Headaches are one of the most common reasons people seek medical help. Almost everyone has had a headache at one point in his or her life. Although some headaches are a signal of a serious underlying illness—such as a tumor, aneurysm (ballooning of a blood vessel), or other illness—recurrent headaches more often occur without any underlying disease present. Crucial to the appropriate treatment of headache is the proper diagnosis of its type, and migraine headache is a particularly common form of recurring headache.
This article provides an overview of migraine and its treatment, but it should not substitute for a thorough discussion with your physician. Sometimes a separate visit to your doctor to discuss your headaches specifically may be necessary. In some cases, especially if there are unusual features of your headache or if medicines don’t appear to be helping, your doctor may choose to refer you to a headache specialist.
The Causes and Symptoms of Migraine
Approximately 25% of women and 8% of men suffer from migraine at some time in their lives. The precise cause of migraine is unknown, but it is probably related to chemical changes in the blood vessels supplying the brain and its coverings. These changes may involve constriction (narrowing) and dilatation (widening) in some brain blood vessels. Migraine headaches are usually described as a one-sided, throbbing pain of the temple, forehead, or eye. The headache usually, but not always, comes on over several minutes; on some occasions it may occur suddenly, like a thunderbolt.
Other symptoms (Table 1) may accompany the headache, including nausea, vomiting, or the feeling that light bothers the eyes (photophobia) or sound bothers the ears (phonophobia). The headache may last for minutes, hours, or even days. Pain may be mild or severe, and it may vary in intensity between different episodes in a single person. Migraine is characterized as an episodic headache problem because sufferers generally feel well between attacks. Some people may have more constant or daily headaches in between full-blown, severe attacks.
The headaches may occur as infrequently as once every few years or as frequently as daily.
|Table 1. Symptoms of migraine|
|Photophobia (light aversion)|
|Sonophobia (sound aversion)|
|Paresthesias (tingling feelings)|
Migraine headaches can be so severe that they temporarily disable people. Some people need to leave work or school, or they may be unable to socialize normally or take care of home activities. If the headaches occur frequently enough, they can lead to a more constant inability to carry out one’s regular activities or routine. The disability caused by migraine is undoubtedly vastly underestimated.
People with so-called "classic migraine" may experience an "aura" before the onset of the headache. This aura most often consists of painless visual phenomena appearing off to one side of the visual field. Many different kinds of visual symptoms have been described, including flashing lights, jagged lines, sharp-edged shapes, or quivering or scintillating forms. Sometimes there is also an area of lost vision (a "scotoma"), typically located off to one side and moving slowly toward the center of vision over several minutes. This hole in the vision will gradually become larger as it moves. The headache may then begin as the visual symptoms diminish. The aura may serve as a warning to some people that a headache will come. Sometimes other symptoms constitute the aura, including tingling about the lips and fingertips, dizziness, difficulty speaking, or a feeling of weakness of one side of the body. Because these symptoms are similar to those of a stroke, their occurrence should prompt medical attention when they occur for the first time, before a clear diagnosis of migraine is made.
Migraine attacks often strike without warning, but there are some common, often avoidable triggers. Different people have different triggers for their migraines. Common triggers include specific foods, changes in sleeping patterns, hormonal changes, stress, or sexual activity. Some of the foods that can precipitate migraine in susceptible individuals are listed in Table 2. The most common food triggers are chocolate, cheeses (particularly aged cheeses), aged meats, nuts, bananas, and avocados. Alcohol, particularly red wine, may also be a trigger. It may be useful to experiment to see if eliminating specific foods helps decrease the frequency of headaches. Many people find that headaches actually tend to come on during periods of relative freedom from stress and sleeplessness, such as the weekend or on vacations. Menstruation is a common trigger in many women, some of whom may get migraines only at the time of their periods. Certain environmental triggers may also bring on headaches, including allergens, fluorescent lighting, or changes in temperature. A headache diary in which one keeps track of headaches and possible environmental or other triggers may help one determine factors that precipitate headache, and thus help one learn to avoid these triggers.
|Table 2. Foods and drinks that may cause migraine|
|Chocolate||Alcohol (especially red wines)|
|Nuts||Aged, canned, cured or processed meats|
|Bananas||Yeast and yeast extracts|
|Fava beans||Broad beans|
|Monosodium glutamate (MSG)||Soy sauce|
Doctors group the treatment of migraine into 2 major categories: abortive therapy--the use of a medication for the treatment of an attack, and prophylactic therapy--the use of a medication on a regular basis to prevent headache occurrence in the first place. Each category comprises several kinds of medicines, and recent research has led to the development of newer drugs for this purpose (see article on New Medications in this Focus). Other treatments, such as acupuncture, biofeedback therapy, and relaxation therapy, may also be helpful for some people (see article on Alternative Treatments in this Focus).
Abortive treatments for mild to moderate headaches may include both over-the-counter and prescription medications. Effective over-the-counter medicines include acetaminophen (Tylenol), aspirin, ibuprofen (Advil or Motrin), and other similar drugs. Caffeine may also be a good migraine treatment for some people. The combination of acetaminophen, aspirin, and caffeine, sold over-the-counter as Excedrin Migraine, is effective for many people with mild to moderate headaches, reducing pain significantly after 2 hours in 59% of people, compared with 33% of those given an inactive drug.
Prescription drugs are also very effective, but because they can have serious side effects and may be unsafe for certain types of people, it is important that these only be taken under the advice of a physician. The combination of isometheptene, dichloralphenazone, and caffeine (Midrin) is a good first try. Other types of drugs include medications like metoclopramide (Reglan) and phenothiazines (Compazine, Phenergan) which may not only help with the nausea and vomiting that can occur, but also reduce pain. Some of these can be given as an injection into the muscle or as a suppository (placed into the rectum) in people unable to keep medicine down because of the nausea and vomiting. Ergotamine is another medication which can help; it comes in both oral and injectable forms. It has to be used carefully in people with high blood pressure or heart disease. A family of medicines called the triptans acts by blocking the activity of a chemical in the brain called serotonin. Sumatriptan was the first of these. Originally it could only be given as an injection under the skin, which is the fastest way to get the drug into the body and therefore the fastest way to get relief. It is now available as a pill and a nasal spray for people who can wait a little longer for relief, and who would prefer not to have to give themselves an injection. Other, newer triptan drugs include naratriptan, rizatriptan, and zolmitriptan (see article on New Medications in this Focus). Heart attacks have been reported after triptan use by people with heart disease (and even in some with only risk factors for heart disease), so they should be used cautiously by such people, if at all.
Preventive, or prophylactic treatment, also has many options, but should always be initiated under the guidance of a physician. Beta-blockers (like propranolol or atenolol) and calcium channel blockers (particularly verapamil) have shown beneficial results. Certain antidepressant drugs, like amitriptyline and the other drugs in its family (the tricyclics), can be very effective. Many people are unnecessarily wary of taking these medicines because of an unfounded fear that they are somehow mind-altering. More recently, certain seizure medicines, like valproate (Depakote) have been shown to reduce the frequency of attacks (see article on New Medications in this Focus).. Because each of these medicines has potentially dangerous side effects, people should be monitored while taking them.
It is important to remember that different people benefit from different medicines, and it is still not clear why. It can take some time and adjustment of medicines and doses until the right combination of treatment—both abortive and prophylactic—is found for any one person. Keeping careful track of headaches and other symptoms in relation to medication usage, even using a diary specifically for this purpose, can be a helpful tool in determining the best regimen for you.