You asked, we listened.

Welcome to Ask the Migraine Expert, a column about managing life with migraine from Deena Kuruvilla, MD. Kuruvilla is a board certified neurologist and director of the Westport Headache Institute in Fairfield County, Connecticut. Got a question for the migraine expert? Submit your question via this form.

Dear Migraine Expert,

Why does medication stop working, or not work as well for some as it does for others? What makes some people refractory or resistant to treatment?

— Courtney Lynn, Migraine Healthline community member

Even though a whopping 40 million people have episodic migraine (fewer than 15 headache days per month) and around 4 million people in the United States have chronic migraine (15 or more headache days per month), receiving an accurate diagnosis and an optimal treatment plan can have several hurdles.

Research from 2016 shows that 40 percent of people with migraine do consult with a healthcare professional. Of those, however, only 1 in 4 receive an accurate diagnosis. And only and 44 percent of people who get an accurate diagnosis go on to receive optimal preventive and abortive treatments for migraine.

Even if you do receive an accurate diagnosis, finding an effective treatment regimen can be tricky. Migraine is a complex condition that involves multiple different pathways within your brain.

Often, it may take a combination of two or more preventive treatments to manage your pain.

According to the American Headache Society, migraine doctors should consider a preventive treatment if migraine headaches are occurring 4 or more days per month or if any migraine headache is resulting in significant disability.

The goals of preventive treatments are to reduce:

  • the number of overall headache days
  • the severity of each individual headache
  • the amount of as-needed medication being used
  • migraine-related disability

When someone hasn’t responded to two classes of preventive treatments and three classes of acute treatments, we call this “refractory migraine.”

It’s important for migraine doctors to identify people with refractory migraine, because they have more day-to-day disability. They may require multiple specialists on their care team, including a:

  • headache specialist
  • sleep specialist
  • psychologist
  • psychiatrist
  • physical therapist

Migraine episodes are thought to be caused by several different mechanisms, such as:

  • genetics
  • an inflammatory storm
  • atypical electrical activity in the brain
  • the fluctuation of chemicals like serotonin, dopamine, and norepinephrine in the brain

The different migraine prevention treatments we have available target these different mechanisms.

Since an individual with migraine may have one, two, or more mechanisms causing their migraine episodes, a multifaceted approach may be necessary to effectively provide treatment.

To make an individualized treatment plan, I often discuss the following with my patients:

  • lifestyle modifications
  • nonmedication approaches, such as devices
  • mainstream preventive medications
  • rescue medications

We also work to address other health concerns that are common with migraine, such as anxiety and sleep disorders.

Specific risk factors can convert episodic migraine into chronic migraine.

Some of the nonmodifiable risk factors include:

  • having been assigned female at birth
  • being white
  • having a previous head or neck injury
  • stressful life events, such as divorce or work changes

Treatable risk factors include:

  • overuse of as-needed medications
  • obesity
  • depression or anxiety
  • sleep disorders, such as obstructive sleep apnea

As I’ve mentioned, migraine treatment can be complicated. There are three main factors that can make migraine more difficult to treat.

Medication adaptation

Medication adaptation headache, also known as medication overuse headache, has the following characteristics:

  • headache present on at least 15 days per month
  • regular overuse for at least 3 months of one or more drugs that can be taken for acute or symptomatic treatment of headache
  • headache has developed or markedly worsened during medication overuse
  • headache resolves or reverts to its previous pattern within 2 months after discontinuation of overused medication

I’m frequently asked, “What counts as overuse?”

If you’re using sumatriptan, opioids, or medications that contain a combination of caffeine, acetaminophen, opioid, or aspirin 10 or more days per month, you’re at risk for medication adaptation headache.

If you’re using simple over-the-counter analgesic medications, such as ibuprofen or naproxen, 15 or more days per month, you’re at risk for medication adaption headache and your headaches could become more frequent and severe.

If someone is using as-needed medications this frequently, I often optimize their migraine preventive treatments to assist them in reducing the amount they’re using.

Anxiety and depression

Mood disorders are commonly a package deal with migraine.

In my experience, about half of people with migraine have anxiety disorder and about 1 in 4 people with migraine have depression.

Mood disorders must be addressed when assessing migraine. If one of my patients shares feelings of anxiety or depression, I often recommend a preventive treatment that has been studied for both mood disorders and migraine prevention.

It’s also important for us as neurologists to partner with psychologists so we can offer nonmedication approaches to mood management, such as:

  • cognitive behavioral therapy
  • biofeedback
  • relaxation
  • mindfulness-based strategies

Sleep-related disorders

I commonly encounter obstructive sleep apnea and insomnia in my headache practice.

Many patients report that they have trouble getting to sleep or putting their minds to rest at night, wake up frequently, snore, or wake up with headaches and feeling unrested.

Partnering with a sleep specialist and psychologist can be fundamental to managing migraine.

Many patients will go for a sleep study to see if they have any pauses in their breathing overnight or to just check their sleeping pattern. Often, a machine to help breathing, a medication to help with sleep, or cognitive behavioral therapy with a psychologist can be extremely helpful tools to add to an individualized treatment regimen.

Migraine is a complicated condition and it’s understandable to feel discouraged if your treatments have stopped working.

However, many people do see improvement after working with their care team to address underlying issues and new treatments. You don’t need to give up on the path toward fewer pain days.

Deena Kuruvilla is a neurologist who’s passionate about all things headache. She has made it her life’s mission to treat, educate, and bring awareness to headache conditions such as migraine. She is the director of the Westport Headache Institute and has conducted research on medical devices, complementary and integrative medicine, and procedures for headache treatment. She has been featured in Prevention Magazine, Neurology Today, the Hartford Courant, and the Wall Street Journal. She lives in Fairfield, Connecticut, with her husband and two children and loves watching “The Masked Singer” with her family. Connect with her on Facebook or Instagram.