Migraine Headaches – FAQs

Migraine headaches are the second most common type of primary headache which affect children as well as adults. Before puberty, boys and girls are affected equally but after puberty, more women than men are affected.

Migraine is a chronic condition of recurrent attacks. Most (but not all) migraine attacks are associated with headache which is intense, throbbing or pounding pain that involves one temple. (Sometimes the pain can be located in the forehead, around the eye, or the back of the head). The pain usually is unilateral (on one side of the head). A migraine headache usually is aggravated by daily activities like walking upstairs. Nausea, vomiting, diarrhea, facial pallor, cold hands, cold feet, and sensitivity to light and sound commonly accompany migraine headaches. As a result of this sensitivity to light and sound, migraine sufferers usually prefer to lie in a quiet, dark room during an attack. A typical attack lasts between 4 and 72 hours.

An estimated 40%-60% of migraine attacks are preceded by premonitory (warning) symptoms lasting hours to days. The symptoms may include sleepiness, irritability, fatigue, depression or euphoria, yawning, and cravings for sweet or salty foods. Usually, the aura precedes the headache, although occasionally it may occur simultaneously with the headache. The most common auras are 1) flashing, brightly colored lights in a zigzag pattern (fortification spectra), usually starting in the middle of the visual field and progressing outward and 2) a hole (scotoma) in the visual field, also known as a blind spot. A less common aura consists of pins-and-needles sensations in the hand and the arm on one side or pins-and-needles sensations around the mouth and the nose on the same side. Other auras include auditory (hearing) hallucinations and abnormal tastes and smells.

Complicated migraines are migraines that are accompanied by neurological dysfunction. The part of the body that is affected by the dysfunction is determined by the part of the brain that is responsible for the headache.

For approximately 24 hours after a migraine attack, the migraine sufferer may feel drained of energy and may experience a low-grade headache along with sensitivity to light and sound.

Migraine headache is caused by a combination of vasodilatation (enlargement of blood vessels) and the release of chemicals from nerve fibers that coil around the blood vessels. The chemicals cause inflammation, pain, and further enlargement of the temporal artery. The increasing enlargement of the artery magnifies the pain.

Migraine-specific abortive medications usually are necessary for moderate to severe migraine headaches which instead of relieving pain; they abort headaches by counteracting the cause of the headache, dilation of the temporal arteries e.g.

(A) Triptans (Sumatriptan) should be used early after the migraine begins, before the onset of pain or when the pain is mild. Using a triptan early in an attack increases its effectiveness, reduces side effects, and decreases the chance of recurrence of another headache during the following 24 hours. Used early, triptans can be expected to abort more than 80% of migraine headaches within 2 hours. Triptans should not be used in pregnant women and are not generally used in young children.

(B) Ergots include ergotamine preprations (Ergomar, Wigraine, and Cafergot) and dihydroergotamine preparations (Migranal, DHE-45). The ergots should not be used in pregnant women because they can cause prolonged contraction of the uterus and miscarriages.

(C) Midrin is used to abort migraine and tension headaches. It is a combination of isometheptene (a blood vessel constrictor), acetaminophen (a pain reliever), and dichloralphenazone (a mild sedative). It is most effective if used early during a headache; however, because of its potent blood vessel constricting effect, it should not be used in patients with high blood pressure, kidney disease, glaucoma, atherosclerosis, liver disease, or taking monoamine oxidase inhibitors.

(D) Narcotics and butalbital-containing medications sometimes are used to treat migraine headaches; however, these medications are potentially addicting and are not used as initial treatment. They are sometimes used for patients whose headaches fail to respond to OTC medications but who are not candidates for triptans either due to pregnancy or the risk of heart attack and stroke.

There are two ways to prevent migraine headaches: 1) by avoiding factors (“triggers”) that cause the headaches, and 2) by preventing headaches with medications (prophylactic medications). Neither of these preventive strategies is 100% effective. The best one can hope for is to reduce the frequency of headaches.

A migraine trigger is any factor that causes a headache in individuals who are prone to develop headaches. Only a small proportion of migraine sufferers, however, clearly can identify triggers. Examples of triggers include stress, sleep disturbances, fasting, hormones, bright or flickering lights, odors, cigarette smoke, alcohol, aged cheeses, chocolate, monosodium glutamate, nitrites, aspartame, and caffeine. For some women, the decline in the blood level of estrogen during the onset of menstruation is a trigger for migraine headaches. The interval between exposure to a trigger and the onset of headache varies from hours to two days. Exposure to a trigger does not always lead to a headache. Conversely, avoidance of triggers cannot completely prevent headaches. Different migraine sufferers respond to different triggers, and any one trigger will not induce a headache in every person who has migraine headaches.

Life-style modifications for migraine sufferers include:

• Go to sleep and waking up at the same time each day.
• Exercise regularly
• Do not skip meals, and avoid prolonged fasting.
• Limit stress through regular exercise and relaxation techniques.
• Limit caffeine consumption to less than two caffeine-containing beverages a day.
• Avoid bright or flashing lights and wearing sunglasses if sunlight is a trigger.
• Identify and avoid foods that trigger headaches by keeping a headache and food diary. Review the diary with your doctor. It is impractical to adopt a diet that avoids all known migraine triggers, however, it is reasonable to avoid foods that consistently trigger migraine headaches.

Prophylactic medications are medications taken daily to reduce the frequency and duration of migraine headaches. They are not taken once a headache has begun. There are several classes of prophylactic medications: beta blockers, calcium-channel blockers, tricyclic antidepressants, antiserotonin agents and anticonvulsants. Medications with the longest history of use are propranolol (Inderal), a beta blocker, and amitriptyline (Elavil), an antidepressant. When choosing a prophylactic medication for a patient the doctor takes into account the drug side effects, drug-drug interactions, and co-existing conditions such as diabetes, heart disease, and high blood pressure.

Not all migraine sufferers need prophylactic medications. Individuals who should consider prophylactic medications are those who:

• Require abortive medications for migraine headaches more frequently than twice weekly.
• Have two or more migraine headaches a month that do not respond readily to abortive medications.
• Have migraine headaches that are interfering substantially with their quality of life and work.
• Cannot take abortive medications because of heart disease, stroke, or pregnancy, or cannot tolerate abortive medications because of side effects.

Prophylactic medications can reduce the frequency and duration of migraine headaches but cannot be expected to eliminate migraine headaches completely. The success rate of most prophylactic medications is approximately 50%. Prophylactic medications usually are begun at a low dose that is increased slowly in order to minimize side effects. Individuals may not notice a reduction in the frequency, severity, or duration of their headaches for 2-3 months after starting treatment.