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Mitigating Migraines

Experts Shed Light on How to Reduce Blinding Headaches

Dr. Karin Johnson

Dr. Karin Johnson says the severity and pain of migraine symptoms can be frightening, and some people go to the emergency room thinking they are having a stroke.

If you suffer from migraines, you are not alone.

About 36 million Americans experience these debilitating headaches, and at least 24% have gone to a hospital emergency room due to intense pain and the constellation of symptoms that can accompany them.

“It’s a common disorder. About 20% of people have migraines,” said Dr. Karin Johnson, a neurologist and director of Baystate Medical Center’s Sleep Center. “They are diagnosed according to their symptoms, which can include nausea, vomiting, and sensitivity to light and sound. Migraines last at least four hours, and some people get a preceding aura of flashing lights or zigzag lines in their vision.”

Dr. Michael Sorrell of Springfield Neurological Associates agrees, and says migraines worsen with movement. “There is no laboratory diagnosis, and in my view the only difference between someone with tension-type headaches and migraines without aura is genetics,” said the neurologist, who is a board-certified headache specialist. “We know they run in families and genes make someone susceptible.”

Research shows that up to 90% of sufferers have a family history of migraines and if one parent gets these headaches, there is a 40% chance their children will also be affected. If both parents get migraines, the likelihood of their children having the headaches rises to 90%.

During childhood, they affect more boys than girls, but adult women are three times more likely than men to suffer, with their first attack usually occurring by age 40.  The condition tends to improve in the late trimesters of pregnancy, and menopause affects it, with changes split between improvement, worsening, or no change.

Sorrell says migraines occur when specific areas of the brain stem are stimulated, which provokes the production of irritating chemicals. “The chemicals cause blood vessels to enlarge, which irritates the sympathetic nerve endings,” he explained, adding that prescription medications that shrink the blood vessels can reduce the pain.

“When I was training in Atlanta, the remedy for headaches was to take two aspirins and a Coca-Cola,” he told BusinessWest. Although that may seem simplistic, Fiorinal, a drug commonly prescribed for migraines, contains aspirin (an anti-inflammatory) and caffeine, and Coke also contains caffeine.

Drugs to treat headaches can be expensive, costing as much as $15 or $20 per pill, Sorrell said, adding that this is a multi-billion-dollar business today. But the research that went into creating the medications has provided physicians with a wealth of information about the biochemical nature of migraines.

 

Diagnosing the Problem

Since these headaches can last up to 72 hours, and 90% of people cannot function normally when they occur, the life and livelihood of migraine sufferers can be severely affected. Research by the Migraine Research Foundation shows American employers lose more than $13 billion each year as a result of 113 million work days lost to migraines.

The severity of pain and symptoms can be frightening, and some people go to the emergency room in the belief they are having a stroke, only to discover they have a migraine. “You don’t usually have a headache with a stroke,” Johnson said. However, in rare instances, migraine symptoms can put people in a coma for days.

Dr. Michael Sorrell

Dr. Michael Sorrell says migraines occur when specific areas of the brain stem are stimulated, which provokes the production of irritating chemicals.

Sorrell said there are approximately 250 categories of headache and facial pain listed in the International Classification of Headache Disorders, and it is critical for a doctor to determine what type the person is suffering from before the correct treatment can be prescribed.

Many people get tension headaches, which cause annoying pressure, but they don’t usually last long or affect the person’s ability to function. Cluster headaches fall into another category and cause extremely severe, one-sided pain that usually occurs in or around the eye and can result in a runny nose and red and watery eyes.

Cortical spreading depression can also cause headaches, and starts in the occipital lobes in the back of the brain that control vision. “There is a wave of excitation in the brain which causes neurons to fire; that leads to increased blood flow followed by depression and reduced activity in the brain cells,” Johnson explained. “When this happens, it triggers an inflammatory response, which irritates pain centers in the brain, and a headache results.”

However, migraines are different due to the severity of the pain. Although auras can accompany them, Sorrell says they occur in less than 20% of people who get these headaches. “An aura is a biochemical event that triggers the start of a cascade of chemicals,” he said. “It is a central nervous system phenomenon caused by dysfunction in a particular area, which will produce a specific set of symptoms. The aura often occurs because of a reduction in oxygen utilization and a slowing of brain activity in one part of the brain which travels to another part.”

Although complicated migraines can cause speech problems, visual difficulties, and weakness or numbness in the fingertips, these symptoms usually last only about 20 minutes. “But almost everyone who gets migraines without aura has muscular pain, or knots in the muscles and ligaments of their head, neck, and shoulders,” Sorrell said, adding that they are formed by stress and result from things people do without realizing it.

This includes poor posture, especially if the person spends a lot of time on a computer. In addition, muscles can be affected by depression and anxiety, and Sorrell said the knots can be present even if people are unaware of them.

“But if they push on them, they become uncomfortable,” he said, adding that the pain can travel. “The nausea, vomiting, and sound and light sensitivity associated with the headaches comes from the brainstem cascade of biochemical events. But the migraine headache without aura usually comes from the muscles, while the migraine headache with aura can come from the muscles or from the brainstem events.”

 

Effective Remedies

But people can reduce their migraines and employ tactics that lessen their severity if they become knowledgeable. Applying heat or ice often helps, said Johnson, and some people find massaging the back of their head or their temples can provide relief.  “So can sleeping, and some people wear sunglasses to help with the light sensitivity,” she said. “Most people can treat themselves by figuring out their triggers and other exacerbating factors and by using over-the-counter medication when the headaches occur.”

Triggers can range from fluorescent lights to coffee, chocolate, and red wine, along with caffeine withdrawal, missed meals, changes in sleep patterns, smoking or exposure to smoke, and changes in hormone levels during a woman’s menstrual cycle or that result from birth control pills. Alcohol, stress and anxiety, certain odors or perfumes, loud noises, or bright lights can also jump-start a migraine.

If eliminating triggers doesn’t work, the next step is to visit one’s primary-care physician, who may provide prescription medication. There are two main types: abortive drugs, which include ibuprofen and Tylenol; and prescriptions taken after the onset of the headache and preventative drugs, which Johnson said are recommended when people use headache medications more than a few times each week.

“They are taken in small doses every day to reduce the severity and frequency of migraines,” she said. These drugs include Topamax, Amitriypaline, and Propanol.

Unfortunately, too much of anything can be a problem, and overuse of drugs designed to help can cause what are known as ‘rebound’ headaches.

“If people take too many pain medications to reduce the severity of their migraines, the incidence of their headaches often increases,” Johnson said. For example, studies show if people take the very popular medication Fioricet more than seven times a month, they are likely to end up with a headache every day.

Sorrell said frequent use of over-the-counter medication or caffeinated food or beverages such as chocolate and coffee can also be a culprit. “If you use a lot of acetaminophen or drink a lot of caffeinated beverages, and then stop them, you may get a headache within three days as a result of withdrawal.”

Ironically, the problem occurs because these things do work to alleviate pain. “So people use them more and more frequently,” he continued. “Then, when they go without them, they get a headache, which proves to them that they need to continue using them.”

In addition to drugs, other remedies can prove effective. They include trigger-point injections or myofascial release (more on that later) that helps to release tension in muscles.

Sleep studies can also make a difference. “Insomnia is a big trigger, and more than 50% of people with migraines have some sort of sleep apnea,” Johnson noted.

Baystate conducted a recent study that connected sleep apnea and headaches. Johnson said 40% of people who had been seen in their headache clinic and underwent a sleep study with a diagnosis of sleep apnea saw improvements after using machines that provide continuous positive airway pressure. Sleep apnea is a disorder characterized by abnormal pauses in breathing while sleeping.

Botox injections are another treatment recently approved by the U.S. Food and Drug Administration for migraines. “The injections are given in the forehead and back of the neck and have been approved for people who get more than 15 headaches a month,” Johnson said.

Sorrell also conducted a pilot study on people who have migraines. His goal was first to determine whether he could reproduce the pain of a migraine by applying pressure to certain areas of the myofascial tissue in the head and neck (muscles and ligaments) that had knots. If that occurred, the patients were given a home course of physical-therapy exercises.

“In my study, 85% of those with migraine without aura and chronic migraine who had treatment had significant improvement; those who did not have treatment had 10% improvement,” saod Sorrell, who concluded that myofascial exams should be used to determine treatment for people who get migraines, and the treatment was effective.

“If I can reproduce the headache during an exam, then treat it with physical therapy where muscles are stretched along their lengths, the patient may not need medication,” he said.

When Sorrell sees patients with headaches, he always examines the muscles in their head. “I tell people, ‘if a man gets a headache by beating his head against a wall and then stops, the headache stops because he eliminated its source. If you identify one of the sources of the headache and eliminate it, there is a good chance you can prevent the headache,” he said. “So, our job is to find out what the patient is doing to provoke the headache. If we do that, we can often prevent them, which is better than treating a migraine.”

 

Ongoing Battle

Although it’s important to identify triggers, “we can’t stop people from having migraines,” said Sorrell. “The goal is to make them so infrequent and so relatively mild that the patient can take occasional over-the-counter medications and won’t need a doctor anymore.”

He advises people to keep a diary of what they do each day, which includes tracking the frequency and severity of their headaches. If that is too cumbersome, once they get a migraine, they can go back and list everything they did the day before. This includes identifying changes in sleep, arguments, or stressful events that occurred, as well as what they ate in the 24 hours before the onset of the headache.

People can also put themselves on a diet designed for people with migraines and eliminate one suspect food at a time to see if it makes a difference. “But people shouldn’t lead an ascetic existence just because they have headaches,” Sorrell said.

The key perhaps, can be found in the ancient Greek aphorism “know thyself,” as well as the adage “an ounce of prevention is worth a pound of cure.” Migraines may be common, but there is a lot that people can do to help themselves.


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