* Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does not advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is very detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.
Migraine
Headaches
WHAT
IS HEADACHE?
General
Definition of Headaches
The brain itself
is insensitive to pain. Headache pain occurs in the following locations:
- The tissues
covering the brain.
- The attaching
structures at the base of the brain.
- Muscles
and blood vessels around the scalp, face, and neck.
Headache is generally
categorized as primary or secondary.
Primary Headache. A headache is considered primary when
a disease or other medical condition does not cause it.
- Tension
headache is the most common primary headache and accounts for
90% of all headaches.
- Vascular
headaches are the second most frequently occurring primary headaches.
Such headaches are caused by blood vessel abnormalities and
constitute about 8% of all headaches. Migraine has been considered
the most common vascular headache since the 17 th
century. In the past few decades, however, evidence has strongly
suggested that it is a much more complex brain disorder, which
involves a complicated interaction of nerve cells and blood
vessel dilation.
Secondary
Headache. Secondary headaches are caused by other medical conditions,
such as sinusitis infection, neck injuries or abnormalities, and
stroke. About 2% of headaches are secondary headaches caused by
abnormalities or infections in the nasal or sinus passages (sinus
headaches). [ See Box Causes of Secondary
Headache.]
It is not uncommon for someone to experience a combination of headache
types.
Migraine
Headaches: General Description of its Course
Migraine is now
recognized as a chronic illness, not simply as a headache. In general,
there are four symptom phases to a migraine (although they may not
all occur in every patient): the prodrome, auras, the attack, and
the postdrome phase.
Prodrome. The prodrome phase is a group of vague symptoms
that may precede a migraine attack by several hours, or even a day
or two. Such prodrome symptoms can include the following:
- Sensitivity
to light or sound.
- Changes
in appetite.
- Fatigue
and yawning.
- Malaise.
- Mood changes.
- Food cravings.
Auras. Auras
are sensory disturbances that occur before the migraine attack occurs.
Although some studies estimate that up to half of migraine sufferers
have auras, some recent evidence suggests that only about 20% experience
them. Visually, auras are referred to as being positive or negative.
- Positive
auras include bright or shimmering light or shapes at the edge
of their field of vision called scintillating scotoma .
They can enlarge and fill the line of vision. Other positive
aura experiences are zigzag lines or stars.
- Negative
auras are dark holes, blind spots, or tunnel vision (inability
to see to the side).
- Patients
may have mixed positive and negative auras. This is a visual
experience that is sometimes described as a fortress with sharp
angles around a dark center.
Other neurologic
symptoms may occur at the same time as the aura, although they are
less common. They include the following:
- Speech
disturbances.
- Tingling,
numbness, or weakness in an arm or leg.
- Perceptual
disturbances such as space or size distortions.
- Confusion.
Migraine Attack.
If untreated, attacks usually last from 4 to 72 hours. A typical
migraine attack produces the following symptoms:
- Throbbing
pain on one side of the head. The word migraine, in fact, is
derived from the Greek word hemikrania, meaning "half
of the head"; because the pain of migraine often occurs on one
side. Pain also sometimes spreads to affect the entire head.
- Pain worsened
by physical activity.
- Nausea,
sometimes with vomiting.
- Visual
symptoms.
- Facial
tingling or numbness.
- Extreme
sensitivity to light and noise.
- Looking
pale and feeling cold.
[For a more detailed
description see Box Definitions of
Classic and Common Migraine Attacks.]
Postdrome. After a migraine attack, there is usually a postdrome
phase, in which patients may feel exhausted and mentally foggy for
a while.
|
Definitions of Classic and Common Migraine Attacks
Migraines
are defined by whether auras accompany them or not:
- Classic
migraines are those with auras.
- Common
migraine s are without auras.
A person
may experience one or the other at different times.
Migraines without Auras (Common Migraine)
Definition
of Migraine Without Auras. To be defined as a migraine
without aura, a patient should have at least five attacks
that have the following characteristics:
A. Each untreated, or unsuccessfully treated, attack must
last four to 73 hours.
B. It must have at least two of the following four qualities:
-
Pain on one side of the head.
-
Pulsing or throbbing pain.
-
The pain must be severe enough to impair or prevent daily
activities.
-
The pain must be intensified by exertion, such as walking
up stairs.
C. During
a headache at least one of the following symptoms also be
present:
-
Nausea, vomiting or both.
-
Sensitivity to light and noise.
In addition,
other neurologic or medical conditions that might be causing
this pain must be ruled out or if they occur, they are not
related in time to the suspected migraine.
Migraines with Auras (Classic Migraine)
Definition
of Migraines with Auras. To be defined as a migraine with
aura, the patients must have at least two attacks that have
three out of four of the following events.
-
One or more fully reversible aura symptom suggests to
the physician that they originate in the cerebral cortex
or brain stem.
-
At least one aura symptom develops gradually over more
than four minutes or two or more aura symptoms occur in
succession.
-
No single aura symptom lasts more than an hour. (There
may be successive aura symptoms, however, that extend
that time, but each one should not last more than 60 minutes.)
-
The headache itself may begin before, at the same time,
or at an interval of no more than an hour after the hour.
As with
common migraines, other neurologic or medical conditions that
might be causing this pain must be ruled out or if they occur,
they are not related in time to the suspected migraine.
|
Other Migraine Variations
Although migraine
is considered to be a specific chronic illness, it has a number
of various presentations that occur in different individuals.
Ophthalmoplegic Migraine. This very rare headache tends
to occur in younger adults. The pain centers around one eye and
is usually less intense than in a standard migraine. It may be accompanied
by vomiting, double vision, a droopy eyelid, and paralysis of eye
muscles. Attacks can last from hours to months. A CT or MRI scan
may be needed to rule out an aneurysm (a rupture blood vessel) in
the brain.
Retinal Migraine. Symptoms of retinal migraine are short-term
blind spots or total blindness in one eye that lasts less than an
hour. A headache may precede or occur with the eye symptoms. Sometimes
retinal migraines develop without headache. Other eye and neurologic
disorders must be ruled out.
Basilar Migraine. Considered a subtype of migraine with
aura, this migraine starts in the basilar artery, which forms at
the base of the skull. It occurs mainly in young people. Symptoms
may include vertigo (the room spins), ringing in the ears, slurred
speech, unsteadiness, possibly loss of consciousness, and severe
headaches.
Familial Hemiplegic Migraine. This is a very rare inherited
genetic migraine disease. It can cause temporary paralysis on one
side of the body, vision problems, and vertigo. These symptoms occur
about 10 to 90 minutes before the headache.
Status Migrainosus. This is a serious and rare migraine that
is so severe and prolonged that it requires hospitalization.
Menstrual Migraines. About half of women with migraines
report an association with menstruation. Experts believe, however,
that true menstrual migraines are less common than thought.
True menstrual migraines tend not to have auras and to increase
in prevalence between two days before and five days after the onset
of their period.
Persistent
Migraines
In some cases,
migraine patients eventually experience on-going and chronic headaches.
They may be caused by the following conditions.
Rebound Headache. The most common cause of chronic migraine
is the so-called rebound effect, which is a cycle caused by overuse
of migraine medications. The process involves the following:
- Patients
typically have taken pain medication for more than three days
a week on an ongoing basis.
- When the
patients stop taking them, they experience a rebound headaches.
- They start
taking the drugs again.
- Eventually
the headache simply persists and medications are no longer effective.
Medications implicated
in rebound migraines include simple painkillers (eg, acetaminophen,
aspirin, ibuprofen), barbiturates, sedatives, narcotics, and migraine
medications, particularly those that also contain caffeine. (Heavy
caffeine use can also cause this condition.)
Transformed Migraines. In some cases, migraines themselves
evolve into chronic, daily headaches called transformed migraines.
Such headaches resemble tension headaches but are more likely to
be accompanied by gastrointestinal distress and mental or visual
disturbances and, in women, to be affected by menstrual cycles.
|
Other Primary Headaches
Tension
Headache. Tension headache is often experienced in the
following locations:
-
In the forehead.
-
In the back of the head and neck.
-
In both regions.
It is typically
described as a tight feeling, as if the head were in a vise.
Soreness in the shoulders or neck is common. These headaches
can last minutes to days and may occur daily in some sufferers.
Tension headaches do not cause nausea or limit activities
as migraine headaches do, although depression, anxiety, and
sleeping problems may accompany persistent headaches. They
sometimes evolve in people who initially experience migraines,
and, in such cases, can become chronic and difficult to treat.
[For more information on tension headaches
11, Headache.]
Cluster Headache. Cluster headaches are very painful
events. Patients typically awaken a few hours after they go
to sleep with the following symptoms:
-
Very severe, stabbing pain centered in one eye.
-
Excessive tearing, a drooping eyelid, and one stuffy or
runny nostril, all on the same side as the pain.
-
Feelings of intense restlessness are common. People in
the throes of a cluster headache may pace the floor or
may even bang their heads against the wall in an attempt
to cope with the pain.
Cluster
headaches often have a cycle with the following pattern:
-
Attacks themselves are usually brief, lasting between
30 and 90 minutes, although they can persist for up to
3 hours.
-
During an active period, sufferers can experience as few
as one attack every other day to one or more daily. In
a rare form of cluster headache, known as chronic paroxysmal
hemicrania, as many as six attacks per day can occur.
-
An active period of recurrent cluster attacks typically
extends over 4 to 12 weeks.
-
Headache-free periods last several months to even years.
[For more
information on cluster headaches
11, Headache.] |
|
CAUSES OF SECONDARY HEADACHES
About 90%
of people seeking help for headaches have a primary headache
disorder. The balance of secondary headaches, however, is
caused by an underlying disorder that produces the headache
as a symptom. Many conditions cause headache as a symptom.
Some of the most common are listed below.
Sinus Headache. Many primary headaches, including
migraine, are misdiagnosed as sinus headache. Sinus headaches
can occur in the front of the face, usually around the eyes,
across the cheeks, or over the forehead. They are usually
mild in the morning and increase during the day and are usually
accompanied by fever, runny nose, congestion, and general
debilitation. Sinus headaches spread over a larger area of
the head than migraines, but it is often difficult to tell
them apart, particularly if headache is the only symptom of
sinusitis; they even coexist in many cases. Often, the visual
changes associated with migraine can rule out sinusitis, but
such visual changes do not occur with all migraines. (In rare
cases, sinusitis can cause double vision and even vision loss,
a sign of very serious infection.) [For more information,
62, Sinusitis.]
Headache Due to Neck Problems. Some headaches may
be caused by abnormalities of the neck muscles resulting from
prolonged poor posture (such as that caused by sitting in
front of a computer keyboard or driving daily for long periods),
arthritis, injuries of the upper spine, or abnormalities in
the cervical spine (the spinal bones in the neck). Nerves
in the neck converge in the trigeminal nerve in the face and
can generate pain signals that the brain may interpret as
headache. Pain is usually on one side; even if it affects
both sides of the head it is usually more severe on one side.
The quality of the headache may be similar to an aching tension
headache or a mild migraine without aura.
Temporomandibular Joint Dysfunction (TMJ). TMJ is
caused by clenching the jaws or grinding the teeth (usually
during sleep), or by abnormalities in the jaw joints themselves.
The diagnosis is easy if chewing produces pain or if jaw motion
is restricted or noisy. TMJ pain can occur in the ear, cheek,
temples, neck, or shoulders.
Glaucoma. Acute glaucoma is caused by increased pressure
in the eye and requires immediate medical attention. Throbbing
pain may be felt around or behind the eyes or in the forehead.
Patients have redness in the eye and may see halos or rings
around lights.
Brain Tumor. Fear of brain tumor is common among people
with headaches, but headache is almost never the first or
only sign of a tumor. Changes in personality and mental functioning,
vomiting, seizures, and other symptoms are more likely to
appear first. When the headache does develop, it is often
worse early in the morning or may awaken sufferers during
the night.
Neuralgia. Neuralgia is pain due to nerve abnormalities,
which can occur in the facial area and resemble migraine or
sinus headaches.
Hypertension. Although many people attribute headaches
to high blood pressure, the two are rarely associated. An
exception is malignant hypertension, an uncommon medical emergency,
in which the blood pressure abruptly rises to extreme levels,
causing damage to blood vessels in the brain, heart, and kidneys.
Strokes Caused by Blood Clots or Hemorrhages. A blood
clot or hemorrhage in the brain leading to a stroke can cause
a severe headache, sometimes referred to as a thunderclap
headache when it is very sudden and severe. The onset of such
a headache, particularly if it is associated with confusion,
stupor, or other neurologic symptoms, mandates prompt medical
attention. It is important to determine if a clot or bleeding
is causing the stroke, since treatments are very different.
Head Injuries. It is obvious that a significant blow
to the head will cause pain. Post-injury headaches, however,
can reflect serious damage, ranging from skull fractures to
internal bleeding.
Disorders of the Meninges. The meninges are the membranes
covering the brain and the spinal cord. In very rare instances,
ordinary physical strain may injure or weaken the meninges,
causing a leakage of cerebrovascular fluid (the fluid that
bathes the brain). This can cause severe headache and nausea,
which are relieved by lying flat. The condition is very treatable.
Meningitis, which is an infection or irritation of these membranes,
is an uncommon but potentially serious cause of severe headache.
Other symptoms include nausea and stiffness or pain in the
neck.
Gynecologic Problems. Many clinicians have anecdotally
linked gynecologic problems, such as ovarian cysts and menstrual
disorders, to chronic headaches, and new data are emerging
to support this association.
Temporal (Giant Cell) Arteritis. Certain causes of
headaches are unique to the elderly, such as temporal arteritis,
also called giant cell arteritis. Inflammation in arteries
that carry blood to the head, neck, and sometimes the upper
part of the body can cause very severe headaches. The risk
for this headache is highest in people over age 70, especially
among women, people of European heritage, and patients with
polymyalgia rheumatica.
Miscellaneous Causes of Benign Headaches. Rapid consumption
of ice cream or other very cold foods or beverages is the
most common trigger of sudden headache pain, which may be
prevented by warming the food or drink for a few seconds in
the front of the mouth before swallowing. Other common benign
causes of headache include eyestrain, dental problems, allergies,
systemic infections, and caffeine withdrawal. Headaches may
be induced by sexual activity or intense physical exertion.
|
HOW
SERIOUS ARE MIGRAINES?
Possibility
for Remission
In many people
migraines eventually go into remission and sometimes disappear completely,
particularly as people age. Estrogen decline after menopause may
be responsible for remission in some older women. One study reported
that the following people with migraines (called migraineurs)
have a better chance of remission:
- Those
with a family history of migraine with aura.
- People
with migraines that are not triggered by light.
- People
with no other primary headaches.
According to
another study a history of head trauma or oral contraceptive use
predicted a poorer long-term outlook.
Risk
for Stroke
Studies have
found that migraine or severe headache is a risk factor for stroke
in both men and women, especially before age 50. About 19% of all
strokes occur in people with a history of migraine. Migraine with
aura carries a higher risk for stroke than without auras.
The actual risk itself for migraineurs is low, however, as indicated
by one study:
- Women
with migraines had a 2.7% risk of stroke, with the time of greatest
risk between the ages of 45 and 65.
- Men with
migraines had a 4.6% risk and their greatest time of risk was
before age 45.
In both genders,
the risk diminished with age.
Studies suggest specific risk factors for younger women with migraines,
particularly those with auras:
- Taking
high-estrogen oral contraceptives (OCs). (Whether progesterone-alone
contraceptives carry any risk is unknown.)
In migraineurs
who take OCs, the risk increases with one or more of the following:
- High blood
pressure.
- Smoking.
Emotional
Disorders and Quality of Life
Anxiety (particularly
panic disorders) and major depression are strongly associated with
migraines. In one 2000 study, for example, 47% of migraine patients
had depression. There does not appear to be any causal relationship,
although headache and emotional disorders may have some common biologic
factors.
In any case, the negative impact of migraines on quality of life,
families, and even work productivity is significant and often underrated
as a serious complication. Studies indicate that people with migraines
have poorer social interactions and emotional health than patients
with chronic medical illnesses, including asthma, diabetes, and
arthritis.
Migraine
and Pregnancy
Effect of
Pregnancy on Migraines. In one study, pregnant women with tension
or migraine headaches experienced 80% fewer headaches, usually after
the end of the first trimester.
Effect of Migraine on the Pregnant Woman or Fetus. Migraine
headaches do not pose any added risks during pregnancy to the mother
or the fetus, although women with migraines may be at higher risk
for having smaller (but not premature) babies.
WHAT
CAUSES MIGRAINE HEADACHES?
Until recently,
the general theory on the migraine process rested solely on the
idea that abnormalities of blood vessel (vascular) systems in the
head were responsible for migraines. Now, however, experts tend
to believe that migraine starts with an underlying central nervous
system disorder, which, when triggered by various stimuli, sets
off a chain of neurologic and biochemical events, some of which
subsequently affect the brain's vascular system. No experimental
model fully explains the migraine process.
There is certainly a strong genetic component in migraine with or
without auras. Researchers have located a single genetic mutation
responsible for the very rare familial hemiplegic migraine, but
a number of genes are likely to be involved in the great majority
of migraine cases. A number of chemicals, structures, nerve pathways,
and other players involved in the process are under investigation.
General
Theories to Explain Migraine
Central Nervous
Disorder. One theory that attempts to integrate many of the
known events in the migraine process is as follows:
- The migraine
process begins with over-excitation of the nerve cells in the
trigeminal pathway. (This nerve pathway runs from the brain
stem to the head and face.)
- The excitation
triggers the release of certain protein fragments called peptides
(including, peptides known as Substance P, calcitonin gene-related
peptide, and others).
- These
peptides dilate blood vessels and produce an inflammatory response
that spreads to the meninges (the membrane covering of
the brain). While the brain itself is insensitive to pain, the
meninges and blood vessels around the brain are sensitive to
pain.
- This reaction
reaches the cerebral cortex (the outer layer of the brain) and
reduces blood flow (referred to as spreading depression). Certain
regions of reduced blood flow are associated with auras. Some
experts describe the effect as an electrical wave spreading
through the brain just as a wave of water is caused by the dropping
of a pebble.
- It is
not clear, however, where migraine pain originates. One theory
supposes that the wave ripples across the top of the brain and
down into the brain stem where pain centers are located.
Abnormal Calcium-Channels.
Some migraines may be due to abnormalities in the channels
within cells that transport the electrical ions calcium, magnesium,
sodium, and potassium. Calcium-channels appear to play a particularly
critical role in migraine patients:
- Calcium-channels
regulate the release of serotonin, an important neurotransmitter
in the migraine process. (A neurotransmitter is a chemical messenger
that allows communication between nerves in the brain.)
- Magnesium
interacts with calcium-channels and magnesium deficiencies have
been detected in the brains of migraine patients.
- Calcium-channels
also play a major role in cortical spreading depression, the
brain event that appears to be important in migraine symptoms.
Some patients
with migraine may inherit one or more factors that impair calcium-channels,
making them susceptible to headaches. For example, mutations in
a gene that encodes calcium channels appears to be responsible for
familial hemiplegic migraine.
The
Role of Serotonin and Other Neurotransmitters
Neurotransmitters
are chemical messengers in the brain. Two important ones, serotonin
and dopamine, appear to be critical in the processes leading to
migraine.
Serotonin. Serotonin (also called 5-hydroxytryptamine or
5-HT) is involved in regulation of pain perception and depression,
among other important functions. A number of studies have suggested
that serotonin serves as a brake in the migraine process. To support
this are the following observations during a migraine attack:
- Higher-than-normal
levels of a serotonin compound are excreted in urine.
- Levels
of serotonin in the blood drop.
- Drugs
that target receptors in the brain for serotonin are generally
effective in stopping a migraine.
The receptors
for serotonin implicated in migraine are found on the trigeminal
nerve endings. Serotonin appears to block the peptides involved
in over-stimulating nerves and producing inflammation.
Dopamine. Dopamine, another important neurotransmitter, may
act as a stimulant of the migraine process. Some evidence
suggests that certain genetic factors make people over-sensitive
to the effects of dopamine, which include nerve cell excitation.
Such nerve-cell over-activity could trigger the events in the brain
leading to migraine. The prodromal symptoms (mood changes, yawning,
drowsiness), for example, have been associated with increased dopamine
activity. Dopamine receptors are also involved in regulation of
blood flow in the brain.
Other
Factors Involved in Migraine
Reduced Magnesium
Levels. Researchers have also noted a drop in magnesium levels
before or during a migraine attack. Magnesium plays a role in nerve
cell function; reduced levels could be a destabilizing factor, causing
the nerves in the brain to misfire, possibly even accounting for
the auras that many sufferers experience.
Female Hormones. The female hormones progesterone and estrogen
appear to play some role but it appears that it is their fluctuation,
not their presence, that is associated with migraines. More research
is needed to determine each hormone's precise effects.
Hypotension. One study suggested that some migraine headaches
might be precipitated by a sudden drop in blood pressure (hypotension).
(Conversely, some cases have suggested that migraine can also cause
hypotension.)
Migraine
Triggers
A wide range
of events and conditions can alter conditions in the brain that
bring on nerve excitation and trigger migraines. They include, but
are not limited to the following:
- Emotional
stress (although the headaches often erupt after the stress
has eased).
- Intense
physical exertion (such as after lifting, athletic endeavor,
and even bowel movements or sexual activity).
- Abrupt
weather changes (such as Chinook winds).
- Bright
or flickering lights.
- High altitude.
- Travel
motion.
- Changes
in sleep patterns.
- Low blood
sugar has been known to trigger headaches and fasting can often
precipitate migraines.
- Chemicals
found in certain foods may trigger headaches in some people.
More than 100 foods have the capacity to trigger migraine headache.
[ See Table Foods That May Trigger
Migraines under How Can Migraine Headaches Be Prevented?.]
WHO
GETS MIGRAINE HEADACHES?
Gender
Migraine affects
between 15% to 20% of women and 6% of men. This significantly greater
incidence in women holds throughout the world and in every culture.
Although the incidence of migraine is similar for boys and girls
during childhood, it increases in girls after puberty.
Hormone Fluctuations in Women. Most migraines in women develop
during the hormonally active years between adolescence and menopause.
Fluctuations of estrogen and progesterone, rather than their presence,
appear to increase the risk for migraines and their severity in
some women.
- About
half of women with migraines report headaches associated with
their menstrual cycle, although true menstrual migraines may
actually be less common. So-called true menstrual migraines
tend not to have auras and to increase in prevalence between
two days before and five days after the onset of period.
- The first
three months of pregnancy can exacerbate migraines in some women,
although one study reported that pregnancy had little effect
one way or the other on severity in most women with chronic
headaches.
- Women
whose migraines are affected by pregnancy or menstruation are
also likely to have worse migraines if they take oral contraceptives
or hormone replacement therapies.
Age
General Age
of Onset. More than 20% of adults with migraine report that
their headaches started before age 10 and over 45% say they started
under age 20. The prevalence of migraine declines in both men and
women after age forty.
Migraine in Children. Migraine headaches occur in all ages
and can appear in children as young as four years of age. Migraines
in children are equally prevalent in boys and girls. Migraine is
common in children and may be underdiagnosed. Some studies estimate
prevalence in children of 5% to 10%. [ See Box Guidelines
for Migraines in Children.]
In one Greek study of children, researchers reported a prevalence
of migraine of 6.2%. Of the children who had migraines, 3.4% reported
headaches without aura and 2.8% experienced aura with at least some
of their headaches.
Migraine Onset in Older Adults. Although uncommon, late-life
migraine occurs in about 1% of the population, usually in men. In
such cases, it often occurs as migraine with visual disturbances
but without headache.
Family
History
Research indicates
that slightly over half of migraine cases may be inherited.
Ethnic
Differences
Caucasians have
a higher risk than either African Americans or Asians. Worldwide,
one study reported that migraines are most common in North America.
They are slightly less prevalent in South America and Europe and
far less common in Asia and Africa. Investigators believe that the
differences are due to genetic variations not environmental factors.
Other
Medical Conditions Associated with Migraines
Certain disorders
predispose people to migraines:
- Asthma
and allergies. Some studies have reported an association between
migraine and asthma. One observed that parents with migraines
had a greater chance of having children with asthma and allergies.
- H.
pylori Infection. People who are infected with the bacteria
H. pylori , the major cause of peptic ulcers, are at
higher risk for migraines.
- Epilepsy.
Patients with epilepsy are twice as likely to have migraines
as the general population.
- Fibromyalgia.
People with fibromyalgia, a syndrome characterized by chronic
fatigue and specific muscle pain, also seem to face an increased
risk for migraines.
Personality
Traits
One study suggested
that women with migraine tend to over-respond to stressful situations.
In the study, they were more likely than other women to be diligent,
conscientious, and to be overly sensitive to pressure from others.
More important, probably, is a person's family history of migraine,
rather than any personality tic, however.
WHAT
TESTS ARE REQUIRED TO ESTABLISH THE CAUSE OF HEADACHE?
Anyone, including
children, with recurring or persistent headaches should consult
a physician. There are no blood tests or imaging techniques that
can be used to diagnose migraine headaches. A diagnosis will be
made on the basis of history and physical exam, and, if necessary,
ruling out other diseases or conditions that may be causing the
headaches. (Tests may be necessary to rule out other conditions.)
It is important to choose a doctor who is sensitive to the needs
of headache sufferers and aware of the latest advances in treatment.
Description
of Symptoms
For accurate
diagnosis, the patient should describe the following:
- The duration
and frequency of headaches.
- Recent
changes in character of the headaches.
- The location
of the pain.
- The type
(eg, throbbing or steady pressure).
- The intensity.
- Any associated
symptoms, such as nausea and vomiting.
- Describe
clearly any visual disturbances, including auras.
It should be
noted that the presence of auras or other disturbances do not always
identify migraine sufferers:
- For instance,
patients with severe sinus infections may experience double
vision or visual loss. (This is an emergency condition, since
it indicates the infection has spread to areas around the eyes).
- Many migraine
sufferers have no auras.
- Many elderly
people with late-onset migraine have auras but no pain.
Headache
Diary to Identify Triggers
The patient should
try to recall what seems to bring on the headache and anything that
relieves it. Keeping a headache diary is a useful way to identify
triggers that bring on headaches. Some tips include the following:
- Be sure
to include all events preceding an attack. Often two or more
triggers interact to produce a headache. For example, a combination
of weather changes and fatigue can make headaches more likely
than the presence of just one of these events.
- Keeping
a migraine record for at least three menstrual cycles can help
to confirm or refute a diagnosis of menstrual migraine.
- Tracking
medications is an important way of identifying causes of rebound
headache or transformed migraine.
- Be sure
to attempt to define the intensity of the headache. It may be
indicated by using a number system:
1 = mild, barely
noticeable.
2 = noticeable, but does not interfere with work/activities.
3 = distracts from work/activities.
4 = makes work/activities very difficult.
5 = incapacitating.
Medical
and Personal History
The patient should
report any other conditions that might be associated with headache,
including but not limited the following:
- Any chronic
or recent illness and their treatments.
- Any injuries,
particularly head or back injuries.
- An uncharacteristic
dietary changes.
- Any current
medications or recent withdrawals from any drugs, including
over-the-counter or so-called natural remedies.
- Any history
of caffeine, alcohol, or drug abuse.
- Any serious
stress, depression, and anxiety.
The physician
will also need a general medical and family history of headaches
or diseases, such as epilepsy, that may increase their risk. Migraine,
in particular, tends to run in families.
Physical
Examination
In order to diagnose
a chronic headache, the physician will examine the head and neck
and will usually perform a neurologic examination, which includes
a series of simple exercises to test strength, reflexes, coordination,
and sensation. The physician may ask questions to test short-term
memory and related aspects of mental function.
Diagnosing
the Cause of Persistent Migraines
Extensive testing
may be advised for anyone with a chronic, daily headache. Tracking
times of medications, withdrawal, and headache, using the headache
diary, is usually very helpful in diagnosis.
Differentiating Rebound Headache from Transformed Migraines.
Migraines that evolve to chronic headache must be first differentiated
between natural transformed migraines and rebound headache (the
most common cause of persistent migraines):
- Rebound
headaches are usually more variable in severity and location
than transformed migraines.
- Rebound
headaches tend to be more sensitive to triggers than natural
transformed migraines.
Differentiating
Transformed from Tension Headaches. If a rebound headache is
ruled out, the physician must then differentiate natural transformed
migraines from tension headaches:
- In most
cases of transformed migraine (but not tension headache) gastrointestinal
or neurologic symptoms are present.
- Transformed
migraine is also frequently associated with menstrual fluctuations
in women.
Imaging
Tests
Imaging tests
of the brain may be recommended under the following circumstances:
- If the
results of the history and physical examination suggest neurologic
problems.
- For patients
with headache that wakes them at night.
- For new
headaches in the elderly. In this age group, it is particularly
important to first rule out age-related disorders, including
stroke, hypoglycemia, hydrocephalus, and head injuries (usually
from falls).
- For patients
with worsening headache.
They are not
recommended for patients with migraine and with no other abnormal
indications. [ See Box, Headache Symptoms
that Could Indicate Serious Underlying Disorders.]
The following tests may be used:
- A CT (computed
tomography) scan may be ordered to rule out brain disorders
or headaches caused by chronic sinusitis.
- X-rays
and other tests may also be used if sinusitis is strongly suspected.
- A neck
x-ray can reveal arthritis or spinal problems.
- Other
tests include an MRI (magnetic resonance imaging), EEG (electroencephalogram),
lumbar puncture, ultrasound testing, and cerebral angiography,
which are only performed if there is reason to suspect an underlying
disease.
|
Headache Symptoms that Could Indicate Serious Underlying
Disorders
Headaches
indicating a serious underlying problem, such as cerebrovascular
disorder or malignant hypertension, are uncommon. (It should
again be emphasized that a headache is not a common symptom
of a brain tumor.) People with existing chronic headaches,
however, might miss a more serious condition believing it
to be one of their usual headaches. Such patients should call
a physician promptly if the quality of a headache or accompanying
symptoms has changed. Everyone should call a physician for
any of the following symptoms:
-
Sudden, severe headaches that persist or increase in intensity
over 24 hours.
-
Sudden, very severe headache, worse than any headache
ever experienced (possible indication of hemorrhage or
a ruptured aneurysm).
-
Chronic or severe headaches that begin after age fifty.
-
Headaches accompanied by memory loss, confusion, loss
of balance, changes in speech or vision, or loss of strength
in or numbness or tingling in arms or legs.
-
Headaches after head injury, especially if drowsiness
or nausea are present (possibility of hemorrhage).
-
Headaches accompanied by fever, stiff neck, nausea and
vomiting (possibility of spinal meningitis).
-
Headaches that increase with coughing or straining (possibility
of brain swelling).
-
A throbbing pain around or behind the eyes or in the forehead
accompanied by redness in the eye and perceptions of halos
or rings around lights (possibility of acute glaucoma).
-
A one-sided headache in the temple in elderly people;
the artery in the temple is firm and knotty and has no
pulse; scalp is tender (possibility of temporal arteritis,
which can cause blindness or even stroke if not treated).
-
Sudden onset and then persistent, throbbing pain around
the eye possibly spreading to the ear or neck unrelieved
by pain medication (possibility of blood clot in one of
the sinus veins of the brain).
|
WHAT
ARE THE GUIDELINES FOR TREATING A MIGRAINE ATTACK
Many effective
headache remedies are now available for treating a migraine attack.
Still, a 2000 survey of European migraineurs found that half seek
no treatment from a doctor, perhaps because of the stigma of migraine.
And, only 27% of patients were given medications that were consistently
effective. It should be noted that as many as 30% of migraine sufferers
also have accompanying headaches resulting from tension, drugs,
infections, or other causes. It is important to distinguish between
headache types in order to determine appropriate treatment. [ See
Table Drugs Used for Migraines.]
General Guidelines. The general goals of treatment are the
following:
- On the
advice of the physician, choose drugs with as few side effects
as possible. Patients should discuss various methods for administering
the medication (pills, injections, nasal spray, or rectal suppositories)
and begin with one they believe will be the least distressing.
- Treat
the attack rapidly and consistently to avoid recurrence.
- Start
with low doses first and build up dosage slowly.
- Drug combinations
are being tested for some patients with migraines that do not
respond to single agents. One such example is an NSAID (such
as naproxen) with a triptan; such drugs have actions that do
not interact with each other.
- Try to
minimize the use of back-up or rescue medications. (A rescue
medication is typically an opiate, which the patient uses at
home for pain relief when other medications fail.)
- Try to
guard against rebound effect. Nearly all drugs used for migraine
can cause rebound headache and none of the drugs should be taken
for longer than two days per week. (Dihydroergotamine and a
naratriptan, a recent triptan, may pose a much lower risk for
rebound than others, although evidence for this is not certain.)
- It may
take two to four months for an agent to be effective.
Stepped-Up
Treatment Approach . Some experts advocate a stepped-up treatment
course for an acute migraine attack. A typical approach is the following:
- Patients
first try general pain relievers (NSAIDs, Exedrin Migraine)
and stress-reduction techniques.
- If these
are not effective within two hours, migraine-specific agents
should be tried next. Triptans are the first choice, then ergot
derivatives (dihydroergotamine [DHE]).
- Injected
or rectally administered drugs may be used for patients with
migraines associated with severe nausea or vomiting. Nausea
itself should be treated with specific anti-nausea drugs, such
as metoclopramide (Reglan).
- If migraine
medications fail to relieve symptoms within four hours, rescue
drugs (opiates, corticosteroids) may be used.
Stratified
Approach. An alternate course is called the stratified approach.
The physician first defines the severity of a patients condition
based on their history. Drugs at less or greater potency are then
prescribed for the first signs of an attack. Agents are prescribed
depending on the severity of the case.
- Patients
with less disabling migraines start with general pain relievers.
- Patients
with a history of moderate to severe migraines start with migraine-specific
prescription medicine.
Some studies
report dramatic relief with the stratified approach, although side
effects may be more severe. It is not clear, yet, whether it is
significantly better than a stepped-up approach, but evidence is
promising.
|
GUIDELINES FOR MIGRAINES IN CHILDREN
Some studies
estimate that between 5% and 10% of children may experience
migraines but that the disorder is underdiagnosed in children.
Symptoms in Children
The standard
diagnostic criteria for migraine in adults, however, may apply
to only about two-thirds of migraines in children and adolescents.
For example, the following differences have been observed:
-
Headaches tend to last for a shorter time (as little as
an hour) in children.
-
Migraine tends to occur in the front of the face and occurs
on both sides in two-thirds of child patients.
-
Children may often have a form of migraine known as a
migraine equivalent or abdominal migraine, which does
not cause a headache at all. Instead children experience
periodic bouts of nausea and vomiting (called cyclic vomiting
syndrome) or other secondary symptoms found in adult migraine,
such as a reaction against light or sound.
Migraine
in children is disabling, as it is in adults. In one study
children with migraine lost more school years than other children.
Migraine triggers in children are similar to those in adults,
but common ones in children are eating ice cream and anxiety
and fear.
Treatments in Children
For most
children with migraines, mild pain relievers and home remedies
may be sufficient.
-
The standard approach for migraine in children is to start
with ibuprofen (Advil) or acetaminophen (Tylenol) as early
as possible. An oral form is recommended but if the child
is vomiting, then rectal administration may be used.
-
Ginger tea or ginger ale may be helpful and soothing.
In severe
cases, more potent agents are used. Some options include the
following:
-
Dihydroergotamine has been an option for children with
severe migraine.
-
Non-oral forms of triptans, such as the sumatriptan nasal
spray, may prove to be safe and effective in children,
although a 2000 study showed effectiveness in only 1 in
10 adolescents. (Studies on oral sumatriptan have not
shown to be at all effective in children.)
-
Intravenous prochlorperzaine may be effective in stopping
intractable migraines in children.
-
For prolonged headache, dexamethasone (an inhaled corticosteroid)
may provide relief by reducing inflammation.
Preventive Measures in Children
-
Non-medication methods, including biofeedback and muscle
relaxation techniques may be helpful. In one study of
children with migraines and poor sleep habits, instructions
in improving sleep without using medications reduced migraine
attacks significantly.
-
If these methods fail, then preventive drugs may be used,
although evidence is weak on the effectiveness of standard
migraine preventive agents in children. Flunarizine, an
anti-seizure agent that also blocks calcium-channels,
has been effective for children in trials but is not yet
approved in the US. The tricyclic antidepressants have
been useful for childhood migraine with cyclic vomiting.
|
Withdrawing from Medications
If rebound migraines
develop because of medication overuse, the patients cannot recover
without stopping the drugs. (If caffeine is the culprit, a person
may only need to reduce coffee or tea drinking to a reasonable level,
not necessarily stop drinking it altogether.) The patient usually
has the option of stopping abruptly or gradually and should expect
the following course:
- Most headache
drugs can be stopped abruptly but the patient should be sure
to check with the physician before withdrawal. Certain non-headache
medications, such as anti-anxiety drugs or beta-blockers, require
gradual withdrawal.
- If the
patient chooses to taper off standard headache medications,
withdrawal should be completed within three days or shorter.
Otherwise the patient may become discouraged.
- Alternative
medications may be administered during the first days. Examples
of drugs that are used include dihydroergotamine (with or without
metoclopramide), NSAIDs (in mild cases), corticosteroids, or
valproate.
- Whatever
approach is used for stopping medication, the patient must expect
a period of worsening headache afterward. Most people feel better
within two weeks, although headache symptoms can persist up
to 16 weeks (and in rare cases even longer).
- If the
symptoms do not respond to treatment and cause severe nausea
and vomiting, the patient may need to be hospitalized.
On the encouraging
side, some patients experience dramatic long-term relief from all
headaches afterward, and one study reported that 82% of patients
significantly improved four months after withdrawal.
Drugs
Used for Migraine
|
Drugs
|
Used
for Treatment
|
Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin,
ibuprofen (Advil), and naproxen (Anaprox, Aleve).
Potent prescription NSAIDs are available.
|
Used as first line for mild to moderate migraines.
Disadvantage: Most NSAIDs are not effective alone for
severe migraines. Gastrointestinal problems, including possible
bleeding, with long-term use.
|
Exedrin Migraine Acetaminophen, aspirin, and caffeine
|
Over-the-counter medication proven to be effective for temporary
relief of migraine.
Disadvantage: Not usually effective for severe migraine.
|
Triptans
|
First choice for moderate to severe migraines.
|
Ergots: Ergotamine, dihydroergotamine (DHE), methysergide
|
Second choice after triptans. Intravenous ergots for severe
migraines. Has more severe side effects than triptans.
|
Lidocaine
|
Nasal drops may be effective in 15 minutes. Limited evidence
on effectiveness.
|
Anti-nausea Agents: metoclopramide (Reglan), domperidone (Motilium),
Prochlorperazine (Compazine)
|
Oral combination of NSAIDs and metoclopramide effective in
treating migraine. Oral forms of metoclopramide or domperidone
reduce nausea and may help absorption of migraine agents.
Intravenous administration of prochlorperazine useful for
severe prolonged attacks in some patients.
|
Butalbital (a barbiturate) plus other compounds including
aspirin and caffeine (Fiorinal, Issocet, Endolor, Femcet)
or acetaminophen (Phenilin, Axocet, Bucet, Fioricet)
|
Has some proven benefits for acute attack. Can become habit
forming over time.
|
Corticosteroids (dexamethasone, hydrocortisone)
|
Rescue therapy for patients with status migrainous.
|
Opioids (oral or nasal spray [Butorphanol])
|
For rescue treatment in very severe pain that does not respond
to other agents. |
WHAT
ARE THE SPECIFIC DRUGS AND REMEDIES FOR TREATING A MIGRAINE ATTACK?
Specific
Treatments for Mild Migraine
Exedrin Migraine.
Some patients with mild migraines respond well to over-the-counter
painkillers, particularly if they are administered at the very first
warning of an impending attack. Exedrin Migraine, which contains
acetaminophen, aspirin, and caffeine, is the first over-the-counter
medication to be considered effective for temporary relief of migraines.
Studies have reported significant relief in nearly 70% of patients.
It may also help menstrual migraines.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). NSAIDs are
also first-line drugs tried for mild to moderate migraines. They
are not very effective when used alone against severe migraine headache.
Some experts suggest that the effect that the migraine process has
on the gastrointestinal (GI) tract may prevent the absorption of
NSAIDs. Some used to treat migraines are the following:
- Aspirin,
ibuprofen (Advil Migraine), and naproxen (Anaprox, Aleve) are
all available over the counter, and may have some benefits for
mild migraine. Naproxen appears to be more effective than other
NSAIDs.
- A study
of children who had migraines compared ibuprofen and acetaminophen.
Acetaminophen worked faster, but after three hours, ibuprofen
was more effective. Parents of children with migraines should
consult with their physicians about using a combination of these
drugs.
- Researchers
have combined a high-dose NSAID (equivalent to 900 mg of aspirin)
with metoclopramide (Reglan), a drug that prevents nausea and
vomiting. Several studies show this combination is equal to
oral sumatriptan and superior to DHE, two standard migraine
drugs. People should not take high doses of NSAIDs without some
protective agent since they can cause severe gastrointestinal
distress.
- In one
study, an NSAID combination, diclofenac-potassium (Cataflam),
was as effective as sumatriptan, a standard migraine drug. Cataflam
worked more rapidly and helped reduce nausea. The combination
is not appropriate for people allergic to aspirin or at risk
for bleeding.
- Injectable
NSAIDs, particularly ketorolac, are proving in some cases to
be equally or more effective than powerful migraine medications
used for severe and persistent migraines. It should be noted
that ketorolac has a higher risk for gastrointestinal bleeding
than many other NSAIDs.
New NSAIDs, called
selective COX-2 inhibitors include celecoxib (Celebra), rofecoxib
(Vioxx), and meloxicam (Mobic). These agents may allow high doses
without the accompanying gastrointestinal side effects.
Cooling Pads. Cooling pads may help during an attack. New
products (Migraine Ice, TheraPatch Headache Cool Gel) employ a pad
containing a gel that cools the skin for up to four hours and can
be placed on the forehead, temple, or back of the neck.
Ginger. In general, herbal medicines should never be used
by children or pregnant or nursing women without medical counsel.
One exception may be ginger, which has no side effects and can be
eaten in powder or fresh form, as long as quantities are not excessive.
Some people have reported less pain and frequency of migraines while
taking ginger, and children can take it without danger.
Triptans
Triptans (referred
to as 5-HT 1B/1D agonists by the medical community) help maintain
serotonin levels in the brain and so specifically target one of
the major components in the migraine process. They have the following
benefits:
- They appear
to be effective for most migraine patients.
- They are
beneficial for patients with combination tension and migraine
headaches.
- They seem
to be effective for migraines during menstruation.
- They do
not have the sedative effect of other migraine drugs.
Patient satisfaction
is high with these agents, and triptans are now recommended as first-line
agents for many adult patients with moderate to severe migraines
when NSAIDs, Exedrin Migraine, or other less powerful agents have
not been effective.
Their use should be limited or used with caution in the following
groups:
- Studies
on the effects of triptans in pregnant women are limited. One
study suggested a higher incidence of preterm deliveries in
pregnant women taking sumatriptan. No higher rates of still
births or birth defects were reported. In general, pregnant
women should avoid any medications if possible.
- They may
be safe for children and adolescents, but controlled studies
are needed to confirm this. (Triptans should not, in any case,
be the first-line treatment for children.) [ See Box
Migraines in Children.]
- People
taking antidepressants that increase serotonin levels.
- Anyone
with a history or with any risk factors for stroke, uncontrolled
diabetes, high blood pressure, or heart disease should avoid
triptans.
A number of triptans
are now available:
Sumatriptan. Sumatriptan (Imitrex) was the first drug specifically
developed for use against migraine. It has the longest track record
and is the most studied. It is available the following forms:
- Orally.
- Nasal
spray. The nasal spray form bypasses the stomach and is absorbed
more quickly than the oral form. Some patients report relief
as soon as 15 minutes after administration. The spray may leave
a bad taste and it tends to be less effective when a person
has nasal congestion from cold or allergy. One 1999 study suggested
patients may safely be able to take the nasal spray to quickly
knock out the pain and follow it with the oral form for persistent
relief.
- Injection.
Injected sumatriptan works the fastest, but is inconvenient
and causes pain at the injection site. (Of interest was a 2000
analysis reporting that an inactive placebo injection worked
better than a placebo pill, suggesting that non-oral methods
may have some psychologic advantage.)
Sumatriptan has
proven to bring rapid relief to most migraine sufferers. For example,
sumatriptan relieves migraines more quickly than ergotamine. Ergotamine,
however, seems to provide more sustained relief. Unfortunately,
recurring headaches with sumatriptan develop within the first 24
hours in 20% to 40% of people who have taken the drug.
Newer Triptans. Newer triptans are now available. They include
zolmitriptan (Zomig), naratriptan (Naramig, Amerge), rizatriptan
(Maxalt), almotriptan (Axert), eletriptan, avitriptan, and frovatriptan.
Some of these drugs are not yet available in the US. Studies on
many of them have reported pain relief within two hours in between
60% and 91% of patients.
Few comparative studies have been done, but early results have reported
the following:
- Depending
on the dose, zolmitriptan has a more rapid onset than sumatriptan
and the other new triptan naratriptan. It also has far less
risk for recurrence than sumatriptan.
- Rizatriptan
also has a very fast onset of action. A large study of rizatriptan
suggested that repeated use actually reduced the time it took
to relieve symptoms. It has a recurrence rate similar to that
of sumatriptan.
- Naratriptan
is called the "gentle" triptan. It takes longer to relieve pain
than other triptans. However, it has very few side effects and
has a lower risk for headache recurrence than sumatriptan. (A
comparative study between naratriptan and zolmitriptan, however,
did not find any difference in recurrence rates.)
- Almotritan
(Axert) has a rapid onset (about the same as oral sumatriptan)
but has less risk for recurrence.
Large comparative
studies are still needed to determine if the newer triptans are
significantly more effective than sumatriptan.
Side Effects and Complications of Triptans. Many of the newer
triptans may have fewer severe side effects than sumatriptan. Side
effects of most triptans, however, can include the following:
- Nausea.
- Dizziness.
- Muscle
weakness.
- Other
effects include tingling, a warm sensation, heaviness in the
chest, and discomfort in the ear, nose, and throat.
The following
are potentially serious problems.
- Complications
on the Heart and Circulation. Triptans narrow (constrict) blood
vessels. Because of this effect, very rarely spasms in the blood
vessels may occur and cause serious side effects, including
stroke and heart attack. Such events are not only rare but occur
primarily in patients with an existing history or risk factors
for these conditions.
- Serotonin
Syndrome. Triptans also affect serotonin and so people taking
antidepressants that increase serotonin levels (which are most
antidepressants) should avoid taking both. The effects of such
combinations may cause a so-called serotonin syndrome, which
causes mental changes, restlessness, tremor, chills, sweating,
and colitis. Some physicians believe, however, that the risk
for the syndrome from taking both classes of drugs is very small.
Ergotamine
(Ergot)
Drugs containing
ergotamine (commonly called ergots) constrict smooth muscles, including
those in blood vessels, and are useful for migraine.
Forms of Ergotamine.
- Dihydroergotamine
(DHE) is an ergot derivative. It is administered by injection,
which can be performed at home. A nasal spray form of DHE (Migranal)
may have fewer side effects than the injection. Dihydroergotamine
has stopped migraine attacks in up to 90% of cases and is often
effective against menstrual migraines.
- Ergotamine
itself is available in oral tablets (Ergomar, Wigraine, Ercaf)
and in rectal suppositories (Cafergot). Cafergot, Wigraine,
and Ercaf contain caffeine.
- An ergotamine
inhaler is being investigated.
Side Effects.
Side effects of ergotamine include the following:
- Nausea.
- Dizziness.
- Tingling
sensations.
- Muscle
cramps.
- Chest
or abdominal pain.
The following
are potentially serious problems:
- Toxicity.
Ergotamine is toxic at high levels.
- Complications
on the Heart and Circulation. It also causes persistent blood
vessel contractions, which may pose a danger for people with
heart disease or risk factors for heart attack or stroke.
The following
patients should avoid ergots:
- Pregnant
women.
- People
over 60.
- Those
with serious, chronic health problems, particularly those of
the heart and circulation.
Lidocaine
Nasal drops containing
lidocaine, a local anesthetic, can provide effective pain relief
within 15 minutes for many migraine sufferers. One case report suggests
that taking it during the aura phase may offer significant protection
against developing the full-blown headache. It has certain downsides:
- It is
rather difficult to administer. Patients must be lying down
with their head dangling.
- The headache
often relapses in an hour, and other drugs must then be used.
- Side effects
include unpleasant taste, burning sensation, and facial numbness.
However, the
drug does not cause drowsiness or heart rhythm disturbances as some
other migraine treatments do. And its fast effectiveness and safety
make it a promising first drug during a migraine attack. It should
not be used for any other form of headache.
Opiates
If the pain is
very severe and does respond to other agents, physicians may try
pain killers containing opiates (eg, morphine, codeine, meperidine
[Demerol], or oxycodone [Oxycontin]). Butorphanol is an opiate in
nasal spray form that may be useful as a rescue treatment when others
fail. A number of such opiates use combinations of NSAIDs (ibuprofen
or aspirin) or acetaminophen with an opioid. One study reported
that about half of patients who start opioid therapy for migraine
respond well and the benefits persist over time.
Side Effects. Side effects for all opioids include drowsiness,
impaired judgment, nausea, and constipation. Addiction is a risk.
Such drugs should not be prescribed for patients at risk for drug
abuse, including those with personality or psychiatric disorders.
Agents
Used to Prevent Nausea and Vomiting
Metoclopramide
(Reglan) is used in combinations with other agents to treat the
nausea and vomiting that occurs with other drugs and with the condition
itself. In fact, in one study using only aspirin with metoclopramide
had some significant effect on the migraine itself. This and other
anti-nausea drugs, such as domperidone (Motilium) may also help
the intestine absorb the migraine medications.
Other
Drugs Being Tested for Treating Migraines
Valproate.
The anticonvulsant medication, valproate, has been effective
in some studies for stopping headaches in some patients with persistent
migraines. This and other anti-seizure medications are sometimes
used for preventing migraines.
Botulinum. Botulinum toxin A (Botox) injections are being
used for a number of conditions requiring small muscle relaxation,
including eliminating wrinkles. Researchers are now reporting complete
migraine relief in more than half of patients being tested and improvement
of more than 50% in another 35% of patients. Relief lasted three
to four months with no adverse effects.
Intravenous Antihistamines. In one 1999 study, administering
intravenous diphenhydramine (a common ingredient in many antihistamines)
produced improvement in 32% of patients with daily migraines. (Only
25% of those who were given dihydroergotamine experienced relief.)
Magnesium. Some studies have reported that intravenous magnesium
sulfate is useful for migraine relief in people with low levels
of magnesium. One study reported, however, that it had no effect
on headaches in those with normal levels of magnesium, although
some evidence suggests that the low magnesium levels may play a
role in migraines. In fact, a study on children with migraines reported
a high prevalence of magnesium deficiency and suggested that supplements
may be beneficial. Over-the-counter supplements are of uneven quality
and costly, and many magnesium salts are not absorbed well and may
cause diarrhea. Studies are underway to determine the most effective
magnesium preparation and its benefits, if any, in menstrual migraines.
Herbal
Remedies
Feverfew.
There are claims and even some clinical evidence that the herbal
medicine feverfew helps control the severity and number of migraines
and reduces accompanying nausea and vomiting. It should be noted,
however, that, like all effective headache remedies over use can
cause a rebound effect. Some experts recommend purchasing feverfew
in dried leaf form. Side effects include mouth irritation and stomach
distress. As with most alternative medications, herbal products
are not government tested or controlled. Be sure to let your doctor
know if you are taking an herbal preparation to treat your migraines.
WHAT
ARE THE GENERAL GUIDELINES FOR PREVENTING MIGRAINE ATTACKS?
Lifestyle measures
and non-drug approaches, such as biofeedback, should be tried first
for preventing migraine attacks. [ See What Are the Non-Medication
Measures for Preventing Migraine Headaches?]
In general, patients should discuss using medications on a daily
bases for prevention of migraines when one or more of the following
conditions are present:
- When recurring
migraines significantly interfere with normal activities, even
with treatment.
- It attacks
are severe and disabling.
- If drugs
used for migraine attack are ineffective.
- If drugs
used for treatment are being overused.
- If side
effects of treatment are overly severe.
- If migraine
attacks are frequent (typically striking more than two or three
times a month).
- If the
migraines are rare forms (for example, hemiplegic migraine,
basilar migraine, migraine with prolonged aura).
Specific Approach.
In most cases, the patient takes medications in the following
manner:
- One agent
is usually tested at a time, with the patient taking the least
powerful drug at the lowest dose first and increasing to greatest
potency as agents fails.
- Combinations
may be appropriate (such as a nonsteroidal anti-inflammatory
drug [NSAID] with an antidepressant) for certain individuals.
- Patients
who have certain other medical conditions (eg, heart disease,
history of stroke, epilepsy, anxiety) may be able to choose
drugs that are useful for both conditions.
- Patients
should use a headache diary to evaluate the effects. It may
take two to three months for the patients to experience benefits
from a preventive program.
- Once a
medication has controlled the migraine, the patient should try
tapering the dose after six to 12 months, with the goal of stopping
completely.
It should be
noted that many of these preventive drugs have potentially serious
side effects, and that even with their use, only 10% of patients
become completely headache free. (Medications should never
be taken as preventive measures for tension-type headaches, except
for unusual chronic or very predictable types. In these cases, a
physician should always be consulted.)
Migraine
Medications Commonly Used for Prevention
|
Drugs
|
Used
for Prevention
|
Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin,
ibuprofen (Advil), and naproxen (Anaprox, Aleve).
Potent prescription NSAIDs are available.
|
Low-dose aspirin or other over-the-counter NSAIDs, effective
for prevention in 20% of cases.
Prescription-strength NSAIDs reported to be effective in reducing
frequency of attacks in 50% of patients.
Disadvantage: Gastrointestinal problems, including
possible bleeding, with long-term use.
Rebound Effect
|
Beta-blockers (propranolol)
|
Reduce frequency of attacks and severity when they occur.
Disadvantage. Should not be used with patients with
asthma and certain heart conditions. Used with caution in
those with diabetes.
|
Valproate (Depakote), gabapentin (Neurontin) or other anticonvulsant
agents
|
Reduce frequency of attacks and severity of migraines without
auras. May be useful for patients who cannot take medications
that constrict blood vessels.
|
Antidepressants (tricyclics, SSRIs)
|
Tricyclics (especially amitriptyline) are particularly useful
for combination headaches. They cause frequent side effects,
however. SSRIs and newer antidepressants may be helpful in
some circumstances, although evidence is weak.
|
Calcium-Channel blockers (diltiazem, nimodipine, verapamil)
|
Prevent migraines and cluster. May be particularly useful
in migraine patients at risk for stroke.
|
Ergots: Ergotamine, dihydroergotamine (DHE), methysergide
|
Methysergide proving to be useful for prevention. Other ergot
are not appropriate.
|
WHAT
ARE THE SPECIFIC DRUGS USED TO PREVENT MIGRAINES?
Nonsteroidal
Anti-Inflammatory Drugs (NSAIDs) for Prevention
Nonsteroidal
anti-inflammatory drugs (NSAIDs are very common pain relievers that
are available over the counter or in prescription form. They may
be used for prevention of migraine under the following circumstances:
- Nonprescription
NSAIDs. Regular, preventive use of low-dose aspirin (so-called
baby aspirin), ibuprofen (Advil), and naproxen (Aleve) may reduce
the occurrence of migraine headaches by about 20%. (Even with
nonprescription NSAIDs, no one should take them regularly without
consulting a physician.)
- Prescription-strength
NSAIDs. P rescription-strength NSAIDs can reduce the frequency
of attacks in over half of migraine sufferers. There are many
prescription brands available. Mefenamic acid (Ponstel) and
naproxen (Anaprox) are particularly useful for preventing migraines
associated with menstruation.
Long-term use
of these drugs can lead to ulcers and possibly gastrointestinal
bleeding. [For more information on NSAIDs see How are Headaches
Treated?, below.]
Beta-Blockers
Beta-blockers
are usually prescribed to reduce high blood pressure. Some, however,
are also useful in reducing the frequency of migraine attacks and
their severity when they occur.
- Propranolol
(Inderal) and timolol (Blocadren) have been approved specifically
for prevention of migraine.
- Others
not yet approved may be effective, including atenolol (Tenormin),
metoprolol (Lopressor, Toprol XL), and nadolol (Corgard).
There is some
suggestion that people with migraines who have had a stroke should
avoid beta-blockers.
Side Effects. Side effects may include the following:
- Fatigue
and lethargy are common.
- Some people
experience vivid dreams and nightmares, depression, and memory
loss.
- Dizziness
and lightheadedness may occur upon standing.
- Exercise
capacity may be reduced.
- Other
side effects may include cold extremities, asthma, decreased
heart function, gastrointestinal problems, and sexual dysfunction.
If side effects
occur, the patient should call a physician, but it is extremely
important not to stop the drug abruptly.
Anticonvulsants
Valproate
and Divalproex Sodium. Valproate (Depakene) and a similar drug
divalproex sodium (Depakote) are commonly used for epilepsy or bipolar
disease. They are now approved by the Food and Drug Administration
for reducing severity and frequency of severe migraines without
auras. They are less effective for prevention of mild migraines.
In one study, valproate was used safely for three years. It reduced
migraines by up to 62% by the end of one year, after which the benefits
remained stable.
Side effects vary depending on the potency for the drug, but may
include the following:
- Stomach
and intestinal problems are common. Divalproex sodium (Depakote)
has a lower risk for these side effects than valproate (Depakene).
- Increased
appetite with weight gain.
- Temporary
hair thinning and loss have occurred; taking zinc and selenium
supplements may help reduce the effect.
- Young
girls may develop secondary male characteristics and premenopausal
women are at increased risk for menstrual irregularities and
polycystic ovaries due to elevated male hormones, which are
reversible.
- The agents
can cause birth defects.
- Studies
are reporting symptoms of Parkinson's disease preceded by hearing
loss in people with epilepsy who use valproate for more than
a year, but they were reversible when the drug was withdrawn.
Other Anticonvulsants.
Other anticonvulsants are also being investigated for migraine,
such as gabapentin (Neurontin), topiramate (Topamax), and tiagabine
(Gabitril). In one study, for example, gabapentin was modestly effective
but drop-out rates were high. It may be useful for select groups
of patients.
Antidepressants
Certain antidepressants
are quite effective in preventing all forms of headache, including
migraine. The most effective ones include the following two classes:
- Tricyclic
antidepressants. They include amitriptyline (Elavil, Endep)
and protriptyline (Vivactil). The tricyclics may be particularly
useful for patients who suffer from both migraines and tension
headaches. Low doses may also help prevent cyclic vomiting in
childhood migraine.
- The selective
serotonin-reuptake inhibitors (SSRIs) and similar agents. These
include fluoxetine (Prozac), sertraline (Zoloft), paroxetine
(Paxil), and fluvoxamine (Luvox). Nefazodone (Serzone), which
is similar to the SSRIs, reduced the number of migraine attacks
by more than half in a majority of patients in one study.
The effects of
any of these antidepressants on headaches are most likely due to
their effects on serotonin, a chemical messenger in the brain that
influences depression and migraine. [For more extensive information
on antidepressants, including side effects,
8, Depression.]
Calcium-Channel
Blockers
Calcium-channel
blockers have been prescribed for preventing both migraine and cluster
headaches. They must be taken for weeks to months before any benefit
is noticed. Certain calcium-channel blockers may be particularly
beneficial for preventing migraines in migraine patients who have
experienced stroke.
Verapamil (Calan) is most commonly used for prevention of migraines.
Others used or being investigated for migraines include diltiazem
(Cardizem), nimodipine (Nimotop), nifedipine (Procardia), amlodipine
(Norvasc), felodipine (Plendil), and nisoldipine (Sular). Novel
calcium blockers, such as dotarizine and flunarizine, are being
investigated and show promise for migraines. Flunarizine, available
overseas but not in the US, is effective and may help prevent migraines
in children. (Other calcium-channel blockers are not useful for
children).
Side Effects. They vary among different preparations. They
may cause the following:
- Fluid
accumulation in the feet.
- Drop in
blood pressure, with accompanying dizziness.
- In some
people they cause headaches as severe as the migraines they
are preventing.
- Constipation.
- Fatigue.
- Impotence.
- Gingivitis.
- Flushing,
and allergic symptoms.
Note: Grapefruit
boosts the effects of calcium-channel blocking drugs.
Ergots
Ergotamine and
dihydroergotamine (DHE) are drugs known as ergots and are commonly
used to treat migraines [ see below ]. They are not generally
used for prevention because of the danger of dependency; they may
be used occasionally, however, to prevent predictable migraine
attacks, such as those that occur every month around menstruation.
Methysergide is a more recent ergot that has multiple actions on
serotonin and proven to be effective for protection. It has some
very severe side effects, however.
Hormonal
Agents
Hormonal agents,
such as oral contraceptives (OCs) or hormone replacement therapy,
have a mixed effect on women with migraines. In general agents that
keep hormone levels steady may be helpful.
Oral Contraceptives.
- Negative
Effects. Oral contraceptives have been associated with worse
headaches in 18% to 50% of women and have also been linked to
a higher risk for stroke in women with migraines. Young women
should avoid or stop oral contraception if they have auras preceding
migraines, if migraines worsen or change character after taking
birth control pills, if there is a family history of stroke
or heart disease, or if they smoke. Progestin-only oral contraception
particularly plays no positive role in migraine prevention,
although progestin injections (eg, Depo-Provera) that stop menstruation
can be helpful.
- Positive
Effects. Oral contraceptives, however, appear to help about
35% of women with migraines. Some evidence suggests that OCs
are effective for preventing menstrual migraines (which do not
have auras). In such cases, their benefits may outweigh the
low risk of a serious adverse event. Keeping a migraine record
for at least three menstrual cycles can help to confirm whether
a woman actually has a true menstrual migraine.
Hormone Replacement
Therapy. Some postmenopausal women with migraines reported fewer
headaches after taking estrogen replacement therapy, although some
studies suggest women who had menstrual migraines might have severe
headaches with hormone therapy.
Other
Agents Sometimes Used or Being Investigated for Preventing Migraines
Angiotensin
Converting Enzyme (ACE) Inhibitors. Commonly used for treating
high blood pressure, ACE inhibitors block the production of the
protein angiotensin, which constricts blood vessels and may involved
in migraine. In a small six-month 2000 trial, subjects tended to
have shorter and somewhat less severe migraines when they took the
ACE inhibitor lisinopril than when they took placebo. More trials
are needed.
Leukotriene-Antagonists. Leukotriene-antagonists are anti-inflammatory
agents that blocks leukotrienes, powerful immune system factors
that are important in causing airway constriction. They include
zileuton (Ziflo), zafirlukast (Accolate), montelukast (Singulair),
and pranlukast (Ultair, Onon). These agents are being used in asthma
and some physicians have observed a reduction in migraine frequency
in asthmatic patients who also had these headaches. In one study
that investigated their use for migraine prevention, more than half
of patients experienced a reduction in frequency of severe attacks.
They are not approved by the FDA for migraines, however, nor are
they routinely used by physicians.
WHAT
ARE THE NON-MEDICATION MEASURES FOR PREVENTING MIGRAINE HEADACHES?
Dietary
Factors
Avoiding Food
Triggers. Avoiding foods that trigger migraine is important
in people who are susceptible to these triggers. Keeping a headache
diary that includes tracking diet and headache onset can help identify
them. [ See Table Foods That May
Trigger Migraines.]
Healthy Diet. One study indicates that a diet low in fat
and high in complex carbohydrates may significantly reduce the frequency,
severity, and duration of migraine headaches. Such a diet is healthy
in general in any case.
Eating Regularly. Eating regularly is important to prevent
low blood sugar. People with migraines who fast periodically for
religious reasons might consider taking preventive medications.
Vitamin B2 Supplements. There is reasonable evidence on
the benefits of vitamin B2 for migraine sufferers. In one study,
patients who took 400 mg of vitamin B2 (riboflavin) reduced their
migraine attacks by half, although the vitamin had no effect on
the severity or duration of migraines that did occur. In another
study, it helped increase the effectiveness of beta-blockers, drugs
used to prevent migraines in some people. Vitamin B2 is generally
safe, although some people taking high doses develop diarrhea.
Smelling Pleasurable Foods. One interesting study suggested
that smelling certain pleasurable foods may reduce migraine pain.
(The study used green apples as part of the experiment; patients
with headaches who liked the smell of green apples had less pain.
The scent had no effect on those who didn't like the fruit.)
Foods
That May Trigger Migraines
|
Foods
|
Responsible
Chemical
|
Beers, wines, certain liquors, cheese and cheese-food products,
fresh and processed meat, seafood products, peas, pickles,
olives, and sauerkraut.
|
Tyramine and phenylethylamine. (These chemicals tend to become
more potent in foods that are stored improperly.)
|
Apple juice, coffee, red wine, and tea.
|
Tannin
|
Preservatives in wines, dried fruits, and other products.
|
Sulfites
|
A common seasoning, most notably found in food prepared by
Chinese restaurants but also contained in many commercial
products.
|
Monosodium glutamate
|
Chocolate.
|
|
Sleep
Hygiene
Improving sleep
habits is important for everyone, and especially those with headaches.
[For more details,
17,
Insomnia.]
Aerobic
Exercise
Exercise is certainly
helpful for relieving stress and an analysis of several studies
reported that aerobic exercise might help prevent migraines. It
is important, however, to warm up gradually before beginning a session,
since sudden, vigorous exercise might actually precipitate or aggravate
a migraine attack.
Behavioral
Treatments
Behavioral techniques
that reduce stress and empower the patient may help some people
with migraines. These methods generally include the following:
- Biofeedback
therapy.
- Cognitive-behavioral
therapy.
- Relaxation
techniques.
This approach
may help counteract the tendency for muscle contraction and uneven
blood flow associated with some headaches. They may be particularly
beneficial for pregnant and nursing women, who cannot take most
medications.
Biofeedback. Studies have demonstrated some effectiveness
from biofeedback for migraine headaches. Biofeedback training teaches
the patient to monitor and modify physical responses, such as muscle
tension, using special instruments for feedback.
Cognitive Behavioral Therapy. Behavioral therapy may be useful
alone but is particularly beneficial for patients who are on preventive
drug treatments. It typically employs the headache diary to track
activities and headaches. The patient then works with the therapist
to change or add behaviors or medications that will reduce the frequency
and severity of attacks.
Relaxation Techniques. Muscle relaxation techniques may
be helpful. One interesting 2001 study reported that relaxation
treatments appeared to help adolescents with migraine but not tension
headaches.
Alternative Treatments. Alternative therapies used for headache
management include hypnosis, meditation, visualization and guided
imagery, acupuncture, acupressure, yoga, and other relaxation exercises.
There is no clear evidence that any of these techniques have specific
value for migraines.
Electrical Stimulation. Small studies have found that therapy
with transcutaneous electrical stimulation (TENS) may reduce migraine
headache episodes:
- The TENS
procedure produces a very mild electrical sensation across the
skin.
- One course
of TENS takes about a half hour.
- It is
administered daily.
One report suggests
that using TENS with acupuncture points, along with self-hypnosis
and relaxation techniques, may be an effective management option
among patients with migraine headaches. In one study, TENS reduced
the frequency of migraines by 75%. In the study, patients were eventually
able to administer it to themselves at home. There were no side
effects.
WHERE
ELSE CAN MIGRAINE SUFFERERS GET INFORMATION?
National Headache
Foundation, 428 West St. James Place, 2nd Floor, Chicago, IL 60614-2750.
Call (888-NHF-5552) or (312-388-6399) or (http://www.headaches.org)
American Headache Society (http://www.ahsnet.org/)
and affiliated organization American Council for Headache Education
(http://www.achenet.org/)
19 Mantua Road, Mt. Royal, NJ 08061. Call (609-423-0258)
AHS Publishes the journal Headache (http://ahsnet.org/journal/)
MAGNUM (Migraine Awareness Group: A National Understanding for Migraineurs),
113 South Saint, Asaph Street, Suite 300, Alexandria, VA 22314.
Call (703-739-9384) or (http://www.migraines.org)
American Academy of Neurology, 1080 Montreal Avenue, St. Paul, Minnesota
55116. Call (651-695-1940) or (http://www.aan.com/)
Web site offers good information and provides names of neurologists
for specific locations.
National Institute of Neurological Disorders and Stroke Building
31, Room 8A18, 31 Center Drive, 2540, National Institutes of Health,
Bethesda, MD 20892-2540. Call (301-496-5751) or (800-352-9424) or
(http://www.ninds.nih.gov/)
American Medical Association information site for migraine (http://www.ama-assn.org/special/migraine/)
Upstate Medical University (State University of New York) has an
excellent migraine Website, designed for doctors, but accessible
to the patient, as well. (http://www.upstate.edu/neurology/haas/hpmirx.htm)
|
