Phenotyping the migraine patient

Published on November 30, 2023   37 min
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My name is Rob Cowan. I am a Professor of Neurology and Neurosciences at Stanford University. I'll be talking today about phenotyping the migraine patient.
I have no relevant disclosures relating to this topic, but here are my other activities for reference. The overview of phenotyping is actually
a fairly straightforward issue. We had no diagnostic criteria for migraine and other headache types until the late 1980s, when the International Classification of Headache Disorders was first defined. Since then we've had about three and a half iterations of that classification system. But we still have an issue in terms of where to go once we have identified someone as having the phenotype of migraine and that remains the elephant in the room. How do we decide, given someone has migraine, what the most appropriate treatment strategy should be? How do we monitor for efficacy, most bothersome symptom and other measures that seem to be important to patients and to our research in the field.
Let's start with what I consider the four basic questions. First, who are the most challenging migraine patients? Who are the patients who have a diagnosis of migraine, but are most challenging to us in figuring out what the best treatment strategy is? What is the most important measure of success? By that I mean do our measures of success, things like decrease in frequency, severity, and duration of episodes, correlate with the single most important measure for individual patients. Multiple studies have shown that there's not always a one to one correlation between what the doctor thinks is most important and what the patient thinks is most important. Certainly when do we decide that management is not working? When do we decide if an intervention has not been successful and we need to change gears and how do we make that determination? Then finally, what is chronification? Chronification is a term that we're hearing increasingly, and that's the patient who goes from having a few headaches a month or a year, to having headaches that are increasingly frequent, severe, with more prominent symptoms like cutaneous allodynia and central sensitization. Why is it that some patients go from a few headaches a year to having almost daily headaches, while others just stay low frequency episodic throughout most of their lives.