Many people view going to the doctor as a form of cruelty. You’re already feeling bad. Why make it worse by doing something that just makes you uncomfortable and will most likely result in bad news? But if you’re a headache or migraine sufferer, this attitude actually could be adding to your burden.
Few people understand this better than Roger Cady, MD, founder of the Headache Care Center in Springfield, Mo., and a leader in the field of headache and migraine research for more than 20 years. Dr. Cady is a firm believer in the collaborative care model, in which patients and health care professionals come together to create treatment models that work. This all starts with forging better communication between physicians and patients.
Although Dr. Cady has been working in the field since the early 1990s, he’s been personally involved with headache for much longer than that. He comes from what he calls a “migraine family”—both his mother and sister were affected by migraine—so for him working with headache patients is more than just a job.
Head Wise (HW):What’s the biggest change you’ve seen in the headache field over the years?
Dr. Cady:There’s been a phenomenal amount of change. Basically, migraine was [thought of as] one of those psychosomatic stress disorders, viewed more as a disorder that women had. It really did not have a great deal of respect. When sumatriptan came onto the market, it changed everything because suddenly we had a drug that worked in a receptor, and it validated the whole biologic model of migraine. In those early clinical trials, it was like a miracle because people could literally have a severe migraine turned around in less than an hour. Prior to that, all we were doing was treating symptoms. We really didn’t have medications that stopped migraine or worked on the process of migraine. So this was a huge paradigm shift.
It was a very difficult time for patients prior to that. There weren’t good treatments. There was a lot of impact in terms of missing work. There was this notion that, in some way, people were bringing this on themselves. In the last 20 years, we’ve recognized much more the genetics of migraine, and we’ve developed better treatments. We certainly have a long way to go, but migraine has positioned itself in the field of neurology as a very important disease process.
HW: Is there still a lack of understanding about migraine in the public?
Dr. Cady: Absolutely. Change takes a long time. There’s been a huge education effort that’s been made to help other physicians get involved, particularly in the primary care field. When you consider that migraine affects 18% of adult women—if you want to look at it in a more graphic way, probably one in five women in their reproductive years actually suffers with migraine—you realize that the real change is going to come when we get primary care physicians much more involved and active. I’m happy to say I see that change occurring, albeit slowly.
HW: What’s on the horizon for the headache field?
Dr. Cady: I think one of the things we’re really missing is a diagnostic test. Migraine today is still a syndrome, meaning it’s a collection of symptoms we recognize and say, “This person has migraine because of these symptoms.” But the reality is that there are probably lots of types of migraine, and they all share these common symptoms. For example, you can have different kinds of infections in the lung that cause cough and fever, but there are still different ways in which that infection is being initiated or dealt with at a biologic level. I think for migraine what we’re going to find is that these symptoms are a common final pathway for many different assaults on the nervous system. My hope for the future is that we will be able to subdivide migraine further, and we will be able to define and develop treatments for whatever it is that initiated migraine.
HW: You were integral in ushering in early intervention. How can this help patients?
Dr. Cady: It can help a lot. When I started in migraine, from a scientific point of view, we wanted to know that we were dealing with a “true migraine.” In those studies, we would have people wait until
a migraine was fully developed, so their pain was moderate to severe. They were almost inevitably
nauseated. They had light and sound sensitivity. Many of them were vomiting. They were very, very impacted individuals. That helped us, of course, be certain we were treating migraine. However, when we got into clinical practice—and especially when oral drugs came on, which aren’t as fast-acting as the injection—the idea of allowing people to wait until they were in the throes of a severe migraine was just untenable.
Early intervention came about really as an observation made by my own patients. When they came in, they said, “You know, the earlier I take this, the better it works.” So we did a study in which we actually looked at a group of people who didn’t follow the protocol. They were asked to wait until the migraine was fully developed, but they didn’t want to do that. They took it early. And what we discovered was that this group of people—for those specific migraine attacks—were almost twice as successful at being pain-free from migraine within two hours. They also had fewer side effects from their medicines because their nervous system wasn’t so sensitized from the migraine itself. And they had less recurrence. So this is a very important paradigm, but it’s not a paradigm that can be used every time and by everybody. Some types of migraines come on very quickly. Sometimes they come on when you’re asleep. Sometimes you’re in situation where you can’t take your medicine early on. What people need is to have a multitude of tools so they have the right tool for the right headache.
HW: How much can this condition really be managed?
Dr. Cady: I think there’s a lot that can be done with management. We always like to wait until the horse is out of the barn. People don’t generally start to take this condition seriously until they’ve had years and years of very severe migraine. Unfortunately, the more migraine you have, the easier it is to get your next migraine. I think a lot of this effort needs to be started earlier. At the same time, realize that you can’t control everything that happens in your life. Even saints can get migraine. Sometimes things happen, so you need to have good tools to be able to treat it, and you need to know how to use those tools. In that manner, you can control and certainly reduce the amount of impact and disability migraine creates. Remember, it’s not a failure if you have a migraine.
HW: How can people protect themselves and guard against potential stressors?
Dr. Cady: There are positive things you can do to protect your nervous system. Keep a regular schedule with meals and sleep patterns. Take a good look at your diet. Are you eating on time? Are you eating healthy foods? Are you enjoying regular exercise? Are you recreating—having some type of fun on a regular basis? Are you setting aside a time in the day that you let yourself disengage from the frantic pace of life, step back and recharge your battery? Those kinds of things are very important.
The other thing that is very important to me is a collaborative health care model. What this means is that we literally try to partner with our migraine patients. In that process, they teach us about their migraine, and we teach them about the knowledge we have as health care professionals. Basically, we have two experts in the room, and both of them are working on a one-on-one basis to solve that person’s problems. I find that model very effective. Over time, people become very capable of making good, quality decisions about when to treat, what to treat with and how to protect their nervous system from migraine. And they really do take on an expertise that makes them much more successful as migraine patients.
HW: So patient education is integral to this process?
Dr. Cady: It’s the center of everything. To me, it’s what makes managing migraine so very interesting. It’s an ongoing process in which your patient is learning and so are you. With people who have migraine, you learn a great deal about medicine just in helping people manage their migraine more successfully.
HW: What is the most common question you get from patients?
Dr. Cady: The most common need people have is to understand what is happening. Why do I get migraine? Why am I different than my friends? We go out and we do the same things, and I end up with a migraine and they seem to have no ill effects. When I sit down with patients, I like to make sure they understand that they were born with a brain that is unique and different than the brain of people who don’t have migraine. The brain of a migraineur tends to be more vigilant, more sensitive to its surroundings. That often brings with it some very positive attributes if the nervous system is well controlled. Successful people in all walks of life live with migraine. Our goal is to learn to manage this nervous system successfully and bring out the good attributes—the positive side of this sensitivity. Then I like to make sure they understand why they get headaches. It’s a relationship between the genetics that nature gave them and the environment in which those genetics function. Sometimes we think of migraine as being one thing, but a lot of times, it’s many things that are impacting the nervous system simultaneously and putting that nervous system at risk. For example, if a woman is working to meet a deadline at work, she’s maybe not been sleeping as well as she usually does and it’s getting near the time of her menstrual cycle, that’s probably not the best time to go out and drink some wine and eat cheese.
HW: If you could say one thing to headache sufferers, what would it be?
Dr. Cady: Migraine is a biologic process. There’s a lot that can be done to help manage it more successfully. Part of this, you, as the person that has this nervous system, need to take responsibility for. A lot of it, the medical system can help you discover and learn how to use. Find a partnership. Work with your health care professional, and in almost all instances, migraine can become a well-managed and well-controlled disorder.
