Migraine Headaches: What is happening in your head?
Jeff Unger, MD
Quadrant Medical Education grants permission to reprint this handout for patient education, not for sale or commercial reproduction.
Migraine headaches are intermittent, disabling headaches that often run in the family. Although brain scans show no abnormalities, we now know that certain changes in the nervous system are associated with the migraine process.
A person with migraines is called a "migraineur (my-grain-OOR). About 18 millions Americans are migraineurs, and approximately 90% of them have at least one parent with a history of headaches. The brain of migraineur is often very sensitive to a particular migraine "trigger", such as excessive sleep, consuming certain foods, riding in a car under specific lighting or motion conditions, or just before or during menstruation. For example, sleeping in on Saturday may increase the likelihood of a migraine headache in a migraineur, and this person also skips breakfast and drinks some red wine at dinner, the threshold for the nervous system is crossed and migraine occurs.
Migraine pain is centered in the brain's trigeminal system, and the location of pain depends on which of three branches of the trigeminal nerve is involved. A migraine headache may cause pain on the top or sides of head, around the face (mistakenly believed to be a sinus headache), or in the neck. As the headache intensifies, even small movements will aggravate the pain. The nerves in the skin and joins become highly sensitized, and finally the brain recognizes and processes the lowest level of pain. Therefore, even mild headaches can quickly progress to a major migraine. And patients with intermittent migraine (one to four times per month) may progress to chronic daily headaches occurring more than 15 per month.
Approximately, 85% of migraineurs experience a "prodrome" phase 24 to 48 hours before a migraine. You may note a variety of unique symptoms, including cold hands, mental confusion, yawning, fatigue, irritability, elation, reduce appetite, carbohydrate craving, or excitability. Taking an anti-inflammatory drug at this time may prevent the migraine from occurring.
About 15% of migraineurs experience visual or sensory symptoms 30 to 60 minutes before a migraine. This is called an "aura", and symptoms can include blind spots, flashing lights, numbness in the face or arms, or hearing abnormalities.
An actual migraine headache can last from 4 to 72 hours in adults. During this time, you probably want to stay alone in your room - away from light, noise, and motion. During a migraine, patients are unable to work or perform daily activities as usual, even if they try.
Once the headache is over, there is typically a "postdrome" phase when you may feel "washed out". Just as with the prodrome, taking an anti-inflammatory drug may be helpful at this time.
Patients often experience migraine throughout their lifetime. However, common-sense behavior can dramatically reduce the number of migraines you have
Step include:
- square (default list-style-type for 3rd and higher level ul):
- Eating three meals a day
- Exercising 30 minutes a day, 5 days a week.
- Getting 8 hours of uninterrupted sleep every night.
- Avoiding overuse of painkillers to treat headaches.
- Minimizing consumption of alcohol, caffeine, and nicotine (smoking)
- Keeping a migraine "diary" can help you to identify (and avoid) foods or behaviors that trigger your migraines, and your physician can prescribe drugs that may eliminate migraine attacks altogether.
Treating with triptans
Jeff Unger, MD
Quadrant Medical Education grants permission to reprint this handout for patient education, not for sale or commercial reproduction.
Most patients with migraines (called "migraineurs") have attempted to relieve their headaches with over-the-counter (OTC) drugs and failed. Migraineurs need to formulate a comprehensive treatment plan with their doctor-one that includes prescription migraine medication.
For patients with frequent migraines (one to four per month), doctors often prescribe a triptan. When you take a triptan at the first sign of migraine, the drug will prevent it from progressing to a major headache. Triptans only work for migraine; they cannot stop any other pain. They are among the safest medications on the market, and all of the seven triptans available today are very effective at stopping migraines fast so that you can return to your normal activities.
Some triptans can be taken in pill form, but the fastest-acting triptans require an injection; this is very effective if you wake up in the middle of the night with a migraine or have severe nausea. You can also take triptans as a nasal spray or in a tablet that dissolves on your tongue. In other words, you can choose the triptan form that best suits your needs.
For triptans to work most effectively, you should follow certain rules:
- Take the triptan at the earliest sign of a migraine, but do not take it during the headache aura phase.
- Taking the triptan more that 90 minutes after the headache begins makes the drug less effective and increases the chance of possible side effects.
- Always take the full does of triptans as prescribed by your doctor
- If your headache worsens after 2 to 4 hours, you take one more triptan dose.
- If you headache gets worse within 10 to 15 minutes of using the triptan, ask your doctor about adjusting the dose or taking an anti-inflammatory drug with the triptan.
- Triptans should not be used more than three times per week unless prescribed by your doctor.
- If your headache goes away within 2 hours but returns within day, you can take another triptan dose.
- Report any side effects (chest tightness, numbness in the hands, hot flashes, fatigue) to your doctor; these are usually caused by waiting too long after the headache begins to take the triptan.
- You should try the triptan for at least three migraines before deciding whether or not it works.
- Triptans will not work if you are taking several OTC and prescription painkillers at the same time.
- Make sure you understand how to use the triptan; it's hard to think when you have a headache, so you should know exactly what to do beforehand.
It is also important to let your doctor know how the triptan affects you. For successful treatment, the migraine should disappear within 2 hours of taking the triptan, and it shouldn't return within 24 hours.
The best measure of success is being able to quickly resume your normal activities. It is a good idea to keep a diary of how well the triptan works and any side effects you notice; this will help your doctor to "fine-tune" your treatment.
The Migraine Diary: Your Partner in Headache Treatment
Since there is no laboratory test to measure headache pain, you are the only one who can describe how you feel.
The best way to do this is to keep a "headache diary" to record your symptoms, the treatments you're tried, and how well those treatments worked. The diary can help to determine whether you're having migraines or some other type of headache. Then, after you begin treatment, the diary can show which therapies are most effective and can help your doctor to "fine-tune" your therapy. Your diary can show:
- How many days you have headaches every month
- How long your headaches last
- Whether your headaches occur on 2 or more consecutive days
- The time of day your headaches occur
- How many days a week you use some type of pain medication for headaches.
- How many days of work or school you miss due to headaches
- How often you miss family or social activities due to headaches.
- The type of "prodrome" symptoms you experience 24 to 48 hours before your headache (cold hands, irritability, difficulty concentration, loss of appetite, food cravings, excessive yawning, loss of memory, anxiety, excitability)
- Warning signs (aura) right before your headache (spots or wavy lines in your vision, hearing abnormalities, tingling in your face or hands)
- Symptoms occurring with your headache (nausea, vomiting, light or sound sensitivity, dizziness, difficulty concentrating)
- Things that might trigger your headaches (caffeine, certain foods, prolonged sleep, physical activity, sexual activity, odors, weather changes, noise, smoking, travel, skipping meals, certain medications)
- Headaches associated with your menstrual period that is, occurring right before or during your period.
- You habits (sleep and wake times, exercise, caffeine consumption, smoking, alcohol use).
After your doctor prescribes migraine therapy, your diary can show how effective it is. You should update your headache diary every day, whether your treatment seems to be working or not. Over time, it can help you to pinpoint any changes in your headaches that might require a change in therapy.
| SAMPLE MIGRAINE DIARY | ||||||||
|---|---|---|---|---|---|---|---|---|
| date of the month | 1 | 2 | 3 | 4 | 5 | 6 | 7 | |
| Had headache (Y/N) | ||||||||
| Rate headache pain (1-10) | ||||||||
| Length of headache number of hours | ||||||||
| Time of day headache started | ||||||||
| Headache came back during the same day | ||||||||
| Medication relieved headache (Y/N) | ||||||||
| Triggers (food, stress, fatigue | ||||||||
| Anxiety or excitability(Y/N) |
Migraine Prevention: Prophylaxis Medications
Jeff Unger, MD
Quadrant Medical Education grants permission to reprint this handout for patient education, not for sale or commercial reproduction.
Roughly 28 million people in the United States experience migraines - chronic and often disabling headache episodes that may be accompanied by nausea, vomiting, and sensitivity to light or sound. When you have migraine, anything can hurt. Migraines tend to make people want to lie still in a dark, quiet room until they feel better.
Typically, migraines begin to occur between the ages of 18 and 54 years. Initially, a person who has migraines may try to treat the headache episodes with over-the-counter (OTC) pain medications such as acetaminophen (Tylenol), ibuprofen (Motrin, or Advil), or aspirin. For some, such medications can reduce the pain of migraine, but most eventually see a physician for pain relief.
The most commonly prescribed acute migraine medications (those taken at the first sign of migraine) belong to a class of drugs called triptans. These agents work by blocking the transmission of pain signals to brain stem, constricting, blood vessels in the brain and reducing the inflammation associated with migraine.
Unfortunately, with frequent, regular use, all acute migraine medications - whether OTC or prescribed, start to lose their effect. As you body becomes adjusted to them, you may develop so-called "rebound" headaches that are even more persistent than those you initially experienced.
Recently, however, migraine management has focused on prevention-stopping migraine pain before it stars. Preventive treatment is tailored to each individual's needs, but usually involves avoiding migraine triggers and addressing any disorders affecting migraine treatment.
WHO SHOULD USE PREVENTIVE MEDICATIONS?
Candidates for preventive, or prophylactic migraine medication are those who:
- Use acute migraine medications more than 2 days per week or 8 days per month
- Experience rebound headaches.
- Have two or more migraines per month that prevent participation in such activities as work, school, or social events
- Are unable to use acute migraine medications because of other conditions, side effects, or insufficient pain relieve.
- Frequently require emergency department for migraine.
- Have an uncommon migraine condition.
Prophylactic medications are started at low doses and gradually increased as needed. For some patients, it takes 2 to 6 months to determine the right dose.
MEDICATION THAT PREVENT MIGRAINE
Currently, There are two types of medications that are approved by US Food and Drug Administration for prophylactic migraine treatment in adults: antiepileptic drugs and beta-blocker. Antiepileptic drugs - Divalproex (depakote) and topiramate (Topamax) are believed to work by stabilizing over excitable nerve endings in the brain, thereby preventing them from sending out signals that are involved in migraines.
Beta-blockers-Drugs such as propranolol (Inderal) and tomolol (Blocadren), which were developed to lower high blood pressure, inhibit certain chemical responses that cause blood vessel dilation-one component of the inflammatory process that occurs during migraine.
SAFETY ANF EFFICACY OF MIGRAINE PROPHYLAXIS
Studies evaluating efficacy of approved prophylactic migraine medication have shown that about half of all migraines respond to such treatment. Beta-blockers are generally well tolerated, with the most common side effects being fatigue and slowed heart rate. Side effects most frequently reported with topiramate are "tingling" in the extremities and loss of appetite. Divalproex is associated with liver toxicity, and patients taking this drug should be monitored.
The type of migraine prophylaxis prescribed usually depends on the patient's overall health, any coexisting medical conditions, and potential side effects of the drugs.
Both beta-blockers and topiramate may be taken safely during pregnancy, though beta-blockers should be tapered within the last weeks to prevent complications during labor. Divalproex can cause fetal malformations and should not be used during pregnancy
SUCCESSFUL PREVENTION
A prophylactic regimen is considered successful when migraine frequency is reduced by at least 50%. By working together, you and your physician will determine which prophylactic and acute migraine regimens are right for you.
Migraine Consult Collection. March 2007
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