The audacity of some people! To call a migraine just a headache is almost a type of blasphemy. Millions of people suffer from debilitating migraines every year. Just like fibromyalgia and other conditions that have no outwardly visible effects, it is difficult for people to understand just how awful they are. Let me enlighten you.
A migraine is a type of vascular headache that causes severe throbbing pain or a pulsing sensation, often on one side of the head. The headache often comes with nausea, vomiting, and photophobia and phonophobia (sensitivity to light and sound). An attack can last for hours to days in some cases. The symptoms can be so severe that they can completely shut a person down for days. No garden variety simple headache can do that. This is why a migraine episode is often referred to as a migraine attack. It literally feels like you are under attack.
Let’s go through the possible stages of a migraine attack. The four stages are prodrome, aura, attack and post-drome.
Prodrome occurs one or two days before a migraine. Consider it like a sort of heads up or warning that a migraine is coming. Some symptoms you might experience are constipation, mood changes( depression to euphoria), food cravings, neck stiffness, increased thirst and urination, and frequent yawning.
Aura is something that might happen before or even during a migraine. The symptoms of an aura are reversible neurological symptoms. Usually they are visual symptoms like seeing various shapes, seeing bright spots, seeing flashes of light, loss of vision or tunnel vision. Sometimes a person feels pins and needles in an arm or leg. Sometimes there is weakness or numbness in the face or one side of the body. Some people get aphasia or difficulty speaking. Some people hear noises or music and have uncontrollable jerking or other body movements. Most often these symptoms appear and develop gradually and last for 20 to 60 minutes before the actual headache begins. These symptoms can be truly terrifying, especially if the person does not realize they are about to suffer from a migraine. Think about it. what actually differentiates these symptoms from possible stroke symptoms for example? Yup! Scary stuff. I can remember my first migraine at age 18. I was in college. I can remember suddenly losing vision in my left eye, tingling in my arm and then I had trouble speaking. I could not find a word to say my life without a struggle, if at all. I remember trying to call my mother and not actually being able to speak, which just terrified the both of us. My friends dragged me to the ER, but by the time I got seen several hours later( apparently an 18 year old with stroke symptoms was not concerning), the symptoms were gone and they sent me home…without any real information or guidance. This is how it goes for many patients during their first migraine attack.
The attack of headache itself usually lasts from four to 72 hours if untreated. During the attack, patient feels pain in one or both sides of the head. It usually throbs or pulses. There is intense sensitivity to light and sound. Aaaand let’s not forget nausea and vomiting. Only the best for migraine sufferers
The post drome consists of fatigue and feeling drained and even confused for up to a day. Your head feels sore almost. Even the slightest movement can bring the pain back. It is sometimes referred to as the migraine hangover.
So, we just finished talking about all the phases and the similarity to stroke symptoms. How do you know when to take it more seriously and see a doctor? Obviously, it is a good idea to see a doctor if you are experiencing chronic headaches with any kind of symptoms, just to be safe. When you go to the doctor, it is a great idea to keep a headache diary of all your episodes and symptoms and any triggers you have been able to determine. This will help the doctor get your diagnosis established more quickly and get you the help that you need that much sooner.
You should also see a doctor or go to the ER right away if you have any of the following symptoms: 1) An abrupt, severe headache almost light a thunderclap in your head, 2) A headache accompanied by fever, stiff neck, seizures, mental confusion, double vision, weakness, numbness or trouble speaking, 3) A headache or worsening headache after a head injury, 4) A chronic headache that is worse after coughing or straining or sudden movement, 5) A brain new kind of headache after the age of 50. Yes, there are some of these symptoms that can also occur with a migraine as well, so it can still be confusing. I would say err on the side of caution whenever your symptoms seem new or not consistent with your usual migraine. If you’re wrong, great. It’s a migraine only. If you are not wrong and you ignore it, you could actually be suffering from a stroke, meningitis, a brain tumor, a hematoma or worse.
So, what causes migraines? They aren’t fully understood yet, but we think that genetics and environmental factors might play a role. Researchers have studies changes in the brainstem and it’s interactions with the trigeminal nerve. The trigeminal nerve is a major pain pathway in the body. The trigeminal nerve is also called the fifth cranial nerve. It has branches that go along the temple, along the cheek, and along the jaw line. It is responsible for sensation int he face and motor functions like biting and chewing. Researchers are also studying the role of serotonin imbalances in migraine sufferers. This make sense since serotonin helps regulate pain in the nervous system. They are also lookig at the role of other neurotransmitters like calcitonin gene-related peptide. Stay tuned!
Now let’s look at some migraine triggers. These are just some common ones. They can be different for everybody. Hormonal changes in women are a trigger, especially fluctuations in estrogen before, during or after menses, pregnancy, and menopause. This is where that migraine diary I was referring to earlier comes in very handy. This type of migraine is sometimes referred to as a menstrual migraine because of it’s relationship to hormone changes. Sometimes oral contraceptives or hormone replacement therapy can make migraines worse. There is also some data that suggests that combined oral contraceptives and hormone replacement therapy may not be a good idea in migraine patients anyway because of possible stroke risk. There is other data that suggests hormone modulation may be very helpful. Other times women say that they feel better on these medications. There is not really a good way to determine ahead of time which group your patient will be in. There is some trial and error involved. Having said that, and just to add to the confusion, one of the best treatments that I have found for menstrual migraines is to have a patient put on an estrogen patch two days before their anticipated menses and wear it for several days into their period until the usual point when symptoms would resolve on their own. I have found that, in the right patient, I can eliminate the menstrual migraine almost immediately.
Other possible migraine triggers are drinks that contain alcohol, wine, and too much caffeine. Since migraines are vascular headaches, they may be triggered by things that affect our vasculature. Alcohol causes vasodilation ( dilation of blood vessels) . Caffeine causes vasoconstriction ( stricture of blood vessels). Interestingly, caffeine can become kind of a vicious cycle in migraine patients because it can sometimes ward off a headache in the early stages….and then it can also cause both migraines and caffeine withdrawal headaches. Caffeine is a tricky one. I try to counsel my patients to avoid it all together in the first place if possible. Remember that caffeine is found is several different sources: pop, coffee, chocolate, tea, and dairy products with added sweetener.
Stress is definitely a migraine trigger. This refers to any kind of stress at home or at work. Even stress from illness can trigger migraines. This is why it is important for migraine patients to discover stress relief techniques that work for them.
Sensory stimuli can be migraine triggers. Bright lights, sun glare, and loud sounds can trigger migraines. Strong smells like perfume, paint thinner, second hand smoke and others can trigger migraines. At our office, we have a scent free policy for all patients and vendors. People who show up with any kind of strong scent will be rescheduled. We have too many employees, myself included, that will be down for the count if they smell the wrong thing and then everybody will have to be rescheduled anyway. I wish people wouldn’t fight it so much. You don’t need to take a bath in perfume and then go to the doctor. I won’t be offended if you don’t smell like flowers, cakes, or pie. I promise!
Sleep changes can trigger migraines. Sleep changes refer to insufficient sleep, interrupted sleep, or jet lag
There are certain physical factors that can trigger migraines. Intense physical exertion can trigger migraines in some people. There is a phenomenon called post-climactic migraine as well. Some unfortunate patients get migraines immediately after sexual climax. Talk about unfair!
Weather changes that cause a change in barometric pressure can also cause migraines. This seems to be particularly evident with big changes in temperature or sudden changes like a storm that brews up quickly.
We talked about oral contraceptives and migraines earlier. Essentially, any medications that cause vasodilation can also trigger migraines. This includes medications like nitroglycerin, minoxidil, ACE inhibitors and hydralazine.
Certain foods can possibly trigger migraines like aged cheese, salt, or processed foods. Ironically, most of my migraine patients crave these exact foods. Remember when I talked earlier about cravings preceding a migraine? I think this relationship needs further exploration. I think it is possible, at least with regard to the cheese, that eating it might trigger some sort of histamine release since it is made of mold, almost like an allergic response. Histamine release can cause vasodilation and vasodilation can trigger migraines. This is just my theory at this point. Certain food additives like aspartame and MSG can also trigger migraines. I can image that it is because these additives also have salt. High levels of salt impair the function of the endothelium (lining of the wall) in our blood vessels. Once again, anything that affects the blood vessels can trigger migraines.
What are some risk factors for developing migraines? Family history is one. If you have a family member that gets migraines, you are more at risk for developing them too. Have we found the migraine gene yet? No. But, I am willing to bet that we will some day. Age is a factor as well. Most migraines begin in adolescence, seem to peak in the 30s and then slowly become less severe. This is not true for all patients however. Mine took a turn for the worse not the better in perimenopause, but then seem to be settling down again. Being female seems to be a risk factor for migraines. women are three times more likely to have migraines than men. I am assuming that is related to the whole fluctuating hormones issue.
Now lets talk about how to diagnose a migraine. For the most part, it consists of ruling out everything else. You go to see a doctor specializing in headaches, usually a neurologist. They take your history, family history, mediation history, etc and do a neurological exam. If everything they find is consistent with migraines, they diagnose you with migraines. If you have any unusual symptoms like I listed earlier, they may order an MRI or a CT scan to rule out other serious conditions like stroke, tumor, multiple sclerosis, etc.
What are some treatment options for migraines? They basically fall into two categories: non medication and medication therapies. A migraine diary is essential as the first component to pinpointing effective treatment. It can help to identify triggers and patterns. The first thing that I do with patients is to talk about trigger avoidance and lifestyle changes like avoiding caffeine and getting good sleep, etc. Some of my patients have also benefited from other options like acupuncture and cranio-sacral therapy. These methods are controversial to say the least. However, I am of the opinion that, if an option has not been shown to be harmful, you bet I am going to offer it to a patient.
There are migraine medications available as well. They can basically be divided into two categories: pain relief and prevention. The pain relief drugs are taken during attacks and help stop symptoms. the preventative medications are taking regularly, often on a daily basis to reduce the frequency and severity of migraines.
The pain reliever options fall into seven main options: straight pain relievers, triptans, dihydroergotamines, Reyvow, Ubrelvy, opioids, and anti-nausea drugs.
1) Straight pain relievers are over the counter or prescription medications like aspirin, ibuprofen or Excedrin. You have to be careful and not take these for a prolonged period of time because they can cause other problems like medication overuse headaches, ulcers and gastrointestinal bleeding.
2) Triptans are another category of medications that block pain pathways in the brain. They bind directly to 5ht1D/1B receptors in the intracranial vessels in the brain. They come in pills, nasal sprays, or shots. They are most effective when taken immediately upon onset of prodrome or attack. These are meds like Imitrex, Tosymra, and Maxalt. They may not be safe to use in patients who are at risk for stroke or heart attack.
3) Dihydroergotamines like D.H.E or Migranal are another category of medications. These medications are migraine-specific serotonin agonists that bind to multiple receptors in the brain. Remember how we talked about how important serotonin is in pain perception and transmission? These are most effective when taken shortly after start of symptoms for migraines that tend to last over 24 hours. They can have unpleasant side effects like worsening of migraine-induced vomiting and nausea. They come in nasal spray or injection. Just like triptans, they should be avoided in people with coronary artery disease, high blood pressure, kidney disease, or liver disease.
4) Lasmiditan(Reyvow) is in its own category. It binds to a different serotonin receptor in the brain, 5HT-1F. The exact mechanism is not known, but we assume it has an agonist effect. It is approved for migraine with or without aura. So far it has been great for improving pain, nausea, and sensitivity to light and sound. It is also unique because it is an oral medication. Patients have to be extra careful with this medication because it can cause drowsiness and sleepiness. It also shouldn’t be taken with alcohol or other central nervous system depressants.
5) Ubrogepant(Ubrelvy) is also in its own category. This is an oral calcitonin gene-related peptide antagonist. It is approved for acute migraine with or without aura in adults. It is the first drug of it’s type. So far it is very effective in reducing nausea, pain, and sensitivity to light and sound within two hours. Side effects include nausea, excessive sleepiness, and dry mouth. You cannot take Ubrelvy is you take other CYP3A4 inhibitor drugs like amiodarone ( blood pressure med), itaconazole ( anti-fungal), and clarithromycin (antibiotic).
6) Opioid medications are another category. Some people cannot take other migraine medications as we already discussed because of other medications or health conditions. These address pain only and have the side effects of drowsiness and are highly addictive. They should only be used if there is no other alternative.
7) Anti-nausea drugs are the last category. These are usually taken in combination with pain control medications and can help with nausea and vomiting. These are medicine like Reglan, Compro, Zofran, and Chlorpromazine.
Preventative medications fall into five main categories: blood pressure-lowering medications, antidepressants, anti-seizure drugs, botox, and calcitonin gene-related peptide monoclonal antibodies.
- Blood pressure-lowering medications include beta blockers like propranolol and metoprolol. They also include calcium channel blockers like verapamil. These are good at preventing migraine with aura. Side effects include drowsiness, dizziness, dry mouth, and cold hands
- Antidepressants are another category. Tricyclic antidepressants like amitryptiline ( Elavil) are good in treating chronic pain and are good in preventing migraine by increasing serotonin levels which then constricts intracranial blood vessels and helps stop a migraine from starting. The side effects include sleepiness and weight gain however.
- Anti-seizure drugs are another category. Migraine activity in the brain has been compared to seizure activity so it makes sense that anti-seizure meds could be helpful. Topamax and Depakote have been used. There are significant side effects with these medications like dizziness, weight changes, nausea, psychosis, etc. They can also cause seizures during the weaning process if a patient decides to go off of them. They are definitely not my favorite first line option.
- Botox injections are yet another category. Botox can be injected every 12 weeks in the areas around the eyes, nose, forehead and neck. This is successful in preventing migraines in some patients. Let’s remember that Botox comes from botulinum toxin, a toxin that causes flaccid paralysis and death. In the proper hands, it can causes minute, targeted, temporary relaxation in the desired muscles. In the wrong hands, side effects could be very serious.
- Last but not least comes the potential holy grail trio of medication options,: the calcitonin gene-related peptide monoclonal antibodies. This group of drugs include Almovig, Ajovy, and Emgality. They are all available in monthly injection. So far, they have been nothing short of amazing in patients with chronic migraine. I have had patients with daily migraines for years reduced to none at all! These medications have truly been lifesavers so far. So far, the most common side effect has been a possible reaction at the injection site. The only drawback at this point that I can appreciate is their considerable expense to the patient and the sometimes lengthy prior authorization process. Unfortunately, that always seems to be the case with a newer medication that is truly effective.
Last but not least, let’s talk about some alternative medicine options for migraines. Acupuncture is one option that we talked about earlier already. Biofeedback also seems to be effective in relieving migraine pain. It teaches the patient how to monitor and control certain involuntary physical responses ( like muscle clenching) to negative stimuli. The negative responses are monitored and the patient is taught how to recognize them and reverse them. There is some argument for cognitive behavioral therapy as well. This type of therapy teaches patients how behaviors and thoughts affect how they perceive pain. Herbs ,vitamins and minerals also play a role in migraine prevention and symptom reduction. Feverfew has been shown to potentially prevent migraines. Butterbur was recommended in the past, but now not so much because of safety concerns. Vitamin B2 (riboflavin)may be helpful in migration prevention and severity. There is some possible data on Coenzyme Q10, but more information is needed. Some research suggests that magnesium levels are low in migraine patients so magnesium supplements have been tried. The results are mixed so far.
Well, that was probably more than you ever wanted to know about migraines. I am sure there is a lot more to know in the future, but that’s all I have for now. I hope this was helpful and that you are now convinced that a migraine is not “just a headache.”