Posted by Not just a headache. Debilitating. Neurovascular torture. If you’ve had a migraine, you know you can’t just pop an Advil and get on with your day. Your day is over before it started if you wake up with a migraine. Have one come on while at work? You’re likely leaving early. Today, I’ll delve into what a migraine truly is, why certain people suffer from them, and how to treat these episodes.
A migraine headache is normally, but not always, localized to one side of the head, is throbbing in nature, and is often accompanied by symptoms such as light/sound sensitivity, nausea, and vomiting. A migraine can last from around 4 hours to 3 days, and is normally debilitating during its painful phase. When a patient makes an appointment with me to discuss migraines, I first ensure they are actually suffering from migraines and not another type of headache, of which there are many.
The criteria for chronic migraine disorder according to the American Headache Society are:
- Headache for more than 15 days in a month for at least 3 months
- Headaches last from 4 to 72 hours
- Have at least 2 of the following:
- Unilateral location of the pain
- Pulsatile quality to the headache
- Moderate-severe intensity
- Aggravation by normal physical activity
- AND Have at least 1 of the following
- Nausea and/or vomiting
- Sensitivity to light (photophobia) and/or sound (photophobia).
One study spoke with 1,750 migraine patients, and the top triggers reported in order of most common were: Emotional stress, hormones (females), not eating, weather, sleep disturbances, odors, neck pain, lights, alcohol, smoke, sleeping late, heat, food, exercise, and sexual activity.
You may have heard of people seeing spots/ lights/ zigzags in their vision when they get a migraine. Maybe they complain of numbness in their arm (some confuse this with stroke, understandably). Maybe their words get jumbled or they hear a sudden ringing in their ear. These phenomena are a part of something called “aura.” This used to be thought to always come before the painful headaches set in, but now research has shown that the headache can come amidst the aura. How terrible to suffer this! Can you imagine the inability to speak correctly, have sudden vision changes, or weakness in a limb, and a throbbing headache all at once? This is why people think they are suffering from a potential stroke sometimes, but it’s “just” a migraine. About 25% of migraine sufferers experience at least one aura symptom (Cutrer, 2019). People can even have auras and never get the proceeding headache…another reason it’s confused with a stroke. This is called a migraine equivalent.
Now, the actual anatomy and physiology of a migraine is super complex. I won’t give you a headache while reading about headaches. But trust me when I say that heavy amounts of research is currently being performed and has been done regarding the array of migraine disorders and how to best treat and even eliminate attacks in patients.
Migraines have a genetic component for sure. At least three genes have been identified to cause family-patterned migraines (CACNA1A, ATP1A2, and SCN1A). A mutation in these genes causes the actual pain to initiate during a migraine and spread through the nerve and across the brain, called cortical spreading depression (I’m telling you, the science behind migraines is COMPLEX!). In the 90s, twin studies and family studies showed that someone has a 50% chance of inheriting migraines (Ducros, 2013).
There are lots of treatments for migraines, and the medications are getting better and better. I have a few favorites I like to reach for, but because some of my favorites are so new, only certain insurances cover them on my first try. It’s always best to start a patient on what we call a “prevention” medication. This keeps the blood vessels in the brain calm and prevents them from getting to the throbbing state. Beta blockers, specifically propranolol, help with preventing migraines. This drug class is actually intended for blood pressure control, but has great use in migraine prevention. It can help you sleep well, too, when you take your dose in the evening. Remember, quality sleep is important! You can also take amitriptyline (originally an antidepressant, but has tons of uses), gabapentin, topiramate, and valproate, to name a few.
Botox is something that’s known to give some benefit to migraine prevention. The botox is injected into the head/neck area, and it prevents the nerve pain signals from setting in. Studies have shown it reduces the number of headache days per month, therefore quality of life improves.
In my opinion, the most exciting migraine treatment option is the group of monthly injectables. Emgality was first to market, then Ajovy and Aimovig. Once a month, you inject the medicine into your thigh. Boom. Done. After 1 month, your number of headache days will diminish majorly, and by month 3, your migraines will basically be non-existent. Patients often tell me, “I’ve only have one migraine in 6 months…this has changed my life.” That 1 migraine is usually in the first month of treatment. Someone told me last week they’d kiss the inventor of the drug if they knew who it was. She felt alive again, and called it “her miracle.” These injectables are newer, and as I said before, have coverage in mainly commercial insurances.
There are “abortive” or “rescue” treatments that you can take when you feel a migraine coming on. The triptan drug class is famous for quick relief of a migraine headache (Imitrex and Maxalt are members of this group). There are a couple of nasal sprays, too, that work amazingly but, again, insurance coverage can be a bear. I only have two patients who use the spray (again, insurance limitations). Excedrine is always an option, as well as other over the counter headache meds, but they likely won’t give a strong enough relief for complete resolution.
If you have migraines and aren’t satisfied with your treatment regimen, please contact your PCP or your neurologist. But you also have to do your part in preventing them. Drink your water (8 glasses daily), get good sleep, and avoid your known triggers. Quality of life and the literal “loss” of an entire day or a few days out of your week gets to be life-altering. Don’t let migraines control your life.
References:
Cutrer FM. Pathophysiology, clinical manifestations, and diagnosis of migraines in adults. 2018 November 17. Retrieved December 4, 2019 from https://www.uptodate.com/contents/pathophysiology-clinical-manifestations-and-diagnosis-of-migraine-in-adults?search=migraine&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H203275062.
Ducros A. Genetics of migraine. 2013 May. Rev Nerol. 196 (5) 360-71. Retrieved December 4, 2019 from https://www.ncbi.nlm.nih.gov/pubmed/23618705.
Escher C et al. Botulinum toxin in the management of chronic migraine: clinical evidence and experience. 2017 Feb. There Adv Neurol Disord. Retrieved December 4, 2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367647/.
Sutherland HG and Griffiths LR. Genetics of migraine: Insights into the molecular basis of migraine disorders. 2017 April. Headache. 57: (4): 537-569. Retrieved December 4, 2019 from https://www.ncbi.nlm.nih.gov/pubmed/28271496.
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