Often debilitating and misunderstood, migraine headaches and the options available to treat them are sources of much debate. Anger, frustration and desperation can plague both patients and physicians. Our panel navigates a case of migraine and the often confusing information that surrounds pain management and prevention.
There are several types of headache, but migraine is probably the most painful and debilitating. Migraine sufferers describe the pain as pulsing or throbbing, usually in one area of the head, and they can become nauseous, extremely sensitive to noise and light, and unable to do anything but lie down in a quiet, dark place. A typical migraine headache can last from four to seventy-two hours.
An estimated 28 million Americans get migraine headaches; 75% of them are women. That's about 18% of all women and 6% of all men (or about 12% of the population as a whole). Children can also get migraine; in fact, about 5 to 10% of children under 18 suffer from migraine. It can even affect infants, although most people develop the disorder between the ages of 5 and 35.
What causes migraine?
We don't know exactly what causes migraine headaches. Some older theories point to changes in blood flow to the brain caused by arteries narrowing (constricting) or widening (dilating). Some say these changes in blood vessels lead to biochemical changes in the brain, such as the release of various chemicals that either produce pain or increase sensitivity to it. Newer theories suggest that genes that control the activity of certain brain cells may be involved.
We also don't know why more women are affected than men, nor do we understand the relationship (if one exists) between female hormones and migraine. Some women get headaches around the time of their menstrual period; the headaches disappear when they're pregnant. But other women suffer their first migraines during pregnancy and still others after menopause. Similarly uncertain is the relationship between oral contraceptives and migraine. Some women say they have more frequent and severe migraines when they take oral contraceptives; others say the exact opposite.
Researchers around the world are investigating all these issues.
- An estimated 28 million Americans get migraine headaches; 75% of them are women. We don't know yet why more women than men are affected.
- All migraines can cause nausea and extreme sensitivity to light and sound as well as pain.
- "Classic" migraines start with "auras," such as seeing flashing lights, zigzag lines, or colors, which usually occur several minutes before the actual headache.
- "Common" migraines are the more frequent type, and do not begin with an aura (but some people do have "premonitions" that they will soon have an attack).
- Besides migraine, there are several other types of headache. Ninety percent of all headaches are probably tension headaches, a type of "muscle contraction headache" unrelated to migraine.
- Migraines are diagnosed mainly by the patient describing her or his symptoms, including frequency, severity, and longevity of the attacks. Other considerations include family history of migraines and the results of tests done to rule out other conditions.
- Migraine triggers are things that seem to provoke migraines in many people, including stress, certain foods, strong sensory input, intense physical exertion, environmental changes, and smoking.
- Migraine treatments include a variety of drugs, biofeedback training, stress reduction techniques, dietary changes that eliminate food triggers, and avoiding or eliminating other triggers.
Ask Your Doctor
This list of questions is a good starting point for discussion with your doctor; however, it is not a comprehensive list.
- Do I have migraine or some other form of headache? How do you know?
- What tests should I take to rule out serious conditions that can cause headaches?
- Please explain what happens during these tests, and how I should prepare for them.
- What suggestions can you give me to help me avoid migraine triggers?
- Should I be on a special diet?
- I take the following medications:________. Could any of them be involved in causing migraine headaches?
- What drugs can I take to reduce the symptoms of migraine?
- What drugs can I take to prevent migraines from even starting?
- How often should I take these drugs?
- What side effects can these drugs have?
- How likely is it that I will experience the side effects?
- What steps can I take to reduce or prevent these side effects?
- Do the benefits of these drugs outweigh the risks?
- What other treatments do you recommend?
- Can you discuss and compare their risks and benefits?
- Do you think I would benefit from biofeedback training?
- What lifestyle changes should I make to prevent migraine or reduce its effects?
Key Point 1
Migraine is a disease. Migraine headaches are real and can be disabling.
There are, in fact, several types of migraine. Most specialists refer to two basic types, classic and common. Both kinds of migraine can happen at any time and as often as a few times a week or as rarely as once every few years.
Classic migraines, which affect about 20% of migraine sufferers, start with one or more "warning signs" that tell the victims they will soon have a migraine. These are neurological symptoms that usually begin between half an hour and ten minutes before the actual headache, and can last for a few minutes only, or continue during and even after the headache. These symptoms are called "auras" and include:
- Temporary blindness
- Seeing flashing lights or colors
- Seeing zigzag lines
- Difficulty speaking
Some classic migraine sufferers also talk about feeling weak in an arm or leg, feeling a tingling or burning in the hands or face, or feeling vaguely depressed, irritable, or confused before a headache. The pain of a classic migraine usually begins on one side of the head and may or may not move to the other.
Common migraines do not start with an aura. But some people do notice other, often vague, "premonitions" that they will have a migraine. These include:
- Feeling mentally blurry
- Changes in mood, such as feeling unusually energetic or elated or feeling the opposite (angry or depressed)
- Craving sweets
- Fluid retention
The pain of a common migraine often lasts longer than that of a classic migraine, but it also usually begins on one side of the head and may or may not move to the other.
Other Types of Migraine
The National Institute of Neurological Disorders and Stroke (NINDS), one of the National Institutes of Health (NIH), describes several other, less common types of migraine, including:
- Hemiplegic migraine, which causes temporary paralysis on one side of the body
- Ophthalmoplegic migraine, which causes pain around the eye and is associated with a droopy eyelid, double vision, and other vision problems
- Basilar artery migraine, which is suffered mostly by female adolescents and young adults and whose symptoms include vertigo, double vision, and poor muscular coordination
- Benign exertional headache, which is brought on by running, lifting, coughing, sneezing, or bending and rarely lasts more than several minutes
- Status migrainosus, a rare, severe migraine that can last 72 hours or longer and causes such intense pain and nausea that victims often must be hospitalized
- Headache-free migraine, which causes many migraine symptoms (such as visual problems, nausea, vomiting, constipation, or diarrhea) but does not cause actual pain
You can get more information about these conditions at NINDS.
Other Types of Headache
In addition to migraine, there are several other types of headache. In fact, migraine itself is one type of headache within a larger category. The categories are:
- Muscle contraction: the most common category of headache, thought to be caused by the tightening (tensing) of neck and facial muscles. Two types of muscle contraction headaches are:
- Tension, which are temporary (relatively short duration) and often brought on by stress. Ninety percent of all headaches are probably tension/muscle contraction headaches
- Chronic, which can last for days, weeks, or longer
- Vascular: headaches caused by (or thought to be caused by, though the actual causes may be different) problems in the brain's blood vessels (vascular system). Migraine is often considered a type of vascular headache. Other vascular headaches include:
- Cluster headaches, a relatively rare but extremely painful type of headache that happens in "clusters", that is, at the same time(s) of day for several weeks. Cluster headaches generally begin with pain on one side of the head, often behind or around one eye and may be preceded by symptoms similar to the aura of a migraine
- Toxic headache caused by fever from diseases such as pneumonia, measles, mumps, and tonsillitis
- Toxic headache caused by exposure to various chemicals, such as
- Nitrite compounds, found in some heart medicines and in processed meats, such as hot dogs
- Monosodium glutamate (MSG), found in various packaged foods, such as soy sauce
- "Common" poisons, such as insecticides, carbon tetrachloride, and lead
- Chemical solvents (such as benzene) found in turpentine, spray adhesives, rubber cement, and inks
- Drug-related headache
- Alcohol hangover headache
- Chronic high blood pressure headache
- Traction: headaches that are symptoms of other diseases or conditions
- Inflammatory: headaches that are also symptoms of other diseases or conditions. The diseases/conditions range from sinus infection to stroke
You can get detailed information about the symptoms and treatment of these types of headaches at NINDS.
Key Point 2
Dealing with migraines can be very frustrating for the patient and doctor. Effective communication is critical to the treatment process.
The process of diagnosing migraine begins with patient/doctor communication. As described in Key Point 1 there are many types of headaches. To be sure your headaches are actually migraines, your doctor will start by asking for a detailed description of their severity, longevity, frequency, and other symptoms. For example, you'll be asked if the headaches are preceded by auras, whether they cause nausea, or sensitivity to light and noise, all symptoms of migraine.
You'll also be asked about what seems to provoke or help bring on your headaches. Although we don't know exactly what causes migraine, we do know that certain things seem to trigger them in many people. These so-called "migraine triggers" include:
- Stress (and other emotions). Some people develop migraine hours after a stressful situation, including the middle of the night during sleep; they may be having a delayed reaction to the stress.
- Food, including common items such as:
- Aged cheese
- Alcohol, especially beer and red wine
- Aspartame (an artificial sweetener)
- Caffeine (in excess)
- Certain canned or processed foods
- Fermented, pickled or marinated foods
- Lima beans, and some other beans
- MSG (monosodium glutamate, often found in seasonings and Asian food served in restaurants)
You'll find a more detailed list of possible "food triggers" at the on-line resource Family Doctor Some scientists think "food triggers" contain chemicals that can constrict blood vessels, beginning a chain of events that leads to migraine. Others think these foods provoke an allergic reaction.
- Strong sensory input, such as:
- Glaring, flickering, or very bright lights
- Loud noises
- Strong smells, both pleasant (flowers, perfume) and unpleasant (smoke, some chemicals)
- Intense physical exertion (including sexual activity)
- Tiredness or changes in normal sleep pattern
- Changes in environment, including:
- Humidity (barometric pressure)
- Time zone
- Fasting or missing meals
- Some medicines
Another important consideration in the diagnosis of migraine is your family history. The exact genetic nature of migraine is not yet known, but it does seem that having one parent with a history of migraine is a risk factor, and having both parents with them is an even stronger one. (Risk factors are things that increase your chance of developing a disease or condition, but they do not mean you definitely will get it.)
Finally, to rule out other possible conditions that could be causing headache pain (such as thyroid disease, anemia, and some infections, as well as an aneurysm [an abnormal ballooning of a blood vessel], meningitis and certain brain tumors), your doctor may order some tests, such as:
- Blood tests
- Electroencephalogram (EEG): a painless test in which electrodes are attached to the head to measure brain activity (somewhat similar to the electrocardiogram or EKG which measures heart activity)
- Computerized tomography (popularly known as CT scan or "CAT scan"): a sophisticated imaging system that creates a series of very detailed, cross-sectional images. In this case, a CT scan of the brain can detect bleeding blood vessels or tumors.
- MRI (magnetic resonance imaging): an imaging technique that "sees through" bones and other obstructions (like an x-ray) to produce detailed cross-sectional pictures ("slices") of internal organs and body part. An MRI of the brain can also help locate bleeds or tumors.
- Angiogram: an x-ray of the inside of the arteries. A contrast dye is injected into the patient and it is carried by the bloodstream into the brain. This enables problems in the blood vessels to be seen on the x-ray.
- Lumbar puncture (spinal tap): a test in which a small amount of cerebrospinal fluid (CSF) is removed between two vertebrae in the lower back and then sent to the lab for analysis. This analysis can detect a variety of conditions including meningitis.
When a reliable diagnosis is reached, treatment and/or management can begin.
Key Point 3
While there is no cure for migraine, effective management of migraine is possible through lifestyle changes and pharmacologic interventions.
Currently, the most common ways to prevent and control migraine involve medicine, biofeedback training, dietary changes to eliminate "food triggers," and stress reduction.
Medicine can be used to prevent migraine headaches or relieve the pain and other symptoms after they happen.
Symptom relief drugs include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs): these are the well-known non-prescription, over-the-counter (OTC) drugs marketed for headache relief, such as aspirin, acetaminophen, ibuprofen (the generic name for Advil, Motrin, and others), etc. However, they may not be strong enough to combat migraine. And NSAIDs can cause gastrointestinal problems (such as ulcers or bleeding) if they're taken too often or in too large amounts.
- Triptans: these are expensive but fairly effective drugs that, when taken early in a migraine attack, can reduce not only the pain but also the nausea and sound and light sensitivity it may cause. Seven triptans are currently available; they differ in their effectiveness and side effects. They are:
- Sumatriptan (Imitrex)
- Rizatriptan (Maxalt)
- Naratriptan (Amerge)
- Zolmitriptan (Zomig)
- Almotriptan (Axert)
- Rrovatriptan (Frova)
- Eletriptan (Relpax)
Triptans should not be taken by people:
- Who have had a stroke or heart attack
- With coronary artery disease
- Who suffer from angina (chest pain)
- Who suffer from basilar migraine
- With severe hypertension (high blood pressure)
- Who suffer from vascular disease
- With liver disease
- Who smoke
Triptans should be prescribed with caution for:
- Men over 40
- Women over 50
- People with high cholesterol
- People with diabetes
- Significantly overweight people
- People with a family history of early heart attack or stroke
- Ergots: Ergotamine tartrate (Ergomar) is an older, less expensive, but less effective drug than the triptans. It works by constricting the blood vessels in the brain that may expand (dilate) during an attack. Dihydroergotamine is a newer form of ergot that appears to be more effective and have fewer side effects
- Other drugs sometimes prescribed include anti-nausea drugs, the sedative butalbital combined with aspirin, acetaminophen, caffeine or codeine, and opiates (narcotics) for conditions that don't respond to other medicines.
Preventative medicines, often prescribed for people who have migraines several times a month, need to be taken carefully, as they can have serious side effects. These medicines include:
- Drugs developed specifically to treat migraine, such as Serotonin agonists which imitate the effects of serotonin, an important brain chemical
- Drugs known primarily for treating other conditions, such as
- Anti-depressants (used to treat depression)
- Cardiovascular drugs (used to treat high blood pressure and coronary artery disease)
- Anti-seizure drugs
Biofeedback is the general term for techniques that teache people how to monitor and control various body functions. Two types of biofeedback are thermal biofeedback, which teaches people how to consciously raise the temperature of their hands, and electromyographic or EMG training, which teaches people how to control muscle tension in the face, neck, and shoulders. Learning these techniques takes time and commitment, but both have been shown to be very effective in treating and preventing migraine. Biofeedback training can also help reduce stress. (See "stress reduction" below.)
Dietary changes may help people who are especially sensitive to the foods that appear to trigger migraine. (For more information on this, go to Key Point 2). Eliminating these foods may significantly reduce the number of migraines. Other people may be helped by diets that prevent low blood sugar (hypoglycemia), which can cause headache. Your doctor can give you a special diet to stabilize your blood sugar level. The blood sugar level can also drop during normal sleep periods, when you don't eat. One treatment for this is to eat smaller, more frequent meals.
Stress reduction is good for everyone, even those without migraine. Stress has been implicated in an array of conditions, from heart problems to migraine. In fact, "ordinary," non-migraine headaches are primarily the product of stress. Any steps you can take to reduce stress, from biofeedback training to regular exercise to learning relaxation techniques to taking a vacation, can be very beneficial to your general health and especially helpful in preventing migraine.
Some alternative, complementary, or non-traditional treatments, such as acupuncture, massage, some herbs, vitamins and minerals, may have some benefits, though more clinical testing is needed before they can be absolutely recommended.
Conduct an off-site search for Migraine information from MedlinePlus. These up-to-date search results are based on search terms specific to Second Opinion Key Points.