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.
- The most common is called migraine without aura (common migraine),
and this accounts for about eighty-five percent of all sufferers.
People who experience migraine without auras have episodes of
severe pain that usually affect only one side of the head. (The
name "migraine' comes from the Greek "hemicranin,"
meaning half a head.) Although they may be bilateral, the headache
is usually described as throbbing, although again this is not
invariable. The signature of these headaches is that they are
usually associated with feeling sick in the stomach or being sensitive
to light, sound, or even any sudden movement of the body. The
sufferer usually wishes to avoid all environmental stimuli and
wishes to lie down in a dark and quiet room, waiting for the storm
to pass.
- The second most common type is called migraine with aura (classical
migraine). This accounts for most of the remaining fifteen percent
of sufferers. In this type of migraine, the sufferer will often
report some disturbance in the nervous system before the headache
begins. Typical disturbances involve the vision with bright flashing
lights, black spots, or partial loss of vision. There may also
be some numbness and tingling over one side of the body. These
disturbances are usually short-lived, being less than one hour
for most sufferers, and they usually leave no long-term effects.
Much has been written about the migraine aura and the various
neurologic symptoms that may be associated with it. Anything from
speech and language disturbance, inability to calculate, mild
confusion, severe dizziness, and even abdominal pain in children
have all been associated with migraine. The headache phase of
the bout follows the aura and varies from mild discomfort to intense
and disabling pain. The head pain can last from a few hours to
several days, but it persists for less than a day in most people.
The one-sided nature of the pain has already been mentioned, but
do remember that migraine head pain is one-sided in only sixty
to seventy percent of patients. The pain may be bilateral at the
onset of the attack, or begin on one side and then become generalized
as the bout continues.
In patients with one-sided pain, the side affected in different attacks
may vary or may be invariably on the same side in each attack. The
pain is usually located in the front or side of the head, or in, around,
or behind the eye. But any region of the head and face may be affected,
including the side of the head and the back of the head, and even
the jaw and teeth may be all involved. Many patients state, "It
is my sinuses," because the pain is located in the middle of
the face. Rest assured that in the vast majority of cases it is not
"sinusitis," but rather the pain of migraine being "referred"
to different regions of the head and neck. It would be just as foolish
for someone complaining of a heart attack to go to an orthopedic surgeon
because the left arm is painful, as it would be for a migraine sufferer
to go to an ENT because the front of the face hurts or go to a dentist
because there is pain in the teeth.
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.
- HEREDITY - There is no doubt that heredity plays a major role.
A family history of migraine can be elicited in seventy to eight
percent of patients with this disorder. However, having the genetic
predisposition does not mean that one is condemned to having frequent
attacks. Other factors come into play, both internal and external.
Let us take a look at external.
- EXTERNAL FACTORS - There are external factors that can precipitate
migraine in those who are genetically vulnerable. The extensive
literature on migraine refers to an almost inexhaustible list
of stimuli in the external environment that can bring on an attack
of migraine. We will look at some selected examples.
- DIET: A wide variety of foods can lead to an attack of migraine
in selected individuals. Chocolate, cheese, fried and fatty
foods, oranges, and tomatoes are the ones most frequently
implicated. Monosodium glutamate, which is usually added to
Chinese food, causes headaches, "the Chinese restaurant
syndrome." The nitrates and nitrites in precooked meats,
such as hot dogs, salami, etc., can lead to headaches, "the
ballpark syndrome." Red wine is another important trigger,
as are other forms of alcohol. Red wine especially contains
tannins; these are substances found in the skin of the grape
that gives red wine its distinctive color. Some say the cheaper
the red wine, the more likelihood that one will experience
headache!
Over the course of the years, we have heard our patients implicate
every possible food substance as a cause for migraine. A word
of caution: Migraine is an unpredictable and whimsical disorder.
People cannot tolerate its unpredictability and so we try
to blame "the last thing we ate" as the cause of
our discomfort. However, it is counterproductive to obsess
about diet. Many of our patients become quite obsessed about
this, and they waste a good deal of time and valuable energy.
My advice to the headache sufferer is if you find a clear-cut
connection between a certain food and headache, then avoid
that particular foodstuff. If not, do not spend hours agonizing
over what food might have triggered the headache. Avoid especially
those bogus allergy tests "out there" which try
to tell you which food you might be allergic to. Otherwise,
you will discover another trigger to your headache, fraud.
- HUNGER: Especially in the young migraine sufferer, attacks
of headache may occur after missed meals. It is suspected
that hypoglycemia is a major trigger in such headaches. Migraine
sufferers should always try to avoid prolonged fasting.
- CLIMATE: The frequency of migraine attacks often increases
in humid and hot weather. A few patients claim that any change
in the weather will invariably precipitate a headache. When
the Santa Ana winds blow in Southern California, many patients
experience a surge in their headache frequency and intensity.
The precise connection is not clear.
- BRIGHT LIGHT: Sensitivity to glare appears to be very prominent.
Some patients wear sunglasses all of the time. A small number
of patients report that flickering lights from a movie or
TV screen can provoke a headache.
- INTERNAL FACTORS
- STRESS: Though migraine is not a psychologic illness, stress
and excitement are the most common precipitants, not only
for a single attack, but also for a temporary increase in
frequency and severity of the headache. In our society, we
are very resistant to the notion that stress or "psychologic
factors" have any role to play in the causation of headache.
Many assume that if this is the case, then the migraine patient
is "weak" or "mentally unstable." Nothing
could be further from the truth. Stress in all of its forms
causes definite changes in the body, be it tightening of the
muscles, constriction of blood vessels, increased acid flow
to the stomach, etc. These physiologic changes can lead to
marked discomfort. It is also important to note that not only
"bad stress" can cause headaches. It is not unusual
for children with migraine to suffer an attack before a pleasant
experience, such as a party. Here a pleasant anticipation,
rather than worry is a sufficient stimulus.
There is another phenomenon commonly seen in migraine, the so-called
"let-down or holiday migraine." A number of people experience
headaches mainly during periods of relaxation. They will predictably
have an attack every Saturday or Sunday, particularly if the preceding
week was stressful and not all of their set goals and ambitions could
be achieved. It is not uncommon to see migraine sufferers heading
for vacation and stacking one corner of their suitcases with medications,
knowing they are about to get hit with a siege of migraine.
- HORMONES: Migraine occurs four times more often in females than
in males. Although migraine headaches are more common in young
boys than in young girls, the number of girls affected increases
sharply after onset of menstruation. It seems clear that certain
hormonal changes that occur during puberty and growth, and remain
throughout adulthood, are implicated in the triggering and frequency
of migraine attacks in women. There is little doubt that the rise
and fall of serum estrogen is one of the major precipitants for
migraine attacks. This "unstable estrogen milieu" is
one of the main reasons why so many women are victims to this
disorder. About eighty percent of women report worsening of their
attacks immediately before, during, or after their menstrual period.
There are also a small percentage of patients, approximately ten
to twelve percent, who experience attacks only at the time of
their menses.
- 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.
- 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.
- 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:-
Sinuses are often cited, but it is rare that sinus disease
is a cause for headache.
- Allergies and the link to migraine are extremely unclear at
best. We do not advocate prolonged desensitization as a treatment
for migraine.
- Temporomandibular joint disturbance may, indeed, cause localized
pain but rarely, if ever, is it a significant factor in recurrent
migraine attacks throughout a person's life.
- 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.
- 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.
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.
- 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 a particular
sufferer abstains from alcohol, eliminate chocolate, stops birth
control pills, gets adequate sleep, or keeps a regular diet.
- 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.
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.
- Pharmacologic treatment - There are three levels of drug treatment
for migraine: prevention, treatment of the acute attack, and symptomatic
treatment.
- 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.
- 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 four triptans available, and we expect others to
be rolling off the production belt in the next year or two. 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."
-
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
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