Headache Hell?

Graphic descriptions like these are common among migraine sufferers. Migraines, also known as vascular headaches because blood vessels in the brain dilate, are usually intense and incapacitating with pulsating pain on one half of the head. Often nausea, vomiting, light intolerance and/or sensitivity to sound accompany the pain. Once the attack is full-blown, many people also find anything touching their head to be painful. Migraines usually last from four to 72 hours.

Most migraines fall into two categories: 1) classic migraines are associated with an aura (unusual visual, olfactory or other sensory experiences that are a sign that the migraine will soon occur); 2) common migraines have no aura.

How common are migraines?
According to the National Headache Foundation, more than 29.5 million Americans suffer from migraine, with women being affected three times more often than men. It is most commonly experienced between the ages of 15 and 55, and 70 percent to 80 percent of sufferers have a family history of migraine. Fewer than half of all migraine sufferers have received a diagnosis of migraine from their health care provider. It is often misdiagnosed as sinus headache or tension-type headache.

What causes migraines?

According to the Mayo Clinic, the cause of migraines isn’t understood, but genetics and environmental factors both seem to play a role.

Whatever the exact mechanism of the headaches, a number of things may trigger them. Local allergy/immunology specialist Paul H. Ratner, M.D., has specialized in migraines for the past 15 years. He says any of the following may be triggers:

Allergic reactions
Bright lights, loud noises and certain odors or perfumes
Physical or emotional stress
Changes in sleep patterns
Smoking or exposure to smoke
Skipping meals
Menstrual cycle fluctuations, birth control pills, hormone fluctuations during the menopause transition
Tension headaches
Foods containing tyramine (red wine, aged cheese, smoked fish, chicken livers, figs and some beans), monosodium glutamate (MSG) or nitrates (like bacon, hot dogs and salami)
Other foods such as chocolate, nuts, peanut butter, avocado, banana, citrus, onions, dairy products and fermented or pickled foods
Long exposures to light from computer screens, video screens and TV screens
Some medications
Often migraine sufferers are encouraged to keep a headache diary as a way of identifying triggers. For some, simple lifestyle changes such as nixing caffeine or sticking to a regular sleep regimen can reduce the number of migraines they experience.

Ironically, half of chronic migraines, and as many as 25 percent of all headaches, are actually “rebound” episodes triggered by the overuse of common pain medications, says an article in The New York Times. Both prescription and over-the-counter drugs may be to blame. The only way to know whether medication is contributing to your headaches is to stop taking it. Unfortunately, it can take as long as two months for medication-dependent patients to see an improvement.

Migraine sufferers seem to be especially susceptible to rebound episodes. Many doctors begin weaning these patients off painkillers by prescribing drugs to help prevent attacks, then gradually reducing doses of the painkillers used to treat acute episodes.

Prevention without drugs
The June 2010 issue of the journal Neurological Sciences reported on the efficacy of various non-pharmacological approaches to migraine prevention:

Acupuncture, a therapy used for more than 3,000 years, is effective and should be considered for people with frequent or insufficiently controlled migraine attacks. Among vitamins and other supplements, riboflavin and coenzyme Q10 significantly decreased the frequency of migraine attacks. The prophylactic efficacy of magnesium, particularly for children and menstrually related migraine, has recently been substantiated.

Among the herbal remedies:

Butterbur significantly decreases attack frequency.

Feverfew was not confirmed as effective, probably because of the 400-percent variations in the dosage of its active principle.

Ginkgolide B has proved significantly effective in controlling migraine with aura and pediatric migraine in uncontrolled studies that need a confirmation.
New research is raising concern about people who might unknowingly use migraine medicines along with popular herbal remedies like ginseng, ginkgo biloba and St. John’s Wort. “I think anyone who is using St. John’s Wort needs to bring that to the attention of their physician,” says Dr. Sarah DeRossett, a neurologist and headache specialist. St. John’s Wort, when taken with prescription antidepressants that are good for preventing migraine headaches, can dangerously magnify the effect of that medication and create a toxic reaction.

“And the result of this could be serious, even fatal,” stresses Dr. DeRossett.

Also, there is some concern that certain herbs, including gingko and even valerian root, which is used as a sleep aid, will actually cause or worsen migraine headaches. “The nonprescription preventives are not going to be as effective as prescription preventives,” she says. “And you have to worry about the fact that they are not under FDA regulation.”

Of course, people suffering from chronic migraine should seek medical advice from neurologists or headache specialists to ensure proper diagnosis and care.

Prevention with drugs

People who have frequent or chronic attacks and can’t find a pattern or trigger(s) for their migraines often need prophylactic drugs. Nearly half of those who get migraines could benefit from preventive medication, yet only about one in 10 people take it. You may be a candidate for preventive therapy if you have two or more debilitating attacks a month, if pain-relieving medications aren’t helping, or if your migraine signs and symptoms include a prolonged aura or numbness and weakness.

Classes of preventive medications include:

Cardiovascular drugs — Beta blockers and calcium channel blockers may be helpful in preventing migraines. Researchers don’t understand exactly why some cardiovascular drugs prevent migraines. Side effects can include dizziness, drowsiness or lightheadedness.

Antidepressants — Most effective are tricyclic antidepressants. These may reduce migraines by affecting the level of serotonin and other brain chemicals. You don’t have to have depression to benefit from these drugs. Other classes of antidepressants called selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) haven’t been proven as effective for migraine prevention. However, preliminary research suggests that one SNRI, venlafaxine (Effexor), may be helpful in preventing migraines.

Anti-seizure drugs — Some anti-seizure drugs seem to reduce the frequency of migraines. In high doses, however, these anti-seizure drugs may cause side effects such as nausea and vomiting, diarrhea, cramps, hair loss and dizziness.

Cyproheptadine — This antihistamine specifically affects serotonin activity. Doctors sometimes give it to children as a preventive measure.

Several drugs have been approved to prevent migraines. The most recent is topiramate (Topamax), which, studies suggest, may lessen the frequency of attacks for up to 14 months. In addition, early trials suggest that Botox injected into the scalp can prevent or reduce the frequency of both migraines and tension headaches.

Although not yet approved by the Food and Drug Administration for headaches, botulinum toxin is being offered by a growing number of headache clinics. When it works — which is by no means certain— it can provide relief for up to three months.

Coping with the pain

Dr. Ratner says approximately one-third of people who suffer from migraine headaches perceive an aura, a warning sign a migraine will soon occur. Treating a migraine early can make the difference between agonizing pain in a dark room for who-knows-how-many hours or continued ability to function. Whether you get kaleidoscope eyes or neck tension, taking pain-relieving drugs as soon as you experience signs or symptoms of a migraine may preempt a full-blown attack.

Quinn Baker, a local tax attorney at Cox Smith, has been getting migraines for about 10 years, starting in his early 20s. “I take Excedrin Migraine™, and if it’s not too late in the day, I will drink a Coke for the extra caffeine,” says Baker. “I try to keep the room as dark as possible and avoid reading or looking at a computer or TV.”

Dr. Ratner agrees with Baker’s approach, saying the first line of treatment is over-the-counter abortive medication. “Some non-steroidal anti-inflammatory drugs (NSAIDs) can effectively alleviate migraines,” he says. “Most notably, a randomized controlled trial found that naproxen can abort about one-third of migraine attacks, which was 5 percent less than the benefit of sumatriptan (Immitrex).” He also notes research trials have consistently found a 1000-mg dose of aspirin can relieve moderate to severe migraine pain, with similar effectiveness to sumatriptan.

Simple analgesics combined with caffeine may help (e.g. Excedrin). “During a migraine attack, emptying of the stomach is slowed, resulting in nausea and a delay in absorbing medication,” explains Dr. Ratner. “Caffeine has been shown to partially reverse this effect. Even by itself, caffeine can be helpful during an attack, despite the fact that in general migraine sufferers are advised to limit their caffeine intake.”

Those with severe, debilitating migraine attacks often require a “rescue” drug. Triptans are the drug of choice. They are effective in relieving the pain, nausea and sensitivity to light and sound that are associated with migraines.

Although the triptan drugs provide effective relief for many people, a substantial number don’t respond to these compounds. A new class of antimigraine drugs is on the horizon, one of which is Telcagepant. It appears to be just as effective as the triptans but without the side effects of vasoconstriction.

Another new migraine therapy from MAP Pharmaceuticals called LEVADEX is in Phase 3 development. Administered via an oral inhaler, it is designed to be fast acting and easy to use with sustained pain relief.

Old-fashioned coping strategy

Of course, you can always take Jennifer Juergens’ advice and self-medicate the old-fashioned way. “When I feel a migraine coming on, I have a giant glass of scotch and lots of water,” she laughs. “The liquor constricts the blood vessels, and I don’t get the headache. Of course, the next day I have a bit of a hangover — but it’s worth it not having the terrible pain!”

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