I’ve been warned by countless neurologists over the years that more than 10 triptan days per month puts me at an exponentially higher risk for MOH. This means that every time that I take this medication, I am doing a mental calculation of how many I’ve already taken that week (or month). If I exceed my limit by too much, or too many months in a row — my neurologist and I have to come up with a new preventative tool to interrupt my migraine cycle. Usually, this is done with a short course steroid taper (I have also tried infusions and nerve blocks in the past). For many, the only option is to turn to inpatient care for a cycle of five to 10 days.

4. It’s extremely frightening when the pain just won’t stop.

This is something just about anyone with migraine disease can relate to, but the experience of chronic migraine can take it to a whole new level. I clearly remember a day, about eight months after my CM diagnosis, a few days after my first trip to the ER for migraine pain, where the pain was so unrelenting that it forced me to tears. My only thought was that I just needed it to stop. But almost immediately after coming to that conclusion — I was faced with the harsh reality that as badly as I needed that break, I couldn’t make it happen.

The pain was going to persist and exist on its own timeline. There was nothing I could do to make that “break” I so desperately wanted come to pass. This truth is so scary. When you have severe CM and are being treated by expert neurologists in the field, it’s terrifying when you realize that you are already working with the people who “know how to help you” and that even they can’t make it stop, at least not immediately.

I am passionate about spreading awareness about the broad spectrum in which migraine disease exists. Every single migraineur deserves empathy, but it is up to us to raise awareness about the intense variation of each migraine warrior’s experience of this disease. My sincere hope is that by speaking up for the CM community, there will be greater awareness and understanding of those of us living on the far right end of the migraine bell curve, the CM warriors.

Originally published: August 16, 2020
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