MIGRAINE HEADACHES

Nothing in medicine is as controversial or more perplexing than migraine headaches.

A. They are often misdiagnosed.

B. The pathogenesis (what happens that causes a migraine) is constantly being re-defined or re-hypothesized. 

C. Patients who think they are taking a medicine that helps are often making them worse.

D. Many patients just accept migraines as part of life and dismiss effective treatment. 

Migraine headaches are the sixth most common cause of disability in the world. Of course that’s down the list, a bit, but since migraines are very disruptive, are really painful, and last 4 to 72 hours, that ranking is misleading. Migraines always severely disable the migraineur (patient with a migraine headache), so time lost from work and family have a familial economic impact. 

Typical migraine headaches are one-sided, throbbing and pounding, made worse by light, sound, and movement, and are accompanied by nausea, vomiting, and an accentuated sensitivity to external stimuli that renders the migraineur unable to function. It’s common for the sufferer to lie down alone in a quiet, dark room, and beg to be left alone until the headache goes away. The location of pain favors the forehead, nose, or other areas adjacent to the eye. 

Women are three times more likely to have this inherited disorder. If your mother had migraines, there’s a good chance you will, too. Migraines are frequently worse at the time of a menstrual period, but mercifully ease or disappear during or after menopause. From this, one might think there is a hormonal component to migraines, but nowhere have I found such a conclusion.

Migraine headaches are of two main types:

     Migraine with Aura

     Migraine without Aura

Aura is the reversible event occurring prior to the onset of headache pain and signals to the person a migraine headache will soon be coming. Aura occurs in about one-third of migraineurs. An Aura is most frequently an unusual visual phenomenon, but a strange sound, a strong noxious odor, or a physical body movement can be auras, too. Even epileptic seizures have been classed as an aura. An aura can last a few minutes to an hour or more and always precede the headache. Two-thirds of migraines are not preceded by an aura. And conversely, an aura can occur without a headache following. 

Migraines have numerous identifiable triggers, such as foods, drugs, and environmental changes. Common triggers are chocolate, caffeine, red wine and other alcoholic beverages, milk, cheese, nuts, citrus fruits, aspartame, processed meats, monosodium glutamate, and fatty foods. Fasting or missing a meal, lack of sleep, weather changes, odors such as strong perfumes, stress, and menstruation are other triggers. 

So much time and money have gone into researching what happens in the brain during a migraine, but the answer is still uncertain. It seems, though, the vascular spasm-vasodilation hypothesis is no longer accepted. What is known is the brain of a migraineur has a tendency to “lose control of its inputs;” it behaves abnormally resulting in severe head pain. During a headache “brain systems dysfunction,” but the exact mechanism for pain remains obscure.

Something occurs that generates a seriously painful headache that can last 3-4 days. After the headache subsides, the patient feels tired, listless, foggy-headed, and irritable for several days.

The focus for many patients is prevention of migraine headaches. Once a migraine has reached maximum severity, however, a patient’s only option is analgesia. Something must be taken to stop the pain. Multiple types of drugs are used to relieve migraines. Triptans such as Imitrex, Zomig, Relpax, Axert, Maxalt, Amerge, and Frova are first-line migraine treatment. Pure analgesics like NSAID’s and acetaminophen, and anti-nausea drugs are next, with narcotic analgesics a last resort. 

Migraine headache prevention is a broad subject. Volumes have been written on the topic and many headache clinics have opened that focus mainly on the preventive approach. It works for motivated, adherent patients who take their medicine. It starts by avoiding migraine triggers (see above) of all types, which in some instances is easy, but in others, not so. The next step is an elimination diet that avoids triggers, plus is high in brain-friendly substances. A diet such as a low fat diet, high in folate, low in omega-6 fatty acids, and high in omega-3 fatty acids is the recommended approach. You’ll need help from a dietician to make the right food choices, but this diet has been shown to help. 

Relaxation techniques, cognitive behavior therapy, electromyographic feedback, and even acupuncture have shown promise, as well. 

If headaches persist, or re-occur, the next option is drug prophylaxis. Numerous drugs have been tried, but beta blockers, calcium channel blockers, antidepressants, anti-convulsants, ACE inhibitors, and ARB’s have all been effective. Topamax, Tegretol, calcitonin, and even botulinum toxin type A have helped. After a period of trial and error, a single drug, or a combination of drugs, are taken daily to prevent migraines from occurring  

A new treatment concept for migraine is “surgical therapy.” This involves the identification of migraine trigger sites within the nerve structure of the scalp. Compression of these nerves by spasms of scalp muscles, “triggers” the severe pain of a migraine headache. Local injections of botulinum toxin type A into trigger sites have achieved remarkable, lasting relief in many patients. The “surgery” is actually a local injection of Botox which paralyzes the offending muscles. Success rates of up to 90% have been seen, and in 40% to 60% of cases, complete elimination of migraine symptoms has occurred.

In spite of the severity of the pain and lost time from work or family, migraine headaches go away. They can last 4 or 5 agonizing days, but there is an end point. There are, however, instances where patients’ headaches are caused by serious underlying problems and don’t go away. These patients have “red flag” symptoms that should grab the doctor’s attention and warrant additional investigation. The sudden “thunderclap” headache can be a subarachnoid hemorrhage. Fever and or a stiff neck with or without focal neurologic symptoms can be meningitis, encephalitis, or a brain hemorrhage. Any change in level of consciousness, ie. delirium, coma, is a serious sign, as is papilledema (swelling of the optic nerves due to increased pressure in the brain). Fortunately, “red flag” symptoms don’t happen very often, but when they do, the physician needs to look aggressively into what’s going on. 

Dr. G’s Opinion: Migraine headaches are quite painful and disruptive to life. My mother-in-law had migraines in the pre-triptan era. She had them once or twice a month, and each episode erased 2-4 days from her life. Her only treatment at the time were narcotic analgesics which caused her all sorts of problems. She passed the migraine gene to her daughter, my wife, but her migraine era was both pre- and post-triptan. Life changed for her when the first triptan, injectable Imitrex, came on the market. It was to be taken as soon as a migraine occurred to stop the “attack.” The first subcutaneous injection I gave her was accompanied by side effects so serious I thought I would need to do CPR, but within 20-30 minutes, the headache subsided and so did the side effects. She was headache-free. We thought we had found a miracle drug. 

She had success prophylactically with a calcium channel blocker, diltiazem, which was prescribed for something else. With diltiazem, her migraines all but disappeared. Then menopause eliminated them for good. By then, oral Imitrex was available, and despite a more acceptable route of administration, it never worked as quickly and completely as injectable Imitrex. Now, several stronger, more effective triptans are available, improving the lives of users.

Migraine headaches are a very bothersome problem. Your family doctor or neurologist can treat migraines effectively so work with him/her to find a regimen that works for you. There are now eight triptans available and any number of other preventive drugs. It’s a matter of trial and error until the right combination is found. Botox is being used more now, too, so treatment options have broadened. There’s no longer any reason a patient should suffer with migraines. Effective treatments and prevention are readily available and are beneficial if used persistently. 

References: Hindiyeh NA, Zheng N, et al. The Role of Nutrition in Migraine Triggers and Treatment: A Systematic Literature Review. J Head Facial Pain 2020 April;60:1300-1316.

Ha, H, Gonzalez A. Migraine Headache Prophylaxis Am Fam Phys 2019 January 1;99(1):17-24.

Guyuron, B. The evolution of migraine surgery: Two decades of continual research. Plast Reconstr Surg 2021 June 1;147(6):1414-1419.

Goadsby PJ, Holland PR, et al. Physiology of Migraine: A Disorder of Sensory Processing Physiol Rev 2017 April;97(2):553-622. 

Wormald, JCR et al. Surgical Intervention for chronic migraine headache: A systematic review.

JPRAS OPEN 2019 June;20:1-18.

Viera AJ, Antono B. Acute Headache in Adults: A Diagnostic Approach. Am Fam Phys 2022 September;106(3):260-268.