Guest: Dr. Richard Lipton
Presenter: Neal Howard
Guest Bio: Richard B. Lipton, M.D., is the Edwin S. Lowe Professor and Vice Chair of Neurology, Professor of Epidemiology and Population Health and Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine. His research focuses on cognitive aging, Alzheimer’s disease and migraine headaches as co-Director of the Montefiore Headache Center, an interdisciplinary subspecialty center focused on headache, patient care, research and education.
Dr. Lipton holds leadership positions in several professional societies. He is a Past-President of the American Headache Society (AHS). He serves on the editorial boards of several journals, including Neurology. He has written 11 books. Dr. Lipton enjoys mentoring medical students, residents, PhD students and fellows. Over the last decade he has mentored 7 CRTP students and 6 K-award recipients. He has received both the CRTP Mentor of the Year Award and the Einstein Faculty Mentoring Award.
Dr. Richard Lipton was a speaker at the inaugural Migraine World Summit in 2016.
Segment overview: Dr. Richard Lipton, Vice Chair of Neurology, Professor of Epidemiology and Population Health Director of Montefiore Headache Center, discusses the neurological condition of Chronic Migraine.
Health Professional Radio – Conditions of Episodic and Chronic Migraine Headache
Neal Howard: Hello and welcome to Health Professional Radio. I’m your host Neal Howard, thank you so much for joining us on the program today. Our guest in studio is Dr. Richard Lipton, Vice Chair of Neurology and Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine. He’s in studio today to talk with us about the differences between episodic and chronic migraine headache. Hello and welcome to Health Professional Radio Doctor.
Dr. Richard Lipton: Thank you so much.
N: I don’t suffer from migraines myself but I’ve heard that there are some practitioners who scuff at its existence, much like some people claim that fibromyalgia doesn’t really exist. How real is migraine headache especially to those who suffer?
L: So chronic migraine is an episodic migraine for that matter is certainly a legitimate medical disorder by any standard. We know migraine has a genetic foundation, if we study identical twins they’re more than twice as likely to have migraine in common as fraternal twins and for some forms of migraine particularly familial hemiplegic migraine, we’ve identified specific genetic variants that lead to migraine. In addition using brain imaging modalities including MRI, particularly functional MRI and PET scan and during headache attacks we see very striking differences between the migraine brain and the brains of people free of migraine. So by all of those standards, migraine has a firm genetic basis. We can take pictures of migraine attack by imaging the brain and in addition it’s certainly a very real disorder because of all the suffering that it causes. So for example the World Health Organization and its Burden of Disease Initiative rated disability caused by broad range of medical disorders and the most disabling group, according to the World Health Organization was a group with severe Alzheimer’s disease, quadriplegia and migraine. Now that’s not to say of course that if you have a choice between having migraine and quadriplegia that anyone would need to think about which one they wouldn’t rather have. What the WHO means by its rating is that in a day with severe migraine attacks is as disabling as a day with quadriplegia because when people have severe pain, movement makes the pain worse, light and sound makes the pain worse, the pain is often associated with nausea, so the impact of the severe migraine attack during the attack is really enormous.
N: Well how would you go about diagnosing a migraine, a person suffering from migraine and further whether or not it’s a chronic or episodic?
L: Right, so the migraine diagnosis itself depends primarily on history and the migraine headaches have particular headache characteristics, pain tends to be one sided, pulsatile, quite often severe and the pain is inevitably associated with other features like extreme sensitivity to light or sound, nausea or characteristic neurologic symptoms that are usually referred to as aura. The distinction between episodic and chronic migraine is made based primarily on attack frequency. So by definition, people are said they have episodic migraine if they have less than 15 days of headache a month, which is almost everyone who knows migraine but there is a group that has headache on 15 or more days a month and that group is referred to as chronic migraine. Not surprisingly this group with more frequent headache, people with chronic migraine are much more severely impacted by their headaches than those with episodic migraine and some of the people who we see in headache subspecialty practice may have headaches every single day and when that happens it certainly interferes with work and school, family and social leisure activities and the basic ability to enjoy life.
N: So you’re having a migraine attack, do you just take regular pain killers or are there specific pain killers for migraine headache?
L: Yes. So treatment for both chronic migraine and episodic migraine overlaps in terms of approach. So the approach is are non-pharmacologic treatments, pharmacologic acute treatments which you take at the time of the attack to relieve pain and restore function and then preventive treatments which we use to reduce the frequency of attack. Now everyone with migraine benefits from non-pharmacologic methods and acute treatments but roughly a third of people with migraine though everyone with chronic migraine benefits from preventive treatments. And I can say a little more about each category if you like.
N: Can you determine who is a likely candidate for migraine due to genetic testing?
L: Yes. So we know a fair amount about genes that are related to migraine and the genes that we’ve identified either influence ion channels, calcium channels, channels that regulate the entry of calcium into cells or the genes that are involved in sodium or potassium entry into cells are involved in sodium-potassium ATPase, a pump that maintains ionic radius across nerve cells, there’re also some genes that been identified that influence excitatory and/or inhibitory levels of amino acid transmitters, so for example the genes for migraine that regulate glutamate, the main excitatory neurotransmitter in the central nervous system in reality at the moment that we do genetic discovery in people who have migraine and contrast their genetic profiles with people free of migraine, primarily to gain insight into disease and at this point we probably wouldn’t use, we don’t use as a matter of routine this kind of testing is a diagnostic method with the exception of rare disorder called familial hemiplegic migraine where people have migraine with aura but the aura is hemiparesis, weakness on one side of the body and to those individuals we do genetic testing because it helps guide therapy and helps to exclude other disorders that caused transient neurologic dysfunction like multiple sclerosis or seizures or transient ischemic attacks on a vascular basis.
N: Do migraines ever cause injury to the brain or the psyche simply by the level of pain or actual physical changes in the brain?
L: So we know that people who have migraine with aura in particular are increased risk for heart attack, for stroke, for claudication and for all-cause cardiovascular disease and the vast evidence for that comes from studies done by Tobias Kurth and Julie Buring as part of the Women’s Health Study and as part of the Physician’s Health Study which are a couple of large cohort studies out of Harvard and in those studies was shown for women with migraine is that over up to 20 years of follow up to twice is likely to have heart attack, twice as likely to have stroke and twice as likely to have all-clause cardiovascular mortality. Now the important thing to remember though is the difference between absolute risk and relative risk. So the relative risk is that the risk doubles that the risk of stroke in a young woman might be 20/100,000, so if that risk doubles and goes to 40/100,000 risk is still low even though relative risk is high and that should be at least somewhat reassuring but migraine with aura is associated with vascular disease and damage to the brain and it’s also associated with subclinical changes on MRI and that’s been shown in a number of cohort studies both cross sectionally and longitudinally.
N: Now briefly doctor talk about your role as Population Health Director of Montefiore Headache Center.
L: Well, so I’m the Director of Montefiore Headache Center and I’m a Professor of Neurology and Epidemiology and Population Health. So many neurologists have subspecialty areas of interest and one of my major areas of subspecialty interest is migraine headaches and also epidemiology. So in that role I both direct the clinical center where we deliver treatment to patients with the broad range of headache disorders and conduct population studies to understand risk factors for migraine, factors associated with migraine progression…the trouble with migraine which include as I mentioned stroke and heart attack but also Reynold’s and asthma, obesity, depression, anxiety disorders and a variety of other health conditions and some of those disorders also are associated with migraine prognosis. So the issue with episodic versus chronic migraine is that most people who have migraine begin with episodic migraine with just 2 or 3 or 4 headache days per month and over time in the setting of risk factors they may evolve to a picture of chronic migraine whereby definition they’re having headache more days than not and so from a population health perspective the goal was to identify risk factors and keep people with episodic migraine from developing chronic migraine. From a treatment perspective, the goal is, one of the goals is to take people who have chronic migraine and clinically intervene to reduce attack frequency to bring them back to episodic migraine and to help them work and function normally despite their illness or as normal as possible.
N: We’ve been in studio with Dr. Richard Lipton, Vice Chair of Neurology, Professor of Epidemiology and Population Health and Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine. And he’s been in studio today with us discussing the differences between episodic and chronic migraine and some of the diagnosis, methods and treatment methods as well. It’s been great having you here with us today Doctor.
L: Thank you.
N: Transcripts and audio of this program are available at healthprofessionalradio.com.au and also at hpr.fm and you can subscribe to this podcast on iTunes.