SAN DIEGO–William N. Devor, M.D., lead physician in sleep medicine and assistant chief of the Neurology Department for Kaiser Permanente San Diego, offers insight on the causes and treatments of migraines as part of National Migraine Awareness Month.
“Migraine suffering is common, affecting upwards of 18% of the population, and for those who face them on a regular basis, you know, a migraine is more than just a headache. Yet with the proper understanding of the triggers, migraines can be avoided,” said Devor.
He described the perfect storm for a migraine as the combination of weather conditions, sleep patterns, low blood sugar, motion sickness, odors, smoke, and diet choices.
The word migraine is derived from the Greek word hemicranium which means half-head, as migraine headaches are often worse on one side of the head. The symptoms, triggers and treatments vary by individual.
· Pain in the temple and around the eye that worsens, and throbs
· Sensitivity to bright light
· Blurred vision with black spots surrounded by sparkling halos
· A vague sense of numbness on the side of the body
In about a quarter of patients with migraines, there are associated neurological symptoms including disturbance of vision, vertigo, numbness affecting portions of the body and speech difficulty. Sometimes the neurological symptoms can precede the development of the headache and are referred to as migraine auras. The pain from migraine becomes worse with exertion.
Migraines can occur unpredictably but in many patients, triggers can be identified. Some of these include:
· Weather conditions, particularly storms with low atmospheric pressure and Santa Anas with high atmospheric pressure.
· Low blood sugar from skipping a meal
· Motion sickness or sea sickness
· Odors such as heavy perfumes, diesel exhaust, chemical fumes and cigarette smoke
· Meats preserved with nitrites
· Alcohol, especially red wine
· Freshly baked breads
Sometimes a single trigger will not result in a migraine but when multiple triggers are present, there is a “perfect storm” leading to the migraine.
Treatment options for migraine depend partly on the frequency of the headaches. Most individuals with migraine suffer from them only occasionally. For them, sleep, when it comes, can finally alleviate the pain.
At the other end of the spectrum is Chronic Migraine where the headaches occur daily. Recent evidence indicates that medication overuse can transform a migraine from being occasional to daily. Even a single dose of a narcotic analgesic (drugs that relieve pain, can cause numbness and induce a state of unconsciousness) can worsen the natural history of migraine. Although for many patients, having a potent analgesic to use a few times a year can be a godsend.
For the majority of migraine sufferers, non-steroidal anti-inflammatories are effective including ibuprofen (Advil, Motrin), naproxen (Aleve) and aspirin. Caffeine can be helpful as well.
About 50% of migraines begin between the hours of 3:00 a.m. and 9:00 a.m. so that there is a tendency to wake up with them. A cup of coffee in the morning will sometimes make the headache disappear. An old folk remedy is to take two aspirin plus a can ice cold Pepsi or Coca-Cola as the caffeine in these beverages works with the aspirin.
The earlier medication is taken for the headache, the more likely it will be effective. If triggers are evident, then trying to eliminate them, if you can, is a good approach. Keeping regular sleep hours, avoiding foods that are triggers, avoiding alcohol and eating regularly generally help.
While exercise can worsen a migraine once it has started, regular exercise may actually help prevent migraines. Some of the triggers like changes in the weather and exposure to odors cannot be controlled.
There are a number of prescription medications available for migraine. Many of these are in a drug family called triptans. Triptans constrict blood vessels in the scalp. Since migraine, in the majority of patient, results from excessive blood flow to the scalp, constricting these blood vessels is therapeutic. The most commonly used triptan is sumatriptan or Imitrex. Others include naratriptan, rizatriptan and frovatriptan. Discovery of these compounds was a major breakthrough in the treatment of migraine as they are safe and effective.
For patients with frequent migraines, medications can be taken on a daily basis for prevention. Examples include propranolol, nortriptyline, valproate, gabapentin, pregabalin and topiramate. Non-prescription medications include magnesium and riboflavin.
Other medications can be used to treat nausea, some of which also help the headache. Promethazine, metoclopramide and prochlorperazine would be examples; however, the consensus presently is to avoid the usage of narcotic or opiate analgesics.
For those patients who have headaches that don’t respond to oral medications, Botox injections are used and can be dramatically effective. The use of Botox for treatment of migraine was approved by the FDA about 2-3 years ago after a lengthy series of randomized controlled drug trials. Dr. Andrew Blumenfeld pioneered this treatment and trained many San Diego physicians in the technique. Botox must be administered by injections. Small doses delivered through a thin needle are given to an average of about 20 sites over the face and head. The injections are temporarily painful but other than cosmetic effects, there are few if any significant side effects. The benefit is temporary and usually lasts about 3 months so that periodic re-treatment is necessary.
More information about migraine headaches is available on kp.org.