When Nothing Works: Treatment-Resistant Chronic Migraine

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Key Questions
  • What is the difference between episodic and chronic migraine?
  • Why is it easy to misrepresent the true severity of migraine?
  • How do we get full access to our medical records?
  • Why do some people with migraine become chronic while others do not?
  • What are some risk factors for chronic migraine?
  • When should someone with migraine consider prevention?
  • How does a world-leading headache clinic approach the most difficult migraine cases?
  • What is medication overuse headache?
  • When should someone change the provider they see for migraine disease?
  • What are some other treatment options for frequent nausea or vomiting?
  • What can be done for people who have intractable migraine that is destroying their quality of life?
  • What is the SEEDS acronym?
  • What do we need to know about migraine guilt?
  • How should we think about different migraine tools and treatments?
  • What role does self-awareness play in migraine management?
  • Is chronic migraine related to brain sensitization?
  • Are there any findings from general pain research that apply to migraine?
  • How can we retrain the brain?
  • What role do neuromodulation devices play in the management of migraine?
  • How effective are oral medications, injectables, and devices?
  • Why doesn’t one treatment or tool work for everyone with migraine?
  • Why should someone with chronic migraine stay hopeful?
Interview Notes

Find more about Amaal Starling, MD and her work here:

Treatments Mentioned
  • Botox injections
  • CGRPs
  • Cognitive behavioral therapy
  • Injectables
  • Meditation and mindfulness techniques, such as progressive muscle relaxation
  • Neuromodulation devices
  • SEEDS (Sleep hygiene, Exercise regularly, Eating healthy and less processed food, Drinking water and preventing dehydration and Stress management)
  • Topiramate
  • Triptans

Please note: The Migraine World Summit’s aim is to bring you a variety of perspectives and expertise, independent of bias or judgment. Alternative theories presented in this video have not been medically reviewed. Views expressed in this interview do not necessarily represent the views of the Migraine World Summit. Please always consult your health care professional and do your own research before making changes to your treatment plan.

Amaal J. Starling, MD, FAHS, FAAN

Neurologist
Mayo Clinic, Arizona

Dr. Amaal J. Starling is an associate professor of neurology at the Mayo Clinic College of Medicine. She joined Mayo in 2012 and is currently a consultant within the department of neurology. Dr. Starling received her MD from the Drexel University College of Medicine in Philadelphia. She completed a transitional year residency, a neurology residency, and a headache fellowship at the Mayo Clinic College of Medicine in Scottsdale, Arizona.

Dr. Starling is an active member of numerous migraine advocacy organizations, including the American Headache Society (AHS), the American Migraine Foundation, the American Pain Society, and the American Academy of Neurology. Annually, she is involved in events supporting migraine, including Headache on the Hill, Miles for Migraine, and the Alliance for Headache Disorders Advocacy. Dr. Starling is currently serving as chair of the advocacy committee of the AHS; Diversity, Equity, and Inclusion Taskforce member of the AHS; and she is a member of the Scientific Advisory Board of the International Concussion Society. Dr. Starling has been the recipient of numerous awards, including the AHS Above and Beyond Award for Service, Manfred D. Muenter Award for Excellence in Clinical Neurology, the American Academy of Neurology Annual Meeting Residency Scholarship, the 2012 Spirit of Mayo Clinic Award, and the Mayo Brothers Distinguished Fellowship Award.

Dr. Starling has several peer-reviewed publications and abstracts related to her fields of interest, which include migraine, concussion, post-traumatic headache, trigeminal autonomic cephalalgias, secondary headaches, telemedicine and teleconcussion, neurology resident education, and professionalism and clinical ethics. Dr. Starling’s hope is that her research and advocacy will advance care for people with migraine, post-traumatic headache, and other headache disorders. She envisions a future in which all people with headache disorders receive personalized, effective, and well-tolerated treatment options to improve their quality of life.

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The American Migraine Foundation (AMF) is a non-profit organization dedicated to the advancement of research and awareness surrounding migraine, a disabling condition that impacts more than 37 million men, women and children in the United States. The AMF was founded in 2010 to provide global access to information and resources for individuals with migraine as well as their family and friends.

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