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Migraine | |
| INTRODUCTION Migraine is a severe episodic headache that affects about six percent of men and about eighteen percent of women - over 28 million people in the United States! Over eighty percent of these people suffer some degree of headache-related disability. In the United States, the estimated annual cost, including costs of direct medical care and lost productivity, exceeds $17 billion annually. We know that the disorder is at least four thousand years old as evidenced by allusions in ancient medical texts. Julius Caesar was a member of the migraine club, scholars believe; so were author Virginia Woolfe, former first lady Mary Todd Lincoln and Elvis Presley. So is Dr. Klein. In practice, there are, broadly speaking, two common types of migraine.
Migraine pain is typically diminished by lying or sitting still and is increased by any activity or effort, or by any active or passive head movement. As mentioned, intolerance of light, known as photophobia, and intolerance of noise, known as phonophobia, are the most frequent symptoms accompanying the head pain. Approximately ninety percent of patients experience nausea, and vomiting affects about fifty percent. Other gastrointestinal symptoms are common and include lack of appetite, diarrhea, constipation, abdominal distention, and cramps. Other patients complain of blurry vision, facial pallor, nasal congestion, cold and clammy hands and feet, etc. Many migraine sufferers will have changes in their psychological and mental state during an attack. Many will feel depressed, hostile, and irritable. Some will feel lethargic or sleepy. Minor cognitive changes are common, including an inability to concentrate, poor memory, and difficulty with abstract thought. Fortunately, in most sufferers the pain diminishes over a period of hours, and many attacks are actually aborted or concluded by sleep. Some patients will have a period after the attack where they may feel "washed out" and listless, although a lucky few actually will experience feelings of intense euphoria. FACTORS INVOLVED IN MIGRAINE The underlying cause of that brain-squall called migraine is still a matter of speculation. The chiropractor finds that it's one disc slipping on another; the allergist thinks it's an allergy, the orthopedist thinks it's in your neck, the ophthalmologist thinks it's your eyes, and the ear-nose-throat doctor is convinced it's all sinusitis. But a growing number of neurologists now believe that migraine is an inherited hypersensitivity in the brain to certain sights, sounds, smells and other cues. In several recent studies, researchers have used imaging techniques to watch what happens in the visual area of the brain when migraine sufferers stare at mesmerizing patterns, such as a checkerboard. Sure enough, their visual cortexes light up, much more so than those of non-migraineurs who stare at the patterns. This neural activity appears to signal the blood vessels feeding the brain to dilate, igniting the pain. What we think is happening is that there is a general threshold problem; that anybody is susceptible to a migraine at some point in their lives, but those who get them regularly have a lower threshold, a hyper-excitability of the cortex. What pushes them over that brink, neurologists say, is most often a combination of specific migraine triggers--bright lights, loud noises, coursing hormones--and the more familiar stresses of modern life, such as work pressure, lack of sleep and ornery kids. For example, a woman may be able to skip a meal, and eat a chocolate bar, both of which are triggers for her, and be fine. But if she does that during her period--wham.
PREGNANCY: Pregnancy also influences migraine. In the female patient with migraine, about seventy percent find that their attacks disappear completely or are much milder during pregnancy, especially in the last six months when the estrogen level remains at a fairly fixed, high level. Naturally, as soon as the baby is born and estrogen levels fall, there may very well be a recurrence of migraine. ORAL CONTRACEPTIVES: Oral contraceptives also affect the incidence of migraine attacks, but the relationship is far from clear, especially in the newer forms with lower estrogen content. Approximately one-third of women will say they get better, one-third will say they get worse, and one-third remains the same. In fact, the same is true for virtually any form of hormone replacement, including hormone replacement therapy in menopause. More information is available regarding this complex topic in the section entitled "Headaches and Hormones. C. PHYSICAL AND MENTAL EXHAUSTION: Some patients state that their attacks are temporarily related to excessive fatigue which can results either from prolonged physical exertion or mental and intellectual performance. This is the opposite to the more common occurrence of migraine during times of relaxation. It is well known that in children migraine occurs frequently in association with intense physical activity. Some patients report intense headache associated with sexual intercourse. Yet others in a recent study found that orgasm relieved their headaches! All of this information implies a further example of the multiplicity of events that alone or in combination with other triggers can push susceptible individuals beyond the brink of their limits of tolerance and result in migraine headaches. D. SLEEP: Weekend or vacation migraines frequently occur when the patient sleeps in. The history provided by such patients indicates that headache appear after arising late in the morning and not after an equal duration of sleep if the patient retired to bed early. The physician should always seek the specific trigger for weekend headaches because the patient can easily avoid attacks by getting up as early on the weekends as on working days. Sleep plays an important role in all kinds of headaches, including tension headache and cluster headache. Researchers are still seeking the precise relationship between sleep and different types of headache. MYTHOLOGY AND MIGRAINE Many migraine sufferers will attribute their migraine headaches to the following: 1. Sinuses are often cited, but it is rare that sinus disease is a cause for headache. 2. Non-food allergies and the link to migraine are extremely unclear at best. We do not advocate prolonged desensitization as a treatment for migraine. 3. Temporomandibular joint disturbance may, indeed, cause localized pain but in our experience are unlikely to be a significant factor in recurrent migraine attacks throughout a person's life. 4. It is unlikely that eyestrain is a major factor in triggering migraine. This does not stop the migraine sufferer, however, from having many frequent visits to the optometrist. 5. High blood pressure is often cited, and many people feel that when their pressure is elevated, they get headaches. But this is far from certain. Hypertension was once called the silent killer." If it led to significant headaches, probably more patients would receive treatment. There is probably little relationship between high blood pressure and headache. SUMMARY We have only scratched the surface of the complex story of migraine. It is a complex jigsaw puzzle with many pieces. Migraine headache may be precipitated by eating a hot dog at a ballpark or may occur after a prolonged period of stress either at home or at work. Adding to the complexity is the fact that the same triggers may not always provoke the headache on every occasion, leaving the patient and the doctor groping for solutions. Just like pieces of a jigsaw puzzle that keep changing shape! INVESTIGATIONS No objective test is currently available that can be used either to make or confirm the diagnosis of migraine. Because of this, laboratory tests are superfluous for most migraine sufferers. On a routine basis, CT, MRI, and EEGs do not appear to be cost effective procedures for the routine screening of patients with migraine headaches who have normal physical examinations. Naturally, if there is anything unusual or "atypical," then an appropriate study will be requested. Study regarding the link to food sensitivities, inflammatory chemicals called cytokines, and migraines are ongoing. PROGNOSIS Migraine is a lifelong disorder, but with appropriate management, the condition of more than ninety percent of patients can be improved dramatically. A subgroup of migraine sufferers may be afflicted with the so-called chronic daily headache syndrome that evolves from migraine. There are many reasons for this, including mood disturbance and over-usage of medications. Occasionally, a patient will develop what we call "status migrainosis." This is the term applied to ceaseless bouts of migraine lasting for more than three days. These attacks are often resistant to the usual pain medicines and are associated with prolonged vomiting and dehydration. They may require hospitalization for correction of dehydration and pain relief. Extended attacks of this nature may be triggered by severe emotional stress, misuse of medications, such as ergot, pain medicines, and narcotics, and dietary indiscretions, etc., etc. Fortunately, these savage bouts of pain are few and far between. Long-lasting or permanent neurologic damage is extremely uncommon in migraine, but every once in a while it will happen, the so-called "migrainous infarction." Mostly it occurs in young people who have migraine with aura, especially those with neurologic symptoms such as weakness, numbness, or tingling. The risk of migraine stroke is, indeed, very low, but it is increased in patients who use oral contraceptives or who smoke. MANAGEMENT OF MIGRAINE The management of the migraine sufferer consists of several components. 1. Elimination of trigger - An ounce of prevention is better than a pound of cure. Determination and elimination of trigger factors is fundamental for effect migraine management. As we just mentioned, headaches may be prevented if you know what foods or food additives to avoid, or if a particular sufferer abstains from alcohol, eliminate chocolate, stops birth control pills, gets adequate sleep, or keeps a regular diet. 2. Non-pharmacologic methods - These methods are very important and include strategies such as biofeedback, relaxation training, conventional psychotherapy, and a daily exercise program. These are invaluable in controlling migraine. No one way is superior to another. A great deal depends upon the patient's belief system and cultural bias. Acupuncture may work best for one person, and yoga for another. Modification of lifestyle, reduction of stress, and elimination of triggers is of huge importance in the management of this condition. A practical approach to the headaches focuses more on quality of life than on batteries of medication and diagnostic testing. Because migraine sufferers are extremely sensitive to even small changes in their routine, become a creature of habit. If possible, eat at least three squares a day, keeping regular mealtimes. It's more how and when you eat than what, and making sure not to skip meals. A "natural" supplement of magnesium, riboflavin and the herb feverfew may help some people, and may certainly be worth a try. Try to go to bed and wake up at the same hour each day too, because sleep disturbance put you in a danger zone. Migraineurs are horrible at adapting to any change in sleep patterns, or circadian rhythms. Jet lag is a big problem. Even napping is potential disaster. Many migraines strike on Saturday and Sunday mornings, after the chaos of the work or school week has passed, which explains another taboo-no sleeping in on the weekends. Exercise has become holy ritual for many afflicted headache patients. You need time out, away from your job, doing some aerobic activity. Almost anything that tweaks the body's equilibrium is a source of concern. 3. Pharmacologic treatment - There are three levels of drug treatment for migraine: prevention, treatment of the acute attack, and symptomatic treatment. A. Prevention - Over the years, it has been discovered, often by chance, that certain families of medications may reduce the frequency and intensity of migraine attacks. High blood pressure medications, such as beta-blockers or calcium channel blockers may be useful. The older family of tricyclic antidepressants has been found to be quite effective. Even certain anti-epilepsy drugs, such as Depakote, may also prove very beneficial. These are reviewed under a separate section. B. Treatment of the acute attack - Seven or eight years ago, the only "migraine-specific agent" we had was ergotamine. Ergot was derived from a fungus on rye and is a very potent constrictor of blood vessels. For years it was used in multiple forms, including injectable, suppository, oral, and sublingual forms. Unfortunately, the side effects were many because the drug has multiple effects in the body. In the early 1990s the "triptans" arrived. Sumatriptan (Imitrex) was the first of these compounds to be released onto the market. There are now a total of six triptans available, in pills, nasal sprays and injection. The mode of action of all of these medications is very similar. Specifically, they squeeze or tighten the dilated blood vessels, thus reducing the pain of migraine headache. Most of these drugs are described in greater detail in the segment called "The Triptans." C. Symptomatic relief - Narcotics, analgesics, and sedative drugs are available when preventative and acute therapies fail. They should be used for a maximum of two to three days per week. At this juncture it is appropriate to again state the following: Any "acute" therapy, including the triptans, if over-used can lead to the phenomenon of rebound headache. Jeffrey F. Klein, M.D., F.A.A.F.P. 1220 La Venta Drive, Suite 201 Westlake Village, CA 91361 805-381-2853 Fax 805-371-9117 http://www.familydoc-klein.com |
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