Migraine Headaches
by Dr. Mo Lerner

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Infomercials have pitch men who try to sell us on the benefits of changing our lives. They claim that if we just buy their tapes, books, lotions or pills they will help us to change our lifestyles so that we can become healthy, wealthy, and wise. But the small print at the bottom of the screen usually includes phrases such as "these images portray exceptional results" or "results may vary." Reading between these microscopic lines, the fact is that customers are probably throwing their money away. You see, as human beings we are a highly addictive species. Once we are used to a pattern we tend to stay in that groove--especially when it is comfortable--even if the habit eventually leads to harm. What this has to do with Migraine Headaches will become evident in this issue's column.

The word migraine is derived from the Greek hemi and krainia referring to "half of the brain," because this fairly common problem classically affects one side of the head. No one is certain what causes migraines but it is likely that there is a genetic component. There are definitely trigger factors. The brain itself, interestingly, does not sense pain. The blood vessels and membranes that surround the brain, however, can be quite sensitive to pain when they are stretched or stimulated.

There are times when the brain or structures in the area require more blood and oxygen, as is the case during exercise or stress. In order to increase blood flow to target areas in need, vessels in various parts of the brain either dilate or constrict in response to a number of chemicals. In some migraine sufferers the blood vessels are overly or inappropriately sensitive to a variety of substances and/or events that trigger blood vessel size changes.

In classic migraine, patients often describe an aura which is a subjective sensation or phenomenon that lets them know they are about to have an attack. Examples include visualization of flashing lights or the experience of nausea. There might be abdominal pain, tingling of the hands and feet, or emotional distress. It is believed that chemicals cause blood vessels in the membranes that surround the brain and perhaps even in the scalp to suddenly constrict. This constriction may deprive certain areas of the brain momentarily of oxygen and nutrients, causing the aura. Moments later the blood vessels, anxious to recover blood flow previously deprived, may rebound and overdilate. It is this overdilation and the subsequent surging of blood through pulsating vessels which is thought to account for the throbbing headache of migraines. The headaches often, but not always, begin on one side of the head. Increased physical or emotional activity may make the pain worse. Nausea, vomiting, and a sensitivity to light, certain smells or noise are very common. As a result most sufferers tend to want to lie still in a dark room. Headaches can start at any time of the day, vary in severity and can last anywhere from a few hours to three days. They may occur in clusters.

WHO
The problem often surfaces in teens and is more prevalent in women for reasons which are unclear. Half of those who suffer have some family history of similar episodes. The problem often results in mid-life possibly because of hormonal changes.

TRIGGERS
The list of potential substances and circumstances that trigger the onset of a migraine are endless, Caffeine, chocolate, and tea are related chemically and can cause blood vessels to constrict. In some people with pulsating, engorged, throbbing vessels this constriction might bring relief from an acute migraine attack. Unfortunately these same substances, if consumed in excess, are also usually triggers that can cause an exacerbation.

The birth control pill or a variety of hormone replacement therapies for menopause can trigger a cycle of brain vessel constriction and dilatation. Anything from emotional upsets to exotic perfumes can cause the problem. Some people are sensitive to a variety of triggers and these can even change as time goes on. This is why it is a good idea for all migraine sufferers to keep a diary and learn to avoid precipitants and events associated with attacks.

IS IT MIGRAINE OR SOMETHING ELSE?
Migraine is one of the last necrologic disorders still best diagnosed by a classic history of the signs and symptoms aforementioned, and a proper physical examination.

Headaches that are very sudden and severe in onset, associated with waxing and waning levels of consciousness, especially occurring after recent trauma, might be the result of an occult bleed in the brain.

A change in emotions, intelligence, behavior, or appetite, especially in older folks, might indicate a tumor.

During a physical exam, doctors tend to look for asymmetry of strength or reflexes. If there is persistent weakness in one part of the body there is likely to be some kind of space-occupying lesion in the brain accounting for headaches.

In the event a doctor is unsure if migraine is the cause of headaches, fancy tests like Electroencephalograms (EECs), Magnetic Resonance Imaging (MRIs) or Computed Tomography (CT) Scans are appropriate in further delineating the problem.

TREATMENT
If a migraine attack ensues one should retreat to a quiet, softly lit environment. Medication should start with traditional pain relievers like Aspirin, Acetaminophen, or Ibuprofen. It is probably better to take higher doses as first (eg. Ibuprofen 800 mg) rather than taking small intermittent doses (200 mg) in order to nip the process early when it is most tractable.

One problem with overuse of any pain reliever is rebound headache. In this situation, not only do migraine symptoms become resistant to treatment, they actually return in an even stronger form than before.

When first line analgesics fail, one might consider a group of medications that are specific for Migraine relief. Some, like Dihydroergotamine (DHE) and sumaptriptan, cause the dilated pulsating vessels to constrict.

Sumatriptan can be taken as a pill or self-injected just beneath the skin in a special spring loaded device. Relief may occur in 15 to 30 minutes. If some alleviation occurs the dose can be repeated once but if no relief occurs, the drug should be abandoned for another. Occasionally, with use of this drug, vessels other than those in the head can become constricted causing Angina (lack of blood supply to the heart). Some also find this drug too expensive and not without other annoying side effects. Sumatriptan is not for everyone.

Dihydroergotamine (DHE) acts in a manner similar to Sumatriptan, but is usually less expensive. Both drugs can also be administered in the nose, which is useful if nausea and vomiting prevent oral use or if one is queasy about injections.

Lidocaine is a solution often injected to induce freezing of skin prior to surgery or stitching. It can also be used nasally in some people with migraines. In theory, if a person lies back with the head tilted slightly toward the area of the throbbing headache, the Lidocaine freezes a special pain-sensitive site, relieving the discomfort. Sadly, only about half of migraine sufferers get relief with this method and there is often rebound pain when the freezing wears off.

PREVENTION
Besides keeping a diary and avoiding trigger factors, there are some useful drug regimens that can be helpful for those who simply can't get their problem under control. If one experiences three or more severe migraine attacks in a month and/or gets limited relief with medications, prophylaxis is the key.

Propranalol and Nadolol are two examples of a group of drugs known as beta blockers which may act either directly on brain blood vessels and/or cause the blood surge from the heart to the brain to calm down.

If the beta blockers fail to control migraines, antidepressants such as Arnitriptyline may do the trick through another mechanism. Of course, if the migraine attacks are causing the sufferer to become depressed there is an obvious added advantage to this agent.

Calcium blockers and anti-seizure medicine can also be used.

Preventative medicine should be tried for at least a few months, with the dosage of medications starting low and gradually increasing until improvement is achieved. Though use of analgesics and preventative medicines concomitantly is acceptable, it is essential that sufferers not abuse analgesics. This would render the prophylactic medicine useless.

SEVERE ATTACKS
One of the biggest dilemmas faced by doctors, especially those who work in emergency rooms, is the arrival of a patient in pain with no overt physical abnormalities. While many practitioners are leery of using potentially addicting pain killers such as narcotics to avoid pain killer addiction, this might well mean the only relief for a migraine sufferer who has tried every other means of escape.

When symptoms become unbearable despite home treatment we often resort to a group of more powerful agents. Steroids may counteract some of the inflammation that is associated with migraines. Antipsychotic agents, traditionally used for patients with schizophrenia and other major disorders, may calm a major migraine when used in a more diluted form.

Finally, when all else fails, a combination of narcotic and antinauseant is highly effective. To the dismay of some physicians who may suspect repeat visitors with headaches of drug abuse, this last treatment seems to be the most popular.

THE NATURAL WAY
In some people migraine attacks can become a preoccupation. In fairness, the medication and lifestyle associated with triggering migraines may become inexorably linked and a form of unintentional addiction may occur. A variety of "alternative" products are promoted that give the impression of an easy quick fix and often prey upon the unreasonable expectations of desperate clients, similar to the situation with the weight loss industry. But as I eluded to earlier, life is not that simple.

Once an attack is in progress there is little escape other than a quiet dark room. After hours or a few days of the problem, most sufferers will lapse into a deep and much deserved sleep. Eating meals regularly and going for walks during times of remission seems to help prevent more serious attacks. Too much caffeine and alcohol may cause rebound migraines. Moderation is the key.

A final bit of advice. Don't assume you have migraine headaches just because the symptoms sound familiar. Always seek objective medical advice. Be well and enjoy life. ß



Heretic Physician