Headache Help (9 page)

Differentiating a mild migraine from a moderate or severe tension headache can be very difficult. Yet, if the headache is recurring, with repeated attacks of throbbing or severe aching, the headache is usually defined as a migraine, whether or not there is nausea, visual disturbance, or sensitivity to light and noise.

People with a migraine often become pale and, less often, flush. During an attack, they may also feel too hot or too cold. Sometimes, migraine sufferers experience pupil dilation or contraction, or a teary eye on the same side of the head as the pain. These are symptoms of a cluster headache, yet people with migraines often experience such aspects of cluster headaches, including the sharp pain about one eye or temple.

AURAS

When your migraine begins, you may see brightly colored lines or dots, known as an aura, thought to be caused when blood vessels supplying the brain and surrounding areas suddenly narrow, thereby reducing the blood flow in these tissues. Regardless of whether you have auras or not, the recommended treatment generally is the same. About 20 percent of sufferers, more commonly men, experience visual auras before the attack. Many people experience these auras only once or twice in a lifetime. Usually, they last fifteen to twenty minutes and may be as troublesome as the pain of the migraine. Sometimes these symptoms occur without pain, more commonly in adults over fifty. If you experience these symptoms, be sure to check with a doctor to rule out other disorders, particularly a condition called transient ischemic attack. Blurred vision is common during migraines, but it is separate and distinct from an aura.

VISUAL DISTURBANCES THAT MAY OCCUR WITH MIGRAINES

• Flashes of light
  
• Spots, stars, lines that are often wavy, color splashes, and waves resembling heat waves
  
• Shimmering, sparkling, or flickering images
  
• Mild loss in vision, with unformed hallucinations
  
• Dark spot in one’s vision, often crescent-shaped, usually with zigzags. There is often a shimmering, sparkling, or flickering light at the edges of the dark spot.
  
• Graying or whiteout
  
• Blurred vision
  

PHASES OF A MIGRAINE

Migraines often occur in several stages.

W
ARNING

From hours to even a day before the pain begins, you may sense subtle neurological changes that are manifested by fatigue, irritability, depression, or moodiness. You may crave certain foods, yawn repeatedly, retain fluids, become more sensitive to light or sound, and be less attentive. Called the prodrome, this phase occurs in about half of migraine sufferers. If you experience it, you can learn to recognize the early symptoms, predict an attack, and prepare.

A
URA

Not everyone who gets migraines experiences this phase. Typically lasting less than an hour, the aura includes visual disturbances, and sometimes neurological ones: you may experience tingling or numbness on one side of the face or down one arm, difficulty speaking or remaining perfectly coordinated, or one of the less common features listed earlier in this chapter.

If you experience auras, your migraines are considered classic migraines; those without auras are called common migraines.

P
AINFUL
H
EADACHE

Lasting four to seventy-two hours, this phase is characterized by moderate to severe pain, often accompanied by sharp “ice-pick jabs.” Most people describe their pain as throbbing, pounding, or pulsating, although some people feel a severe ache. Other symptoms during this phase include lack of appetite, nausea, vomiting, sensitivity to light and sound, and muscle tenderness in the head and neck.

R
ESOLUTION

In this phase, which may or may not occur, the pain is gone but you feel completely washed out, depleted of energy or depressed, and some people may even vomit. Others, however, feel completely relieved and calm, even euphoric. Sometimes, sensations similar to the warning phase may return (changes in food habits, moodiness, and so on). In addition, your scalp may remain sensitive.

CAUSES OF MIGRAINES

As we stressed in Chapter 1, migraine is an inherited physical illness, just like diabetes or asthma. Scientists still aren’t sure what causes migraines. For many years, researchers believed that blood vessel spasms in the face, neck, and head caused these headaches. The theory was that the initial spasm, or tightening, reduced blood flow, which caused general discomfort and the auras; then the blood vessels became inflamed, which caused pain.

The current theory suggests that when a person’s migraine triggers build up and exceed the threshold, normal neurological functioning is disrupted. If the person experiences an aura, it is thought to be the result of a “spreading depression” over the brain. This is an electromagnetic or metabolic change, which has been observed in animals. It occurs like a wave and affects neurons in the brain. Changes in the blood vessels are probably the result, not the cause, of these changes in the brain.

Whether or not the aura occurs, scientists believe that something (perhaps dropping levels of magnesium) causes the trigeminal nerve, a large nerve that branches into the face and jaw and sends signals from the brain throughout the skull, to release small proteins called peptides. The peptides cause the surrounding blood vessels to swell, which in turn irritate surrounding nerve fibers, causing them to pulse and fire inappropriately and send pain signals deep into the brain.

More and more scientists are becoming convinced that serotonin, an essential chemical involved in communication among nerve cells, plays a key role in triggering migraines. The effectiveness of sumatriptan supports this theory. The medication works by binding to serotonin receptors, preventing nerve fibers from releasing their peptides, thereby quieting down the activity of the nerves and stifling their firings.

GENERAL MIGRAINE STRATEGY

Regardless of the biochemical causes of migraines, when you consult a doctor, the agenda typically will be:

• To determine whether you are getting rebound headaches from overdependence on caffeine or pain relievers and to help you get off them.
  
• To help you identify possible triggers, including specific foods.
  
• To be sure you understand the role of relaxation techniques, exercise, the use and overuse of caffeine and over-the-counter medications, and potential triggers.
  
• To give you an effective abortive medication, one that prevents a mild headache from worsening. These drugs work best if you have consistent warning signs even a half hour before the migraine actually starts raging. Abortive medications work either by preventing blood vessel inflammation, constricting blood vessels, blocking nerve cell pain signals, or changing the brain’s blood chemistry.
  
• In some cases, to arm you with medication that can relieve disturbing side effects of a migraine, such as nausea or vomiting, and severe pain. These medications are pain relievers (some potentially addictive and, if misused, likely to cause rebound headaches) and antinausea medications.
  
• To find a daily preventive medication (one that is not potentially addictive) if you need abortive medication too frequently.
  
• To use a trial-and-error approach. The more you understand this strategy, the better you can help the doctor help you.
  

In other words, once it’s clear that you are not experiencing rebound headaches or drug dependence, the doctor will try to prescribe medication to relieve your pain and other symptoms, with the goal of minimal medication and side effects.

Don’t get frustrated if you and your doctor don’t get it right the first time. Although you may feel like a guinea pig or that the doctor is stabbing in the dark, he or she is actually using a systematic trial-and-error approach. If you understand that approach, you will be able to make the treatment work most effectively and efficiently.

5

Treating Migraines in Progress

I
F YOU START
getting a migraine, try to manage it with the techniques we describe in Chapter 2. In summary, these techniques include doing a relaxation exercise, having a caffeine drink or tablet, using an over-the-counter (OTC) pain reliever, applying ice packs, and napping in a dark room. When these techniques do not work, your doctor will probably prescribe an abortive medication, that is, a medicine used to relieve a headache in progress.

In discussing prescription medications, we’ll separate them into “first-line” and “second-line.” First-line medications are the first choices doctors turn to for various reasons. Through a process of trial and error, they will then try other (“second-line”) options if the first-line medications can’t be tolerated (produce side effects), or if they are ineffective or inappropriate because of other medical conditions.

QUICK REFERENCE GUIDE: FIRST-LINE MEDICATIONS FOR TREATING MIGRAINES IN PROGRESS

1. T
   RIPTANS
   (I
   MITREX
   , M
   AXALT
   , A
   MERGE
   , Z
   OMIG
   , R
   ELPAX
   )
       Very effective, no drowsiness or stomach problems, but not for people with major heart disease risk factors.
   
2. N
   ONSTEROIDAL
   A
   NTI
   -I
   NFLAMMATORIES
   (NSAIDS) (
   NAPROXEN, IBUPROFEN, KETOPROFEN
   , C
   ELEBREX
   , V
   IOXX
   )
       Nonsedating, but stomach upset is common.
   
3. A
   SPIRIN AND
   C
   AFFEINE
   (E
   XCEDRIN
   E
   XTRA
   -S
   TRENGTH
   , E
   XCEDRIN
   M
   IGRAINE
   , A
   NACIN
   , BC H
   EADACHE
   P
   OWDERS
   , V
   ANQUISH
   )
       Stomach upset fairly common.
   
4. M
   IGRANAL
   N
   ASAL
   S
   PRAY
       Safer than standard ergotamines; stuffy nose and nausea fairly common.
   
5. M
   IDRIN
       Mild enough for children, but fatigue is common.
   
6. B
   UTALBITAL
   C
   OMPOUNDS
   (F
   IORINAL
   , F
   IORICET
   , E
   SGIC
   , E
   SGIC
   P
   LUS
   , P
   HRENILIN
   )
       Contain a barbiturate sedative so are potentially addictive; commonly cause fatigue, lightheadedness, and nausea.
   

When a migraine comes on and over-the-counter tactics don’t work, most doctors will prescribe a triptan (Imitrex, Amerge, Maxalt, Zomig, Relpax), NSAIDs, aspirin and caffeine compounds, Migranal Nasal Spray, Midrin, or one of the butalbital compounds (Fiorinal, Esgic). Ideally, a migraine medication would not simply mask your pain; it would stop the migraine in its tracks in the brain. Triptans and these other medications leave you alert and able to function. While pain medicine may help to relieve the pain itself, your quality of life is much better with pure migraine medications, such as Imitrex and the other triptans.

Unfortunately, some doctors use heavy-duty narcotic medications just to treat the pain, rather than using a first-line medication to influence the headache mechanism itself. The narcotics are powerful medications that in most cases should be used as a last resort. If migraines strike frequently, well-informed doctors will use a preventive treatment (see Chapter 6) in addition to an abortive one.

Choosing a first-line abortive medication, or deciding to jump to a second-line abortive, depends on:

• Your risk factors for heart disease.
  
• Your age. Some medications, as you’ll see, should be avoided by certain age groups.
  
• Whether nausea occurs. If so, avoid aspirin and the nonsteroidal anti-inflammatories. Also, avoid those products if you have an ulcer or gastritis.
  
• Whether you need to work and function at optimal levels. If so, you should probably avoid the sedating medications.
  
• Your experience with each medication. Often one medication won’t work for you but a similar one will. For someone else, the opposite may be true.
  

Although many of the medications described in this and subsequent chapters have not received specific approval from the Food and Drug Administration (FDA) for migraine use, they are considered reasonable, appropriate, and common treatments for headaches. Consult your doctor before taking any of the following medications.

As with other descriptions of medications in this book, the information that follows is a guideline and is in no way prescriptive.

Here are some details on first-line abortive medications. The over-the-counter medications are listed in their order of consideration; refer to Chapter 2 for more information about them.