Migraine is a severe episodic headache that affects about five percent of men and about fifteen to seventeen percent of women. Over eighty percent of these people suffer some degree of headache-related disability. In the United States, the estimated annual cost, including costs of direct medical care and lost productivity, exceeds seventeen billion dollars annually. We know that the disorder is at least four thousand years old, as evidenced by allusions in ancient medical texts.
In practice, there are, broadly speaking, two types of migraine.
- The most common is called migraine without aura (common migraine), and this accounts for about eighty-five percent of all sufferers. People who experience migraine without aura have episodes of severe pain that usually affect only one side of the head. (The name "migraine" comes from the Greek "hemicranin," meaning half a head.) Although they may be bilateral, the headache is usually described as throbbing, although again this is not invariable. The signature of these headaches is that they are usually associated with feeling sick in the stomach or being sensitive to light, sound, or even any sudden movement of the body. The sufferer usually wishes to avoid all environmental stimuli and wishes to lie down in a dark and quiet room, waiting for the storm to pass.
- The second most common type is called migraine with aura (classical migraine). This accounts for most of the remaining fifteen percent of sufferers. In this type of migraine, the sufferer will often report some disturbance in the nervous system before the headache begins. Typical disturbances involve the vision with bright flashing lights, black spots, or partial loss of vision. There may also be some numbness and tingling over one side of the body. These disturbances are usually short-lived, being less than one hour for most sufferers, and they usually leave no long-term effects. Much has been written about the migraine aura and the various neurologic symptoms that may be associated with it. Anything from speech and language disturbance, inability to calculate, mild confusion, severe dizziness, and even abdominal pain in children have all been associated with migraine.
The headache phase of the bout follows the aura and varies from mild discomfort to intense and disabling pain. The head pain can last from a few hours to several days, but it persists for less than a day in most people. The one-sided nature of the pain has already been mentioned, but do remember that migraine head pain is one-sided in only sixty to seventy percent of patients. The pain may be bilateral at the onset of the attack, or begin on one side and then become generalized as the bout continues.
In patients with one-sided pain, the side affected in different attacks may vary or may be invariably on the same side in each attack. The pain is usually located in the front or side of the head, or in, around, or behind the eye. But any region of the head and face may be affected, including the side of the head and the back of the head, and even the jaw and teeth may be all involved. Many patients state, "It is my sinuses," because the pain is located in the middle of the face. Rest assured that in the vast majority of cases it is not "sinusitis," but rather the pain of migraine being "referred" to different regions of the head and neck. It would be just as foolish for someone complaining of a heart attack to go to an orthopedic surgeon because the left arm is painful, as it would be for a migraine sufferer to go to an ENT because the front of the face hurts or go to a dentist because there is pain in the teeth.
Migraine pain is typically diminished by lying or sitting still and is increased by any activity or effort, or by any active or passive head movement. As mentioned, intolerance of light, known as photophobia, and intolerance of noise, known as phonophobia, are the most frequent symptoms accompanying the head pain. Approximately ninety percent of patients experience nausea, and vomiting affects about fifty percent. Other gastrointestinal symptoms are common and include lack of appetite, diarrhea, constipation, abdominal distention, and cramps. Other patients complain of blurry vision, facial pallor, nasal congestion, cold and clammy hands and feet, etc.
Many migraine sufferers will have changes in their psychological and mental state during an attack. Many will feel depressed, hostile, and irritable. Some will feel lethargic or sleepy. Minor cognitive changes are common, including an inability to concentrate, poor memory, and difficulty with abstract thought.
Fortunately, in most sufferers the pain diminishes over a period of hours, and many attacks are actually aborted or concluded by sleep. Some patients will have a period after the attack where they may feel "washed out" and listless, although a lucky few actually will experience feelings of intense euphoria.
FACTORS INVOLVED IN MIGRAINE
- HEREDITY - There is no doubt that heredity plays a major role. A family history of migraine can be elicited in seventy to eight percent of patients with this disorder. However, having the genetic predisposition does not mean that one is condemed to having frequent attacks. Other factors come into play, both internal and external. Let us take a look at external.
- EXTERNAL FACTORS - There are external factors that can precipitate migraine in those who are genetically vulnerable. The extensive literature on migraine refers to an almost inexhaustable list of stimuli in the external environment which can bring on an attack of migraine. We will look at some selected examples.
- DIET: A wide variety of foods can lead to an attack of migraine in selected individuals. Chocolate, cheese, fried and fatty foods, oranges, and tomatoes are the ones most frequently implicated. Monosodium glutamate, which is usually added to chinese food, causes headaches, "the chinese restaurant syndrome." The nitrates and nitrites in pre-cooked meats, such as hot dogs, salami, etc., can lead to headaches, "the ballpark syndrome." Red wine is another important trigger, as are other forms of alcohol. Red wine especially contains tannins; these are substances found in the skin of the grape which gives red wine its distinctive color. Some say the cheaper the red wine, the more liklihood that one will experience headache!
Over the course of the years, we have heard our patients implicate every possible food substance as a cause for migraine. A word of caution: Migraine is an unpredictable and whimsical disorder. People cannot tolerate its unpredictability and so we try to blame "the last thing we ate" as the cause of our discomfort. However, it is counterproductive to obsess about diet. Many of our patients become quite obsessed about this, and they waste a good deal of time and valuable energy. My advice to the headache sufferer is if you find a clear-cut connection between a certain food and headache, then avoid that particular food stuff. If not, do not spend hours agonizing over what food might have triggered the headache. Avoid especially those bogus allergy tests "out there" which try to tell you which food you might be allergic to. Otherwise, you will discover another trigger to your headache, fraud.
- HUNGER: Especially in the young migraine sufferer, attacks of headache may occur after missed meals. It is suspected that hypoglycemia is a major trigger in such headaches. Migraine sufferers should always try to avoid prolonged fasting.
- CLIMATE: The frequency of migraine attacks often increases in humid and hot weather. A few patients claim that any change in the weather will invariably precipitate a headache. When the Santa Ana winds blow in Southern California, many patients experience a surge in their headache frequency and intensity. The precise connection is not clear.
- BRIGHT LIGHT: Sensitivity to glare appears to be very prominent. Some patients wear sunglasses all of the time. A small number of patients report that flickering lights from a movie or TV screen can provoke a headache.
- INTERNAL FACTORS
- STRESS: Though migraine is not a psychologic illness, stress and excitement are the most common precipitants, not only for a single attack, but also for a temporary increase in frequency and severity of the headache. In our society, we are very resistent to the notion that stress or "psychologic factors" have any role to play in the causation of headache. It is assumed by many that if this is the case, then the migraine patient is "weak" or "mentally unstable." Nothing could be further from the truth. Stress in all of its forms causes definite changes in the body, be it tightening of the muscles, constriction of blood vessels, increased acid flow to the stomach, etc. These physiologic changes can lead to marked discomfort.
It is also important to note that not only "bad stress" can cause headaches. It is not unusual for children with migraine to suffer an attack before a pleasant experience, such as a party. Here a pleasant anticipation, rather than worry is a sufficient stimulus.
There is another phenomenon commonly seen in migraine, the so-called "let-down or holiday migraine." A number of people experience headaches mainly during periods of relaxation. They will predictably have an attack every Saturday or Sunday, particularly if the preceding week was stressful and not all of their set goals and ambitions could be achieved. It is not uncommon to see migraine sufferers heading for vacation and stacking one corner of their suitcases with medications, knowing they are about to get hit with a siege of migraine.
- HORMONES: Migraine occurs four times more often in females than in males. Although migraine headaches are more common in young boys than in young girls, the number of girls affected increases sharply after onset of menstruation. It seems clear that certain hormonal changes which occur during puberty and growth, and remain throughout adulthood, are implicated in the triggering and frequency of migraine attacks in women. There is little doubt that the rise and fall of serum estrogen is one of the major precipitants for migraine attacks. This "unstable estrogen milieu" is one of the main reasons why so many women are victims to this disorder.
About eighty percent of women report worsening of their attacks immediately before, during, or after their menstrual period. There is also a small percentage of patients, approximately ten to twelve percent, who experience attacks only at the time of their menses.
- PREGNANCY: Pregnancy also influences migraine. In the female patient with migraine, about seventy percent find that their attacks disappear completely or are much milder during pregnancy, especially in the last six months when the estrogen level remains at a fairly fixed, high level. Naturally, as soon as the baby is born and estrogen levels fall, there may very well be a recurrence of migraine.
- ORAL CONTRACEPTIVES: Oral contraceptives also affect the incidence of migraine attacks, but the relationship is far from clear, especially in the newer forms with lower estrogen content. Approximately one-third of women will say they get better, one-third will say they get worse, and one-third remain the same. In fact, the same is true for virtually any form of hormone replacement, including hormone replacement therapy in menopause. More information is available regarding this complex topic in the section entitled "Headaches and Hormones."
- PHYSICAL AND MENTAL EXHAUSTION: Some patients state that their attacks are temporarily related to excessive fatigue which can results either from prolonged physical exertion or mental and intellectual performance. This is the opposite to the more common occurrence of migraine during times of relaxation. It is well known that in children migraine occurs frequently in association with intense physical activity. Some patients report intense headache associated with sexual intercourse. Yet others in a recent study found that orgasm relieved their headaches!
All of this information implies a further example of the multiplicity of events which alone or in combination with other triggers can push susceptable individuals beyond the brink of their limits of tolerance and result in migraine headaches.
- SLEEP: Weekend or vacation migraines frequently occur when the patient sleeps in. The history provided by such patients indicates that headache appear after arising late in the morning and not after an equal duration of sleep if the patient retired to bed early. The specific trigger for weekend headaches should always be sought by the physician because the patient can easily avoid attacks by getting up as early on the weekends as on working days. Sleep plays an important role in all kinds of headaches, including tension headache and cluster headache.
The precise relationship between sleep and different types of headache is still being sought by researchers.
MYTHOLOGY AND MIGRAINE
Many migraine sufferers will attribute their migraine headaches to the following:
- "Sinuses" are often cited, but it is rare that sinus disease is a cause for migraine headache.
- Allergies and the link to migraine are extremely unclear at best. We do not advocate prolonged desensitization as a treatment for migraine.
- Temporomandibular joint disturbance may, indeed, cause localized pain but rarely, if ever, is it a significant factor in recurrent migraine attacks throughout a person's life.
- It is unlikely that eye strain is a major factor in triggering migraine. This does not stop the migraine sufferer, however, from having many frequent visits to the optometrist.
- High blood pressure is often cited, and many people feel that when their pressure is elevated, they get headaches. But this is far from certain. Hypertension was once called the "silent killer." If it led to significant headaches, probably more patients would receive treatment. There is probably little relationship between high blood pressure and headache.
We have only scratched the surface of the complex story of migraine. It is a complex jigsaw puzzle with many pieces. Migraine headache may be precipitated by eating a hot dog at a ballpark or may occur after a prolonged period of stress either at home or at work. Adding to the complexity is the fact that the same triggers may not always provoke the headache on every occasion, leaving the patient and the doctor groping for solutions. Just like pieces of a jigsaw puzzle which keep changing shape!
No objective test is currently available that can be used either to make or confirm the diagnosis of migraine. Because of this, laboratory tests are superfluous for most migraine sufferers. On a routine basis, CT, MRI, and EEGs do not appear to be cost-effective procedures for the routine screening of patients with migraine headaches who have normal physical examinations. Naturally, if there is anything unusual or "atypical," then an appropriate study will be requested.
Migraine is a lifelong disorder, but with appropriate management, the condition of more than ninety percent of patients can be improved dramatically. A subgroup of migraine sufferers may be afflicted with the so-called chronic daily headache syndrome that evolves from migraine. There are many reasons for this, including mood disturbance and over-usage of medications.
Occasionally, a patient will develop what we call "status migrainosis." This is the term applied to ceaseless bouts of migraine lasting for more than three days. These attacks are often resistent to the usual pain medicines and are associated with prolonged vomiting and dehydration. They may require hospitalization for correction of dehydration and pain relief. Extended attacks of this nature may be triggered by severe emotional stress, misuse of medications, such as ergot, pain medicines, and narcotics, and dietary indiscretions, etc., etc. Fortunately, these savage bouts of pain are few and far between.
Long-lasting or permanent neurologic damage is extremely uncommon in migraine, but every once in a while it will happen, the so-called "migrainous infarction." Mostly it occurs in young people who have migraine with aura, especially those with neurologic symptoms such as weakness, numbness, or tingling. The risk of migraine stroke is, indeed, very low, but it is increased in patients who use oral contraceptives or who smoke.
MANAGEMENT OF MIGRAINE
The management of the migraine sufferer consists of several components.
- Elimination of trigger - An ounce of prevention is better than a pound of cure. Determination and elimination of trigger factors is fundamental for effect migraine management. As we just mentioned, headaches may be prevented if a particular sufferer abstains from alcohol, elimiates chocolate, stops birth control pills, gets adequate sleep, or keeps a regular diet.
- Non-pharmacologic methods - These methods are very important and include strategies such as biofeedback, relaxation training, conventional psychotherapy, and a daily exercise program. These are invaluable in controlling migraine. No one way is superior to another. A great deal depends upon the patient's belief system and cultural bias. Acupuncture may work best for one person, and yoga for another. Modification of lifestyle, reduction of stress, and elimination of triggers is of huge importance in the management of this condition.
- Pharmacologic treatment - There are three levels of drug treatment for migraine: prevention, treatment of the acute attack, and symptomatic treatment.
- Prevention - Over the years, it has been discovered, often by chance, that certain families of medications may reduce the frequency and intensity of migraine attacks. High blood pressure medications, such as beta blockers or calcium channel blockers may be useful. The older family of tricyclic antidepressants has been found to be quite effective. Even certain anti-epilepsy drugs, such as Depakote, may also prove very beneficial. These are reviewed under a separate section.
- Treatment of the acute attack - Seven or eight years ago, the only "migraine-specific agent" we had was ergotamine. Ergot was derived from a fungus on rye and is a very potent constrictor of blood vessels. For years it was used in multiple forms, including injectable, suppository, oral, and sublingual forms. Unfortunately, the side effects were many because the drug has multiple effects in the body.
In the early 1990s the "triptans" arrived. Sumatriptan (Imitrex) was the first of these compounds to be released onto the market. There are now a total of four triptans available, and we expect others to be rolling off the production belt in the next year or two. The mode of action of all of these medications is very similar. Specifically, they squeeze or tighten the dilated blood vessels, thus reducing the pain of migraine headache. Most of these drugs are described in greater detail in the segment called "The Triptans."
- Symptomatic relief - Narcotics, analgesics, and sedative drugs are available when preventative and acute therapies fail. They should be used for a maximum of two to three days per week. At this juncture it is appropriate to again state the following: Any "acute" therapy, including the triptans, if over-used can lead to the phenomenon of rebound headache.