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Tackling Migraine … Oh What A Pain!

A battle Norton Neuroscience Institute is helping patients win

LOUISVILLE Some people believe severe headache and migraine are the same thing. “Not so!” says Brian Plato, DO, neurologist and headache specialist with Norton Neuroscience Institute.

“Migraine is not a headache. It’s a complex neurological condition with headache as one of its symptoms,” says Plato. “I often treat patients who have migraine but not headaches.”

Migraine symptoms can mimic various conditions. For example, Plato has seen migraine patients convinced they are having a stroke. “We don’t have the benefit of a scan, a blood test or anything I can show patients to explain or confirm what’s causing their pain,” says Plato. “Migraine is a clinical diagnosis essentially made by sitting down and talking with patients for a relatively long time.”

Plato earned his medical degree from the Chicago College of Osteopathic Medicine. He completed his internship and residency in neurology at the UofL School of Medicine where he served as chief resident of neurology and completed a mini-fellowship in headache medicine.

He is board-certified in neurology and headache medicine. He is an investigator on several headache disorder clinical trials. He works through the Alliance for Headache Disorders to raise awareness and advocate for various issues.

A Team Approach to Care

According to Plato, ten board-certified headache specialists practice in Kentucky. Half of them currently work at Norton Neuroscience Institute, along with nurse practitioners who have certificates of qualification in headache care. The program is adding a neurologist who specializes in pediatrics and young adults, and expects soon to have seven physicians board-certified in headache medicine on its team.

Plato stresses Norton Neuroscience Institute is committed to providing every patient with accurate information, plus specialized effective and compassionate care. This commitment applies across the board, beyond headache and migraine care.

“Regardless of a patient’s diagnosis – whether it’s migraine, epilepsy, Parkinson’s disease or any other condition – the level of collaboration at Norton Neuroscience Institute is exceptional when it comes to meeting our patients’ care needs,” says Plato. “This is because our work is driven largely by an environment that is not competitive but collaborative.”

Migraine, and Phases, and Impacts … Oh My

The Centers for Disease Control estimate 12% of the U.S. population suffers from migraine. In Kentucky alone nearly a half-million people live with the condition that tends to impact more women than men.

While every case may not warrant specialized care, many produce disabling impacts. Various health organizations that assess levels of disabling conditions rate acute and persistent migraine attacks as essentially equal to quadriplegia.

Migraine’s symptoms generally fall into four phases. In Phase I (Prodrome) patients often report experiencing various symptoms in the days—or sometimes hours—leading up to the attack. For example, they may have yawned more, suffered neck pain, urinated frequently, felt generally moody or been sensitive to light.

Phase 2, Aura, typically involves transient neurological symptoms caused by the brain’s electrical pulses. Patients may see light flashes, have distorted perception, or temporarily lose vision. Such events are not generally dangerous, but can interfere with daily activity and work.

Not all patients progress to stage three, the headache or “attack” phase commonly associated with migraine. This phase often involves severe pain, light sensitivity, nausea, and vomiting. It may produce language difficulties, loss of balance, numbness or weakness and is sometimes mistaken for a stroke.

Postdrome, migraine’s last phase, can last hours or days after the headache phase resolves. Patients often describe it as “a migraine hangover” because it can produce fatigue, difficulty concentrating, dizziness, and mood swings.

The phases’ collective impact is powerful, says Plato. If you had a Prodrome phase for a day or two, a headache phase for a day, and a postdrome phase for another day more than half your week would be lost to just one migraine episode. Many patients have three or more episodes a week.

Successfully Navigating “Uncharted Waters”

Diagnosing and treating migraine is sometimes like navigating uncharted waters. It can get complicated, and like many aspects of modern medicine it changes rapidly.

Diagnosis generally starts with determining if patients have at least two headache-related symptoms (pain lasting 4 to 72 hours, one-sided, moderate-to-severe in intensity, throbbing quality of pain or avoidance of physical activity). Non-headache symptoms typically include sensitivity to light and sound, nausea, or vomiting.

Plato clarifies that while patients with intense pain sometimes fear a brain tumor or aneurysm, these conditions do not typically present with recurring headaches. American Headache Society guidelines do not indicate brain scans for recurring migraine-compatible headaches because the probability of a normal scan is 99.8%.

Norton Neuroscience Institute’s experts are encouraged to see major shifts in awareness, diagnostics, and treatment that recognize migraine’s impact as a serious medical condition. One key development came in 2010 when the FDA approved Botox for treating chronic migraine. These are episodes that occur 15 or more days per month with at least 8 incidents that meet migraine’s diagnostic criteria.

Botox injections are administered every 12 weeks into 31 designated sites. They work by blocking nerve signals that trigger the release of neurotransmitters during a migraine. Plato finds patients often have “fantastic outcomes” with repeated use of Botox, yet he offers some caveats. For one thing, Botox is not a “one and done treatment.” Patients must commit to several rounds of injections. It can also be difficult to “pinpoint” the treatment’s efficacy rate. A typical efficacy standard for clinical trials is a 50% reduction in headache days per month. Based on this marker, Plato usually tells patients, “You have about a 50% chance of having a 50% or more reduction in the number of pain days per month.”

The problem, he notes, is this isn’t necessarily an effective outcome measure for every patient. He explains using a sample scenario: Imagine a patient who has headaches 30 days a month that gets two Botox treatments. At follow-up the patient reports the headaches still happen every day, but the pain is “ninety percent better.” What used to be an “8 to 10” headache is now a “1 or 2.” This is a statistical failure because the patient did not get 50 percent better, yet the improved pain levels are substantial “success markers.”

Patients typically want to know Botox’s likelihood to help them. Plato explains a key effectiveness marker is the percent of patients willing to come back every three months for injections into their heads.

“Our experience is, if it gives them meaningful relief, patients will continue treatment,” Plato says.

He notes that while Botox does not have the option of dose reduction, its injection intervals can be spread out to 3 or 4 months. They can be even further apart if patients continue to do well.

Beyond Botox therapy, another major “migraine breakthrough” came in 2018 when Calcified Gene Related Peptide (CGRP) received FDA approval. This changed the perception of migraine dramatically and gave providers powerful new treatment options.

“With CGRP, our team is able to say, ‘Here’s a molecule in your body causing your migraines’. This lets us target specific molecules with targeted medicines,” says Plato.

Leading From Expertise

Norton Neuroscience Institute is committed to meeting patients’ ever-changing needs. That commitment plays out in two major ways:

  • Telemedicine Care: Published studies confirm telemedicine’s use as a safe, effective resource for headache care. Plato estimates 30 percent of Norton Neuroscience Institute’s care visits are currently done via telemedicine. Given its effectiveness and convenience, plans are underway to expand its use. Telemedicine eliminates geographic barriers and provides ready access to specialists for those who live near or far away. It also cuts down on “canceled appointments.” Patients whose conditions may worsen after scheduling a visit can complete their visits online.
  • Research and Education: Research is a critical element of Norton’s work. One issue generating significant interest is the role stress plays in migraine attacks. Other studies are looking at why women tend to have more migraines than men. Beyond clinical research, patient and community education are key parts of the institute’s work. Team members have developed a valuable program titled, “The Headache School.” This patient-level collection of video lectures is available online and free to anyone who would find it useful.