Migraines

A migraine can be disabling, with symptoms so severe, all you can think about is finding a dark, quiet place to lie down. Up to 17 percent of women and 6 percent of men have experienced a migraine.

In some cases, these painful headaches are preceded or accompanied by a sensory warning sign (aura), such as flashes of light, blind spots or tingling in your arm or leg. A migraine is also often accompanied by other signs and symptoms, such as nausea, vomiting, and extreme sensitivity to light and sound. Migraine pain can be excruciating and may incapacitate you for hours or even days.

Fortunately, management of migraine pain has improved dramatically in the last decade. If you've seen a doctor in the past and had no success, it's time to make another appointment. Although there's still no cure, medications can help reduce the frequency of migraine and stop the pain once it has started. The right medicines combined with self-help remedies and changes in lifestyle may make a tremendous difference for you.

A typical migraine attack produces some or all of these signs and symptoms:

• Moderate to severe pain, which may be confined to one side of the head or may affect both sides
• Head pain with a pulsating or throbbing quality
• Pain that worsens with physical activity
• Pain that interferes with your regular activities
• Nausea with or without vomiting
• Sensitivity to light and sound

When left untreated, a migraine typically lasts from four to 72 hours, but the frequency with which headaches occur varies from person to person. You may have migraines several times a month or just once or twice a year.

Not all migraines are the same. Most people experience migraines without auras, which were previously called common migraines. Some, however, have migraines with auras, which were previously called classic migraines. If you're in the second group, you'll likely have an aura about 15 to 30 minutes before your headache begins. Auras may continue after your headache starts or even occur after your headache begins. When you're experiencing an aura, you may:

• See sparkling flashes of light
• Perceive dazzling zigzag lines in your field of vision
• Experience slowly spreading blind spots in your vision
• Feel tingling, pins and needles sensations in one arm or leg
• Rarely, experience weakness or language and speech problems

Whether or not you have auras, you may have one or more sensations of premonition (prodrome) several hours or a day or so before your headache actually strikes, including:

• Feelings of elation or intense energy
• Cravings for sweets
• Thirst
• Drowsiness
• Irritability or depression

Migraine symptoms in children
Migraines typically begin in childhood, adolescence or early adulthood and may become less frequent and less intense as you grow older. In addition to physical suffering, severe headaches often mean missed school days and trips to the emergency department, as well as lost work time for anxious parents.

Children's migraines tend to last for a shorter time. But the pain can be disabling and can be accompanied by nausea, vomiting, lightheadedness and increased sensitivity to light. A migraine tends to occur on both sides of the head in children.

Children may also have all of the signs and symptoms of a migraine, nausea, vomiting, increased sensitivity to light and sound ý but no head pain. These "abdominal migraines" can be especially difficult to diagnose.

The good news is that some of the same medications that are effective for adults also work for children. Your child doesn't have to go through the pain and disruption of migraines. If your child has headaches, talk to your pediatrician. He or she may want to refer your child to a pediatric neurologist.

Although much about headaches still isn't understood, some researchers think migraines may be caused by functional changes in the trigeminal nerve system, a major pain pathway in your nervous system, and by imbalances in brain chemicals, including serotonin, which plays a regulatory role for pain messages going through this pathway.

During a headache, serotonin levels drop. Researchers believe this causes the trigeminal nerve to release substances called neuropeptides, which travel to your brain's outer covering (meninges). There they cause blood vessels to become dilated and inflamed. The result is headache pain.

Migraine triggers
Whatever the exact mechanism of headaches, a number of things may trigger them. Common migraine triggers include:

• Hormonal changes. Although the exact relationship between hormones and headaches isn't clear, fluctuations in estrogen seem to trigger headaches in many women with known migraines. Women with a history of migraines often report headaches immediately before or during their periods, and this corresponds to a major drop in estrogen. Others have an increased tendency to develop migraines during pregnancy or menopause. Hormonal medications, such as contraceptives and hormone replacement therapy, also may worsen migraines.
• Foods. Certain foods appear to trigger headaches in some people. Common offenders include alcohol, especially beer and red wine; aged cheeses; chocolate; fermented, pickled or marinated foods; aspartame; overuse of caffeine; monosodium glutamate, a key ingredient in some Asian foods; certain seasonings; and many canned and processed foods. Skipping meals or fasting also can trigger migraines.
• Stress. A hard week at work followed by relaxation may lead to a weekend migraine. Stress at work or home also can instigate migraines.
• Sensory stimuli. Bright lights and sun glare can produce head pain. So can unusual smells ý including pleasant scents, such as perfume and flowers, and unpleasant odors, such as paint thinner and secondhand smoke.
• Changes in wake-sleep pattern. Either missing sleep or getting too much sleep may serve as a trigger for migraine attacks in some individuals.
• Physical factors. Intense physical exertion, including sexual activity, may provoke migraines.
• Changes in the environment. A change of weather, season, altitude level, barometric pressure or time zone can prompt a migraine.
• Medications. Certain medications can aggravate migraines.

Many people with migraines have a family history of migraine. If both your parents have migraines, there's a good chance you will too. Even if only one of your parents has migraines, you're still at increased risk of developing migraines.

You also have a relatively higher risk of migraines if you're young and female. In fact, women are three times as likely to have migraines as men are. Headaches tend to affect boys and girls equally during childhood but increase in girls after puberty.

If you're a woman with migraines, you may find that your headaches begin just before or shortly after onset of menstruation. They may also change during pregnancy or menopause. Many women report improvement in their migraines later in pregnancy, but others report that their migraines worsened during the first trimester. If pregnancy or menstruation affects your migraines, your headaches are also likely to worsen if you take birth control pills or hormone replacement therapy (HRT).

Migraines are a chronic disorder, but they're often undiagnosed and untreated. If you experience signs and symptoms of migraine, track and record your attacks and how you treated them. Then make an appointment with your doctor to discuss your headaches and decide on a treatment plan.

Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different. See your doctor immediately or go to the emergency room if you have any of the following signs and symptoms, which may indicate other, more serious medical problems:

• An abrupt, severe headache like a thunderclap
• Headache with fever, stiff neck, rash, mental confusion, seizures, double vision, weakness, numbness or trouble speaking
• Headache after a head injury, especially if the headache gets worse
• A chronic headache that is worse after coughing, exertion, straining or a sudden movement
• New headache pain if you're older than 50

If you have typical migraines or a family history of migraines, your doctor will likely diagnose the condition on the basis of your medical history and a physical exam. But if your headaches are unusual, severe or sudden, your doctor may recommend a variety of tests to rule out other possible causes for your pain.

Computerized tomography (CT)
This imaging procedure uses a series of computer-directed X-rays that provides a cross-sectional view of your brain. This helps doctors diagnose tumors, infections and other possible medical problems that may be causing your headaches.

Magnetic resonance imaging (MRI)
MRIs use radio waves and a powerful magnet to produce very detailed cross-sectional views of your brain. MRI scans help doctors diagnose tumors, strokes, aneurysms, neurological diseases and other brain abnormalities. An MRI can also be used to examine the blood vessels that supply the brain.

Spinal tap (lumbar puncture)
If your doctor suspects that an underlying condition, such as meningitis or subarachnoid hemorrhage, is the cause of your headaches, he or she may recommend a spinal tap (lumbar puncture). In this procedure, a thin needle is inserted between two vertebrae in your lower back to extract a sample of cerebrospinal fluid (CSF) for laboratory analysis. The procedure takes about 30 minutes. You may feel pressure while the fluid is extracted and have a headache afterward because of a drop in CSF pressure.

Sometimes your efforts to control your pain cause problems. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, others) and aspirin, may cause abdominal pain, bleeding and ulcers, especially if taken in large doses or for a long period of time.

In addition, if you take over-the-counter or prescription headache medications more than two or three times a week or in excessive amounts, you may be setting yourself up for a serious complication known as rebound headaches. Rebound headaches occur when medications not only stop relieving pain, but actually begin to cause headaches. You then use more pain medication, which traps you in a vicious cycle.

Serotonin syndrome
A potentially life-threatening drug interaction, called serotonin syndrome, can occur if you take migraine medicines called triptans, such as sumatriptan (Imitrex) or zolmitriptan (Zomig), along with antidepressants known as selective serotonin reuptake inhibitors (SSRIs) or selective serotonin and norepinephrine reuptake inhibitors (SNRIs). Some common SSRIs include Zoloft, Prozac and Paxil. SNRIs include Cymbalta and Effexor. Fortunately, serotonin syndrome is exceedingly uncommon.

A variety of drugs have been specifically designed to treat migraines. In addition, some drugs commonly used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories:

• Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms that have already begun.
• Preventive medications. These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.

Choosing a strategy to manage your migraines depends on the frequency and severity of your headaches, the degree of disability your headaches cause, and your other medical conditions. You may be a candidate for preventive therapy if you have two or more debilitating attacks a month, if you use pain-relieving medications more than twice a week, if pain-relieving medications aren't helping, or if your migraine signs and symptoms include a prolonged aura or numbness and impaired movement on one side of your body.

Some medications aren't recommended if you're pregnant or breast-feeding. Some aren't used for children. Your doctor can help find the right medication for you.

Pain-relieving medications
For best results, take pain-relieving drugs as soon as you experience signs or symptoms of a migraine. It may help if you rest or sleep in a dark room after taking them:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such as ibuprofen (Advil, Motrin, others) or aspirin, may help relieve mild migraines. Drugs marketed specifically for migraine, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraines, but aren't effective alone for severe migraines. If over-the-counter medications don't help, your doctor may suggest a stronger, prescription-only version of the same drug. If taken too often or for long periods of time, NSAIDs can lead to ulcers, gastrointestinal bleeding and rebound headaches.
• Triptans. For many people with severe migraine attacks, triptans are the drug of choice. They are effective in relieving the pain, nausea and sensitivity to light and sound that are associated with migraines. Sumatriptan (Imitrex) was the first drug specifically developed to treat migraines. Related medications include rizatriptan (Maxalt), naratriptan (Amerge), zolmitriptan (Zomig), almotriptan (Axert), frovatriptan (Frova) and eletriptan (Relpax). Side effects of triptans include nausea, dizziness, muscle weakness and, rarely, stroke and heart attack. In recent studies, a single-tablet combination of sumatriptan and naproxen sodium relieved migraine symptoms more effectively than did either individual medication. This combination tablet will likely be marketed soon.
• Ergots. Ergotamine (Ergomar) has been in use for more than 60 years and was a common prescription for migraine before triptans were introduced. Ergotamine is much less expensive, but also less effective, than triptans. Dihydroergotamine is an ergot derivative that is more effective and has fewer side effects than ergotamine.
• Anti-nausea medications. Since migraine attacks are often accompanied by nausea with or without vomiting, medication for treatment of these symptoms is appropriate and is usually combined with other medications. Frequently prescribed medications are metoclopramide (oral) or prochlorperazine (oral or rectal suppository).
• Butalbital combinations. Medications that combine the sedative butalbital with aspirin or acetaminophen are sometimes used to treat migraine attacks. Some combinations also include caffeine or codeine. These medications, however, have a high risk of rebound headaches and withdrawal symptoms and accordingly should be used infrequently.
• Opiates. Medications containing narcotics, particularly codeine, are sometimes used to treat migraine pain when people can't take triptans or ergots. These drugs are habit-forming and are usually used only as a last resort.

Preventive medications
Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks. Your doctor may recommend that you take preventive medications daily, or only when a predictable trigger, such as menstruation, is approaching.

In most cases, preventive medications don't eliminate headaches completely, and some can have serious side effects. For best results, take these medications as your doctor recommends:

• Cardiovascular drugs. Beta blockers, which are commonly used to treat high blood pressure and coronary artery disease, can reduce the frequency and severity of migraines. These drugs are considered among first-line treatment agents. Calcium channel blockers, another class of cardiovascular drugs, especially verapamil (Calan, Isoptin), also may be helpful. In addition, the antihypertensive medications lisinopril (Prinivil, Zestril) and candesartan (Atacand) are useful migraine prevention medications. Researchers don't understand exactly why all of these cardiovascular drugs prevent migraines. Side effects can include dizziness, drowsiness or lightheadedness.
• Antidepressants. Certain antidepressants are good at helping prevent all types of headaches, including migraines. Most effective are tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and protriptyline (Vivactil). These medications are considered among first-line treatment agents and may reduce migraines by affecting the level of serotonin and other brain chemicals. You don't have to have depression to benefit from these drugs. Newer antidepressants, however, generally aren't as effective for migraine prevention.
• Anti-seizure drugs. Although the reason is unclear, some anti-seizure drugs, such as divalproex sodium (Depakote) and topiramate (Topamax), which are used to treat epilepsy and bipolar disease, seem to prevent migraines. Gabapentin (Neurontin), another anti-seizure medication, is considered a second-line treatment agent. In high doses, however, these anti-seizure drugs may cause side effects, such as nausea and vomiting, diarrhea, cramps, hair loss and dizziness.
• Cyproheptadine. This antihistamine specifically affects serotonin activity. Doctors sometimes give it to children as a preventive measure.
• Botulinum toxin type A (Botox). Some people receiving Botox injections for their facial wrinkles have noted improvement of their headaches. The mechanism by which Botox might prevent migraines is unclear, although the drug may cause changes in your nervous system that modify your tendency to develop migraines. Studies using Botox injections for migraines have had mixed results. Additional research is necessary. Still, if several other preventive medications have failed to control your headaches, you might talk to your doctor about trying Botox.

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