Medication Underuse - IG Live with Migraine Strong and Amy Larsen PA-C

December 6, 2024
December 6, 2024
27
minutes
Medication Underuse -  IG Live with Migraine Strong and Amy Larsen PA-C

Are you taking your migraine medication effectively? Are you undermedicating?

In this informative Instagram Live session with Migraine Strong, Amy Larsen, PA-C, from Neura Health, discusses the often-overlooked topic of medication underuse and its potential link to chronic migraine.

The conversation covers the complexities of migraine management, including striking the right balance between acute and preventive medications, exploring non-pharmacological options, and understanding the nuances of medication adaptation, as well as medication underuse leading to migraine progression from episodic.

Transcript:

Eileen: Hello, everyone, and welcome to our Instagram Live today. Joining us from Neura Health is Amy Larsen, a neurology physician assistant. She treats headache, concussion, stroke, tremor, and other neurology conditions. Thank you so much for joining us today. We really appreciate your time.

Amy Larsen, PA-C: Thank you for having me. Excited to be here.

Danielle: This is a popular topic, one that's close to my heart and Eileen's as well. It's the balancing act of too much headache, when to treat. Everyone has questions about the challenges we face daily. We're thrilled to have you here. I think most people are used to hearing discussions about medication overuse, or medication adaptation headache, or rebound. They don't hear much about medication underuse. But I know there's been a recent study – I was going to print it, but it was 72 pages! It was packed with information. So, we're thrilled to have you on. You're a fantastic resource, and I know this topic is near and dear to your heart because all you do day in and day out is work with people with migraine, trying to navigate these questions. So, to get the ball rolling, how would you define or what would you say about medication underuse?

Amy Larsen, PA-C: I'm excited to talk about this topic. It's a risk factor for chronic migraine that hasn't been readily discussed. It's an underappreciated and underdiscussed concept. It's not a new diagnosis. This isn't like medication adaptation headache, which is an official diagnosis. This is a concept that explains how ineffective treatment of episodic migraine can lead to developing chronic migraine, or chronification.

Danielle: Why do you think it happens in our population?

Amy Larsen, PA-C: There are a lot of scenarios that can increase the risk, especially in high-frequency episodic migraine and chronic migraine. But the why and the how is the big thing. I'll start with the why. Migraine, as we know, is this neurovascular inflammatory process. When we experience a migraine attack and it's not effectively treated, it progresses, and we can experience prolonged inflammation. The analogy I like to use – and this is an oversimplification – is that migraine is a bit like a light switch. If we have this constant nerve activation, that light switch is getting turned on over and over. At a certain point, that light switch gets used to being on and gets turned on for the smallest triggers. This is central sensitization. If we have ineffectively treated episodic migraine, with that sensitized nerve, all of a sudden, we see a pattern of more and more attacks, more episodes, and patients can convert into chronic migraine, which is more than 15 headache days a month.

Eileen: I've heard that analogy before, where it's like you're in this pain cycle where that switch has been flipped, and it's on all the time. I think that's a good analogy.

Who's at risk for medication underuse?

Amy Larsen, PA-C: The patients at greatest risk are those not on a preventative, or they're on a sub-therapeutic preventative – one that's just not working as well as we'd want. Maybe they've stopped it because of side effects. Maybe they take it on and off, just not consistently. That's one population. The other is patients experiencing high-frequency or chronic migraine. They're faced with this chronic decision-making: Do I treat now? Do I treat later? Is this just leftover? Is this a postdrome? Is this something new? That's the population I would say is at risk.

Interestingly, in a publication that came out about a month ago, the population at the highest risk of this poor response – episodic migraine that led to chronification – were patients using simple analgesics, over-the-counter medications, versus those using triptans.  A lot of patients worried about medication overuse or underuse are more familiar with triptans or other acute medications. But the study showed we see this a lot in patients who haven't even been diagnosed with migraine and are trying to take Excedrin or Tylenol.

Danielle: That's interesting. I think a lot of times people just want to use over-the-counter things because, in their mind, they are less debilitated, or they can dismiss it more if they don't have to progress to a prescribed medication. And in social media, especially with Migraine Strong, since so much of what we talk about is natural remedies, I think a lot of people try not to take medication. They do everything they can because they feel like they can use natural remedies to achieve wellness. As much as I know there's a place for natural remedies and lifestyle, a lot of times you need medication to do the heavy lifting. So, when I see people going for months with undertreatment, it makes me nervous because I think it's going to be harder to unwind potentially chronic migraine. That's why I'm excited about this topic. Personally, I wasn't in that category. I had overuse. I was using triptans every day because my doctor prescribed them, and my insurance company allowed it. But I do see people who struggle with, "Well, I don't want to take medication," or "I don't know how to take my medication," or "I don't get enough medication." So, we have so many questions. I'm going to stop talking and go right to them.

Amy Larsen, PA-C: There are a number of scenarios where we see medication underuse come into play, and overuse has been preached. Anyone prescribed acute migraine medication has been told, "Don't use it too much." What we haven't done a good job talking about is what happens if you don't treat your migraine. What happens if you push through it and try to suffer through it? Does that carry risk? The interesting thing about this publication is that it shows it does. It can lead to more migraine attacks.

Eileen: One of the questions is: Once you've been diagnosed with chronic migraine, what options do you have?

Amy Larsen, PA-C: Chronic migraine is tricky because you're dealing with more headache days than half the month. For some people, that's near-daily. When we're talking about acute medications, it's important to differentiate. We always say, "Only use this certain type a certain amount," but that doesn't mean you can't use other medications in between. Medication overuse is reliance on one particular type of medication too often, for a certain number of days, for more than three months. That's how the International Classification of Headache Disorders classifies medication overuse. If we're limited to that one type of medicine for a certain amount of the month, it's important to add more tools to your tool belt. Maybe that's nonpharmacologic things. Maybe that's an additional medication that doesn't interact with or preclude the use of a triptan – utilizing anti-inflammatories, anti-nausea medications, and these newer anti-CGRP medications. CGRP refers to the protein that activates the nerve in migraine. Sometimes we use the suffix "-gepant" for these medications. Utilizing these in your tool belt if you're limited and having frequent attacks is what we recommend. It gives you more options.

Eileen: I think that gets confusing. Say, for instance, someone reaches for a triptan a majority of the time. They've been told no more than two times a week or 10 times a month. Does that preclude them from using NSAIDs during the month if they're going to rely on those 10 triptans? I think that's where it gets confusing because then they think, "Well, if I'm going to use my 10 triptans, then I can't take any ibuprofen or any other anti-inflammatory." Now we know that gepants don't necessarily play into medication adaptation headache, but there's a lot of confusion as to what else they can use.

If they're taking triptans, are they allowed to have an anti-inflammatory component as well?

Amy Larsen, PA-C: Absolutely. Medication overuse, again, is that one type. When patients take a long-acting triptan during menses – sometimes we use those for menstrual migraine – and maybe they use a short-acting triptan for the rest of the month, in that scenario, yes, triptans are the same family, the same type. We have to limit that to two to three days a week because of the evidence of rebounding. But that doesn't mean you can't use an NSAID. That's a different type of medication, a different abortive. How it works on migraine is completely different than what triptans do. Using these different modalities is important because they're doing different things. Now, NSAIDs also have to be limited. But it's not like triptans plus NSAIDs have to be only two to three days. It means triptans can only be two to three days. NSAIDs should be two to three days. Gepants, you're right, are different. Thankfully, we don't see the same risk profile for rebound with those, but the challenge is that insurance often only gives you a small amount anyway. So, we're limited by quantity, not necessarily safety.

Eileen: That opens things up because it has been beat into our heads for so long that you can only medicate two to three times a week. That's it. And if you have migraine attacks five to seven days a week, well, you're just suffering those other four days. Just put an ice pack on and sit in your room. That's pretty much it. I don't think that's it. Like you're saying, that's not necessarily the case.

Amy Larsen, PA-C: Correct.

Danielle: I can't help but notice how the guidance has evolved. I'm not sure if the official guidance has evolved, but I think the care with headache specialists and places like Neura is to have a stepped-up approach to getting symptoms or attacks in check. Years ago, when I was at Jefferson, I remember them saying only treat twice a week, and I had 24/7 pain. So, I would call and say, "What do we do on the other five days? First of all, those two days, it's not working. What do I do?" Now the thinking has evolved. In the toolbox, there are more medications not associated with rebound. You can work with your doctor to find the right balance.

Amy Larsen, PA-C: I would also add that there may be other comorbidities that might limit other things. Anti-inflammatories don't work and can't be taken by certain populations. If you're on anticoagulants or blood thinners, if you have GI sensitivities, a history of gastritis and ulcers, then we avoid those. It's a complex discussion with your provider.

Eileen: Like I have kidney issues, so I don't take NSAIDs. I think it's important. We talk to so many people adamant about only treating twice a week. That's a good discussion to have with your doctor. This information is evolving, and this was a good conversation for people to hear.

Danielle: This is not medical advice. Everyone is here to help educate and encourage you to talk to your doctor. If you're not confident in your doctor's care or knowledge, you can consult Neura Health. We'll put that in our story. You can find a local resource. This isn't specific advice. This question is: My doctor said to treat two to three days with my triptan.

Can I take a different medication on other days if I'm having an attack?

Amy Larsen, PA-C: Yes, just like we discussed. There are other acute medications. I also like to emphasize nonpharmacological approaches. In the past, it was limited to triptans. You were talking about the recommendations way back when. It used to be, "Take an Imitrex, and if it doesn't work, good luck." We have a lot of options now, and more knowledge on medication overuse and rebound. It's important to treat these attacks because we don't want them to become more frequent. The answer is yes, there are other options. What those options are will be between you and your provider, based on your medical history.

Eileen: How do we balance the advice to medicate at the first sign of an attack versus medicating too much?

Amy Larsen, PA-C: It is a balance. It can be challenging to figure out. I always tell patients it's important to know your migraine, know your prodrome, know the initial symptoms. A prodrome is different for everyone. There's no one specific symptom. Studies show certain medications are more effective within a certain window. Some can be more effective taken earlier or later, but triptans tend to be the most finicky regarding efficacy timing. When we're balancing having two to three days of only being able to treat with a triptan, that means know your prodrome. If you start seeing those initial symptoms, that's when you start with an anti-inflammatory versus immediately taking a triptan. I hear this all the time: "I don't want to waste it. What if I have to waste it because I only get so many a month? What if it's not going to progress?" That's true.

We always say, "Just figure it out." Obviously, this is easier said than done. Knowing your migraine is important. Not everyone experiences aura, so we don't always have that neurological deficit or change that helps us predict when the headache pain will start. But studies show triptans are more effective at the onset of headache pain, not necessarily prodrome. If you experience prodromal symptoms, which can vary – brain fog, mood changes, cravings, sleep disturbances, nausea, even neck muscle tension, speech changes – that's the time that taking an anti-inflammatory or even a gepant can be helpful. Within the aura phase, if you experience aura, that's also a window where we can do early intervention. This is also where nonpharmacological interventions can be helpful. When that headache pain starts to escalate, that's when we recommend addressing it with medications like triptans or even ergotamines. If you start feeling that building of intensity, that's the time to take those medications.

We usually say that the pathophysiology is that we have peripheral nerve stimulation within the first 30 minutes to an hour. That's early migraine. Once you hit past an hour to two hours, we start having central activation and development of allodynia, which I think followers are probably familiar with. It's essentially non-painful stimuli that becomes painful. Once we have that central activation, migraines progress, and triptans are less effective. Interestingly, in this publication, they mention that the early triptan studies were done for moderate to severe pain intensity. They waited to treat with triptans in the early studies because they had to meet FDA criteria for migraine, and it's hard to know in the beginning if it's going to be a full migraine. So, they waited until there was moderate to severe intensity to treat with triptans, and compared to placebo, it was still more effective. That's not to say triptans can't be effective if you take them late or miss that window, but the evidence is clear that they're more effective if you take them at onset.

Danielle: We see this a lot in social media.

Is taking a lower dose a risk? Is it safe to take half a pill so there won't be as much drowsiness?

Amy Larsen, PA-C: Taking a lower dose may mean your body is metabolizing less. That's less of an affront to your liver. However, the risk is that if it's ineffectively treating migraine, it may progress. Then, of course, you may have more migraines in the future. The challenge is – and what I always ask my patients is – yes, you can try a lower dose, but is it treating your symptoms? How often are you needing to re-dose? If the answer is, "It only knocks out some of it, but I don't have as many side effects," then the answer is we need to find one that you tolerate better because you're ineffectively treating your attack, and we need to treat this effectively so you have fewer migraines in the future.

Eileen: Are some over-the-counter medications better or worse than others? Like Aleve versus Excedrin?

Amy Larsen, PA-C: Excedrin is a combination medication. It has Tylenol, aspirin, and caffeine. Studies show there's a higher risk of rebound with those than with anti-inflammatories. But again, this comes down to your comorbidities. Are you able to take anti-inflammatories? My preference for over-the-counter, if there are no GI risks or kidney/renal concerns, is a longer-acting anti-inflammatory like naproxen. Individual responses vary, so someone might try this and say it didn't work. But if we're trying an over-the-counter option, the one least likely to rebound within that specified number of days is an anti-inflammatory.

Eileen: Three people have asked a similar question:

What if they have to take NSAIDs or other pain-relieving medications for other conditions besides migraine? What advice do you have for them if they're medicating arthritis, fibro, something like that?

Amy Larsen, PA-C: There are a lot of reasons someone might be on an anti-inflammatory long-term. All those GI, stomach-protective things are important to keep in mind. It's not like the medication knows what it's treating. It's systemic. Taking an anti-inflammatory means it's going to be absorbed in your body. It's not going to say, "I'm only here for joint pain." Those chronic NSAIDs may be helpful for migraine, but if not, then the challenge is we need to find something else to add because we can't take an NSAID on top of an NSAID. That's not recommended. That will damage your stomach and cause kidney issues. We don't want to trade one problem for another. If you take chronic anti-inflammatories, your options are to explore other acute migraine medications – triptans or gepants. Maybe that's adding an anti-nausea medication or an antihistamine.

Eileen: We're talking about medication underuse and how that can lead to chronification. But what goes hand in hand with that is if you're overusing medication as well.

One of the questions we received was about rebound and how to get out of rebound. Do you have any suggestions?

Amy Larsen, PA-C: It's a different topic than our conversation today, but rebound is tricky. It's a constant balance of "I don't want to take too much, but I need to treat my episodes because if I don't, I might get more attacks." They go hand in hand. It's impossible to talk about one without the other. When stuck in rebound, the most important thing is to stop the offending agent. If there's one medicine we've been relying on too often, we need to stop that and find an alternative. That doesn't mean going cold turkey without any migraine medication or pain medication. It means we need to find a safer option. The other important piece is that it often means starting a preventative or adjusting preventatives. Sometimes we have to add something if you're already taking a preventative, adding something as an adjunct. We want to try and decrease nerve sensitivity. That's the goal of preventatives: to decrease the frequency and intensity of episodes.

Danielle: The other aspect of medication underuse is the underuse of preventives. People say, "Well, I'm on X. So now I just use my acutes for breakthroughs." If your preventative isn't preventing enough, it's time to talk to your neurologist about a tweak or an overhaul. That's also part of underuse: an under-effective or less effective preventative strategy. Getting back to the acute aspect, this person has questions about Advil.

How many over-the-counter pain medications like Advil can I use without fear of medication adaptation headache?

Amy Larsen, PA-C: If you're only taking an NSAID like Advil and not adding other anti-inflammatories – again, we don't want to mix anti-inflammatories; they work similarly and can be quite caustic to the stomach – Advil is ibuprofen. It's shorter-acting, so you can dose it more frequently versus a longer-acting one like Aleve or naproxen. The current data for the classification for medication overuse from the International Classification of Headache Disorders (ICHD) is for NSAIDs more than 12 to 15 days per month. That's higher than medications like triptans, which are less than 10. There's a little more wiggle room, but it's still a caution. If you're taking an anti-inflammatory that frequently, is it helping your pain? That's another piece of medication underuse: Is the medicine effective? If we constantly do the same thing but don't see improvement, then you're undertreating the headache. The headache is progressing anyway. You're potentially experiencing more frequent attacks because the migraine isn't being addressed. We don't want to throw the same medicine at it if it's not effective.

Eileen: If you're treating frequently for attacks and not on a preventative, where do you draw the line?

If you're treating migraine attacks but not on a preventative, when should you start talking to your doctor about getting on one to prevent some of those attacks so you can start using less acute medication?

Amy Larsen, PA-C: The current recommendation is if you have more than four headache or migraine attacks a month, it's recommended to be on a prophylactic. That may look different depending on patient preference and side effect profiles. I have a lot of patients who say they want to try a nonpharmacological preventative regimen first. We recommend certain vitamin supplementation, which has good data for decreasing migraines over time. But currently, it's over four, which isn't that many considering some people experience daily headache pain. If you think, "I only get five a month," that's a headache a week. It adds up.

Eileen: We talk to a lot of people in the community, and there's a lot of fear about medication. We don't have any judgment about that, but we address it because I know people are concerned about side effects. I worry about the chronification factor because I am very chronic, and it's difficult to treat and go back from chronic to episodic. I see people resistant to trying medications, and I worry about them getting to my stage.

What advice do you have for people fearful of medication?

Amy Larsen, PA-C: It's an understandable apprehension. I consult with patients daily about those fears, and I empathize. The data highlighted in this publication from last month is that outcomes are better with earlier intervention with a preventative. It's nice to get away with no medication, but the consequence of suffering through migraines might be that your migraine disease worsens over time. Early intervention and prevention can help avoid that.

Danielle: Several months ago, we did an Instagram Live with Cannon, your director of social media, about overcoming medication anxiety. It's a significant problem. It could be because someone is hyper-vigilant about anything medical or fearful of taking any medication. We will link that in our stories.

Can you talk more about strategies besides oral medications and injections?

We've talked about devices before, but some people here might not have heard about them and why or how they might be effective.

Amy Larsen, PA-C: There are non-pharmacologic, non-medical means of treating migraine. When patients experience intractable migraine – headache pain daily – and they're not sure where they are in their episode, or it's early, and you're not sure if you want to take medication, this is the time to initiate nonpharmacological options. It doesn't preclude you from taking medication later if the pain escalates. Neuromodulation devices can be great. I always tell patients the biggest barrier is cost. They're expensive, and I wish they were more accessible because I think they can be helpful. Many have protocols to treat not only acutely but preventatively. Should you experience an attack, there's a rescue treatment. There are so many devices on the market now. The oldest one, which people may be most familiar with, is Cefaly, applied on the forehead. That one has an indication for acute and preventative treatment.

Eileen: I know many people have been trying those in the community and having good results. That's a good option. Another question is, "I'd like to treat my attacks more, but my insurance company only allows..." I'm sorry, that's not the one I wanted to ask.

Amy Larsen, PA-C: I remember that one. Quantity limits are frustrating.

Eileen: I think you already answered that one, too. Where was the one I wanted to ask? It was about ginger. Oh, I remember. I'm sorry, I've got it. "I've been trying to do a more natural approach.

How will I know when I need to use medication instead of things like ginger, ice, and aromatherapy roll-ons?"

Amy Larsen, PA-C: This goes back to what I touched on earlier: Get to know your migraine; track symptoms. This may not be predictable. For some, it's the same every episode. For others, attacks vary, so it can be challenging. I recognize that this advice isn't always easy to follow, but if you recognize your common prodrome symptoms, this is the time for early intervention. These natural, complementary approaches can be helpful because they don't preclude you from using medication later. If you do this, and within 30 minutes, within an hour, you're still having that escalation of pain, you've moved past prodrome, you're now in the headache pain phase. That's the time I wouldn't sit on treating with complementary approaches. We don't want this to progress and lead to chronification. If you have the tools, like a triptan, that's the window to take it – once that pain starts escalating. The onset of headache pain, but before that, there can be many symptoms that indicate a migraine is coming. I touched on what prodromal symptoms are, and I believe Cannon has a slide we can link for followers to look at so they can track these things. It's not always easy, but the more familiar you are with warning signs, the better you can do early intervention, which might mitigate the episode altogether. Getting into a dark room, ice packs, aromatherapy if you have tight muscle tension, a heating pad, or even a hot shower – there are a lot of different things, and they don't work for everybody, but exploring those is the first recommendation. Once the pain starts, that's when I recommend taking medication.

Eileen: Cannon has a great slide, like a circle, that talks about when to take medication. We'll try to link that in stories. It's really great. I've sent it to many people who've asked when they should take which medication.

Danielle: If you're wondering where you can see all these things, it's the @NeuraHealth Instagram account. She knows migraine and what you want to know. She works with all these wonderful resources at Neura Health and pulls together fantastic slides packed with information. She gets help from people like Amy and everyone else at Neura. They have great information. Definitely check them out and follow them. Spend some time going through the educational slides.

For people with intractable or very frequent attacks, 27-plus, or 24/7 attacks, how do you know when to use acute therapy?

Amy Larsen, PA-C: I was hoping we'd address this because it's important. Many patients experience continuous pain or continuous migraine symptoms. When that happens, it's difficult to know when the onset is. When you get an instruction like, "Take this at onset," you think, "But it's been there for years. What do I do?" The first thing I would say, from a non-acute standpoint, is that preventatives are important in treating chronic and intractable symptoms. They should make acute medications more effective and help differentiate the beginnings and ends of attacks. When you have constant, fluctuating symptoms, you have these peaks and valleys of severe intensity and milder symptoms. It's not completely gone. These patients experience headaches every day. If you have these baseline, milder symptoms, you're not starting at a zero out of 10, but maybe a two or three. In that scenario, the time to treat is when you see an escalation from your baseline. If your baseline is here, and you start feeling it creep up, and you're also experiencing other migraine features – nausea, light sensitivity, sound sensitivity, those prodromal symptoms of mood changes, sleep disturbances, etc. – that's the time to treat. You're not starting from zero; you're starting here, but you see a change, and that escalation is the recommendation. A preventative, an appropriate preventative that's working, should help differentiate the start and end of some of these. If we don't see an end, at least we see these peaks and valleys.

Eileen: That's good information. We're getting toward the end here. Danielle, do you have another one you want to ask?

Danielle: Since we're talking about under-treatment – and this is not medical advice, and you're not telling this person to go against their doctor's advice – they're asking for feedback.

"My doctor recommends I take 50 milligrams of triptan, wait an hour, and then take 50 more. Is waiting to take the second dose making it worse?"

Amy Larsen, PA-C: I think the spirit of this recommendation is just trying to get away with the least medication possible, to mitigate potential side effects because triptans can have adverse effects. The spirit of this isn't necessarily wrong. However, my question is: Is 50 milligrams sub-therapeutic? Does it treat your symptoms? How often are you needing to redose after two hours? If the answer is, "It never works; I always have to do that," then what we're experiencing is prolonged inflammation during that attack. We're waiting, and that prolonged inflammation sets off that nerve more and more. That's what leads to chronification. Taking a lower dose isn't wrong unless it's ineffective. If it's ineffective, we need to explore other options. Sometimes that means a different acute medicine; sometimes, it means a higher dose. It depends on the dosage and medication.

Danielle: I think we've gotten through just about all the questions without repeating. I'm scrolling through. I think we got to that one. I can't always see the questions that come up.

Eileen: Rebecca wants to know about Tylenol.

Where does Tylenol fit into this treatment scenario? Is it rebound-associated?

Amy Larsen, PA-C: Tylenol is in the category of simple analgesics. It blocks a pain receptor. The challenge is it is associated with rebound, and migraine, as an inflammatory process, is better addressed with an NSAID. Not everyone can take an NSAID, so sometimes Tylenol is recommended as another option. But it's limiting because we can't use it too often. Tylenol will rebound if used more than – the data is about – 10 to 12 days a month. There may be safer options that are more effective than Tylenol. It's not a wrong medication, but the quantity and how often are things to discuss with your provider.

Danielle: I think we have time for one more. This came in during the live.

"If you take an NSAID first, would you potentially miss the early window for treating with a triptan?"

Amy Larsen, PA-C: Not necessarily. If you do early intervention with an anti-inflammatory, there's no contraindication to taking a triptan later, provided you can safely take NSAIDs. If you can safely take NSAIDs, you take it early. That doesn't mean you can't take a triptan later. The NSAID might mitigate symptoms enough that you don't need to. The earlier you take an anti-inflammatory to try and mitigate these symptoms, the more wiggle room you have to see if it helps before you take a triptan. Once headache pain starts escalating, that's when we recommend taking a triptan. This is about becoming more familiar with those early symptoms and signs.

Danielle: That's super helpful because everyone has questions about timing. What do I do? Here's my toolkit; which do I pick to treat, and when? Thank you so much. We can't thank you enough for your time and information to help people.

Amy Larsen, PA-C: If you can share that publication, it's not too wordy. It can be helpful in defining and guiding what we see with medication underuse. Untreated, ineffective acute medications can lead to more attacks. It's important to discuss with your provider any concerns regarding side effects or efficacy to find the right regimen.

Danielle: If you have someone you have confidence in – and I think everyone here feels like Amy is quite an expert – if you feel like you don't get the expertise you need, consider contacting Neura Health. There might even be a way of special requesting someone like Amy. Please consider contacting Neura if you don't have the local support or expertise you need to get to the next level of migraine management. Thank you again. We look forward to talking to you again.

Amy Larsen, PA-C: Thank you for your time.

Eileen: We appreciate it.

Amy Larsen, PA-C: Take care.

Eileen: Bye-bye.

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Amy Larsen, PA
Amy Larsen is a Neurology Physician Assistant, where she treats headache, concussion, stroke, tremor and other neurological conditions.
About the Author
Amy Larsen is a Neurology Physician Assistant specializing in headache medicine based in Washington state. She began her career in general neurology in Michigan, seeing a range of neurologic conditions. In this practice, she took on a role of acute headache management administering infusions and nerve block procedures for acute migraine and other headache pain. She then moved to Seattle and worked several years as a neurosurgical PA, as first assist for all cranial and spinal procedures and managing/working in a neuro ICU. Within this practice, she moved to a hybrid role with a focus in outpatient headache medicine and inpatient stroke and endovascular care. She was named in SeattleMet’s “Top Docs”, a list of the best health care professionals in the Seattle area in 2019. She graduated from Idaho State University with a Master of Physician Assistant Studies degree. She is a member of the American Academy of Neurology and the American Academy of Physician Assistants.

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