Migraine is a specific type of headache
that occurs in roughly 18% of women
and 6% of men
in the United States (Lipton).1
However, despite the large number of people affected by this condition the pathology
of migraine type headaches is still largely a mystery.
One of the reasons the pathology of migraine type headaches is difficult to pin down is that most patients complaining of migraine like symptoms also suffer from another type of headache as well.2 Since most migraineurs suffer from more than one type of headache, doctors often will either confuse migraine headaches in patients with another type of headache or vice versa. Several organizations, such as the International Headache Society, have tried to combat this by issuing guidelines on what constitutes a migraine and what does not.
According to IHS guidelines "common migraine" (the type without aura) symptoms needed for diagnosis consist of: At least 5 headaches that last 4 to 72 hours, with a unilateral location or pulsating quality or moderate to severe pain that inhibits activity such as climbing stairs; plus either nausea, photophobia or phonophobia where basic neurological exam rules out other diagnosis (IHS Diagnostic Criteria). The efforts of the IHS in their attempt to clearly define migraine have helped increase the amount of people reporting themselves as migraineurs to their physicians.3
Another important reason why migraines need to be accurately diagnosed is the stark physiological differences between migraine and other types of headaches. Common headaches stem from vasoconstriction of blood vessels in the brain, whereas migraine suffers have the opposite, their blood cells tend to dilate. This important difference often makes migraineurs feel worse when their physicians prescribe typical headache treatments such as beta-blockers which dialate the blood cells further (Coleman).
(However, there is an on-going debate as to what exactly the brain is doing during migraine. Some do not like the cell dilation theory. In order to form an opinion on this you probably want to read these two contradictory sources:
http://www.ama-assn.org/special/migraine/newsline/briefing/pain.htm and http://www.migraines.org/myth/mythreal.htm)
The fact that the tissue becomes inflamed before and during the onset of a migraine has lead many to conclude that the root cause of the disease is in the brain. However, because of the great differences in effectiveness that migraineurs have had with various treatments, it has given some in medicine pause to reconsider that idea. Current thinking holds that physiologically there probably is more than one type of migraine, so there is also probably more than one cause (Trust).4
Since the genesis of migraine is a mystery in most patients, doctors often have to try several different therapies before one is found that treats the patient's symptoms well.
Identifying an Attack
It is easiest to treat migraine in patients early in the headache's development. Early treatment only can be achieved however when a patient correctly identifies an on-coming migraine. In most individuals (although not all) there is at least one of several different warning signs.
The most common warning sign is called an aura. An aura is a visual disturbance that is defined by the IHS as, "focal cerebral dysfunction", which often impairs vision and balance and creates nausea (IHS Definitions).5 This "focal cerebral dysfunction", often manifests itself as spots in the field of vision, or as a sudden and short-term blackening of vision. Auras tend to precede a headache but in some cases can last the entire duration of an episode.
Another sign of an impending migraine, some patients report, is a tingling sensation or coldness in their extremities, particularly the fingertips. This sensation is probably due to the brain's increased need for blood since the tissues there are dilated, which pulls blood away from the hands and feet.
Another important thing migraine patients are taught to note, are their moods. Mood changes can be important signs of an approaching migraine. The reason mood changes are useful is because stress often times can be a trigger that sets off a migraine (IHS Definitions).
Along with stress, there are other triggers that can cause migraines in some patients. Much time is generally spent identifying these triggers in patients, because managing exposure, when possible, to these triggers can often be effective, non-medicinal treatment.
One of the triggers found in numerous studies is extreme change in the weather. One such Canadian study found that, "Weather characterized by a drop in barometric pressure, the passing of a warm front, high temperature and humidity and often times rain [are] closely associated with an increased frequency of migraine attacks (Coleman)." Which caused the researchers to conclude, "A number of migraine sufferers may be sensitive to extreme rates of barometric pressure change (Coleman)."
Female patients have also noted increased migraine frequency that corresponds with the beginning of their menstrual cycle. The increased frequency is thought to be because of lower levels of estrogen found in the blood during that time. Since menche-induced migraines can be predicted easily, this type of migraine is possibly the most effectively treated. In most patients a prophylactic regimen can stop the headaches before they become a problem, and in extreme cases, hormone therapy has been effective in stopping the migraines (Coleman).
Finally, some patients have found success altering their diet and avoiding foods that they associate with having migraines. While different foods act differently in people predisposed to migraine, certain foods have been noticed to cause more problems than others. These foods include, wines (and in some cases any alcohol) and heavily processed foods particularly meats and aged cheeses. The chemical reactions the brain has with these foods (with the exception of alcohol) are not very well understood, so the reason why they increase migraines in some individuals is not known.
The medicinal migraine treatments can be separated into two groups: preventative and acute attack.
Preventative medicines are taken on a daily basis, and as the name suggests are taken to reduce headache frequency. The most commonly prescribed drugs in this group are Selective Serotonin Reuptake Inhibitors or SSRIs. These drugs were first developed as anti-depressive medications to treat mental illness. It was only after the drugs came to market that their therapeutic abilities for migraine were discovered. Another class of drug that was found to help migraine sufferers in much the same way was anticonvulsants.
So why does a physician prescribe one kind of drug over another? The first reason typically is personal preference or philosophy. If a particular physician has had success in the past treating patients with one type of drug, they are more likely to favor a similar treatment in other patients. Another reason is potential side effects. Many of the drugs typically prescribed are not processed efficiently by the liver, and in some cases can cause liver damage. If the treatment is to be long term this kind of a side effect needs to be thought about. Other side effects that need to be thought about with these types of drugs are hallucinations, sexual side effects and weight or blood pressure change.
Presuming a physician is open to trying many different treatments, there are different drugs that work better treating certain symptoms. For example, older anti-depressants known as tricyclics, such as Doxepin, Amitriptyline and Imipramine tend help with insomnia as well as the migraine. Whereas the drugs, Effexor and Fluoxitene (commonly known as Prozac) treat both migraine and depression or anxiety. Finally, there are the anticonvulsants such as Depakote, Neurontin and Topamax that treat simply migraine.
Finally, there are other non-medicinal preventive treatments such as bio-feedback/transcendental meditation and acupuncture. Biofeedback is a relaxation technique that relies on the patients breathing and allows for greater body control. Typically, in the beginning of treatment, the patient has several electrodes attached to the body measuring muscle tension and a thermometer attached to an index finger. This allows a quantitative measure of the patient's ability to control his body. Biofeedback hinges on the patient being able to be aware of his breathing, but at the same time not control it. Mastering this self-control, allows the patient to control other aspects of the body such as muscle tension and body temperature. This can be therapeutically helpful for people whose migraine triggers include stress and anxiety.
Acupuncture works in much the same way as biofeedback, in that it helps combat stress and anxiety, but it achieves it in a different way. A physician administers (in the United States) acupuncture during which he places very thin needles in the back, abdomen, neck, feet and face. The needles are placed at an angle and barely puncture the skin. The needles are left in for up to an hour, and can be combined with a small electric current to increase the treatments effectiveness. After the needles are removed, many patients find that they are much "looser" and don't have much muscle tension.
The second type of treatment, treating an acute attack, is almost exclusively done with medication. Most migraine sufferers have a plan for when they get an acute attack with different medications to try if the migraine does not go away promptly.
One popular treatment is a class of drugs that were designed specifically for treating migraines, and attempt to force serotonin production in the brain. Examples of this include Imitrex or Sumatriptan and Zolmitriptan. Another class of drugs called antiemetics, which are commonly used to treat nausea have also been found to be helpful. Examples of this type of drug include Compazine and Reglan.
My Personal Treatments
I was first diagnosed with migraine (common) in 1993, when I was in the seventh grade. During this time I had a fairly regular migraine cycle. I would have minor attacks roughly once a week and full-blown attacks once every six weeks. The full-blown attacks would last two to three days, during which time I would be completely incapacitated.
I sought treatment, and was placed on a combination of Zoloft and Neurontin, after first trying beta-blockers, which were ineffective. At this point the migraines were a nuisance but not life altering.
During the next two years, I began seeking non-medicinal treatment as well. I reluctantly began biofeedback, which I thought was quackery. However, within six months I found that the therapeutic benefits helped me a lot. I also started acupuncture, which I also found very helpful.
Two years past, and despite the benefits of non-medicinal treatments, my headaches started getting worse. I was getting debilitating headaches much more frequently and it was disrupting my schoolwork.
As a result of the change in frequency my medications were changed frequently during this period, and finally I lost all confidence in the neurologist that was treating me. She (in my mind at least) was not open to my suggestions and tended to downplay my symptoms and their effects.
What was the cause of the headaches increased frequency? The fist and most logical choice was a change in neurochemistry due to hormones (I was 14). However, nothing seemed to help, and the migraines kept coming. During this time, I missed a significant amount of school. I like to call this my dark period, because the name works both literally and metaphorically, since this was the worst I felt for a sustained period of time and I had an extreme aversion to light. This period lasted from mid-November to January 1996.
When the headaches finally dissipated some on their own I began to look for the underlying cause of my problems. One suggestion that a family friend mentioned to me was something called "Neurally Mediated Hypotension", which she read was being studied at Johns Hopkins in Baltimore. After persuading my father who was not entirely sold on the idea, I went south to be tested.
The test for the disorder, which is essentially low blood pressure that fluctuates in certain circumstances, is called the tilt table test. My testing, was conducted this way:
I was placed on a table and strapped down with a heart monitor on. The nurse gave me an IV, and the medical technician tilted the table forward, with me on it, to roughly an ninty-five degree position. This meant that I was standing, with some support from the table. I waited there in that position for forty minutes with no noticeable change, other than the fact that I discovered that standing for long periods of time with nothing to do is really unpleasant. Then the nurse gave me a shot of synthetic adrenaline in the IV. My heart started to race and I began to sweat profusely. Visually, I had multiple auras in quick succession and my head began to pound. My visceral reaction would be with in the normal range, but the machinery recording my blood pressure showed something not normal. My blood pressure dipped and shot up repeatedly, making a line that looked like a roller coaster. That kind of cardiac response is not normal. With that result I failed the test and was diagnosed with the disorder.
As a result of my failure, we began treating the disorder with salt tablets and other drugs to keep my blood pressure up. I was pleased, I thought we had finally found the answer and we would be able to treat it. However, the migraines persisted, and would occasionally flair up like they did during my "dark period" some years before.
Sadly, we are still at the same point today. My migraines affect my studies too much and I try to plan my life around the headaches. I have tried many - too many in my opinion - of the drugs I mentioned before with varied success, and I am always on the lookout for new (and sometimes exotic) treatments. The only new information I have as of late is the diagnosis of the particular type of migraine I have - "Migraine Type 1 - chronic", which effects 2% of the migraine sufferers in the United States or 560,000 people (Lipton).
Personally, I think I might find some solutions in my Grandfather's medical history since he had similar migraines during his life. I am in the process of going through his treatment history now; I hope to have some new options soon. It's also my hope that the other twenty-eight million Americans can find some relief in one of the treatments I described.
1 Roughly 28 million people or 10% of all Americans suffer from migraines (Lipton).
2 Of physician diagnosed migraine patients, 44% also suffered from tension headache and 43.1% also suffered from sinus headache (Lipton).
3 "The proportion of migraineurs who reported a physician diagnosis of migraine in the United States has increased over the last decade - from 38% of all individuals with migraine in 1989 to 48% in the present report (Lipton)."
4 Current theories as to the cause of migraines include bacterial infection, gene abnormality, hyperactivity in the nervous system and various neurochemical imbalances.
5 From personal experience auras are generally the most aggravating component of a migraine aside from the general pain. Auras are the most aggravating because they tend to disorient, which causes a full body reaction. Whereas, some of the general head pain symptoms can be muted with medication or relaxation techniques such as biofeedback.
Coleman, John Michael and Burchfield, Terri Miller. "Migraines: Myth Vs. Reality" MAGNUM.
Ducros, Anne, et al. "The Clinical Spectrum of Familial Hemiplegic Migraine Associated with Mutations in A Neuronal Calcium Channel." The New England Journal of Medicine. Vol. 345, No.1, July 5, 2001.
Lipton, Richard B., MD, et al. "Migraine Diagnosis and Treatment: Results From the American Migraine Study II." Headache. Aug. 2001
"Stratified Care Versus Step Care Strategies for Migraine." Journal of the American Medical Association. Nov. 22/29, 2000.
"The Facts About Migraine". The Migraine Trust.
"International Headache Society Definitions."
"International Headache Society Diagnostic Criteria."