Yale-New Haven Hospital: HealthLINK: Women's Health, September 2000

Migraine care depends on careful assessment

Getting effective care for migraine headaches can make the difference between being disabled often by these severe headaches and learning to minimize both the frequency and severity of the pain. If a physician dismisses or minimizes your headaches, doesn’t take the time to discuss your history or immediately suggests a pain medication without investigating possible underlying conditions, you might want to consult with a headache specialist.

"Often the first step in migraine diagnosis is ruling out the presence of another disease."

It’s important to be proactive in seeking treatment and learn everything you can about your condition.

Migraine or garden variety headache?
Not all headaches are migraines and not all migraines are alike, but migraines do share some similarities, such as:

Duration–they usually last between four and 72 hours
Pain characteristics–moderate to severe pulsing or throbbing pain, which may occur on just one side of the head
Other symptoms–nausea, vomiting, sensitivity to light and or sound
Disabling–migraines interfere with the ability to do daily activities such as driving, working or chores

Often the first step in migraine diagnosis is ruling out the presence of another disease. Your physician may schedule diagnostic tests to determine whether your symptoms are the result of other conditions such as stroke, infectious disease, tumor or vascular irregularity that can mimic migraines.

When I first meet with migraine patients, I ask a lot of questions and listen carefully to the answers so I can learn as much as possible about the patient’s medical history, lifestyle, as well as the specific characteristics of his or her migraines. What I learn during that assessment can be key to coming up with an effective treatment plan.

"Hormones, particularly estrogen, may play a major role. Three out of four adult patients are women."

What causes them?
We know some people have a genetic predisposition for migraine. As many as 90 percent of migraine sufferers have a close relative who also has migraines. Hormones, particularly estrogen, may play a major role. Three out of four adult patients are women.

There are also other diseases that can be associated with the presence of migraines such as bi-polar disorder, depression, obsessive-compulsive disorder, high blood pressure and sleep disorders. Lifestyle choices and habits also play a role such as cigarette smoking and misuse of over-the-counter, prescription and illegal drugs. Birth control pills may play a role, as does a lifestyle that entails sustained high levels of stress and a lack of structured sleep time.

Looking for triggers
Some patients link the occurrence of their headaches to specific triggers. Some women can't chop onions, inhale diesel exhaust or go into the perfume section of a department store. Food is a common trigger and common culprits are cheeses, processed meats containing nitrates, foods with MSG, chocolate and fermented beverages such as wine and beer.

There is no magic bullet to cure migraines, but if you can identify a specific trigger for your headaches, avoid it. Treating diseases that are associated with migraines can also help. Therapy and/or medication to treat depression or bi-polar disorders can reduce the incidence and severity of migraines. Some women whose migraines are related to their menstrual cycles can be treated with low doses of estrogen.

Many patients have more complex lifestyle issues such as jobs that entail irregular sleeping cycles or economic pressures that cause chronic stress. Understanding this connection and learning how to modify the lifestyle element related to migraines can help.

Rebound migraines
Rebound headaches develop when patients have headaches and take acute headache remedies or other painkillers regularly. Soon they may be taking these medications several times a day to ward off headaches. As a result of constant exposure, the body becomes accustomed to the drug, and you get headaches whenever you don't take it. And when the drug wears off, the headache bounces back a little bit stronger than when it started.

Medications to treat migraines
During the last decade, there have been major strides in our understanding of the physiology of headaches and in the development of prescription drugs to treat headache pain. The class of drugs commonly referred to as "triptans" can be very effective in offering quick relief. By binding to receptors in the brain and blood vessels for serotonin–a biochemical that transmits information between nerve cells–triptans keep the migraine from intensifying and cause it to end.

There are also drugs that can be taken every day to prevent the occurrence of migraines. I’ve had limited success in some patients with beta blockers, anti-convulsive drugs and antidepressants.

"Most women discover as they reach their late 40s or 50s, the headaches begin to burn out on their own."

Managing headache triggers and related illnesses can lessen the impact of migraines on your life, but if you have a genetic predisposition to migraines, those measures won’t cure the migraines. Most women discover as they reach their late 40s or 50s, the headaches begin to burn out on their own. The good news is that treatment options are increasing dramatically as is our understanding of the complexities of migraine headaches.

Dr. Richard Lipton, a professor of neurology at the Albert Einstein College of Medicine in New York, was a driving force behind the American Migraine Study II. According to Dr. Lipton, "The best available treatment isn’t perfect. But it makes a difference between feeling you’ve got a problem that completely makes your life out of control, to feeling like you have a burden but have the tools to manage it."

Dr. Rizzo is an attending neurologist at Yale-New Haven Hospital and assistant professor of neurology at Yale University School of Medicine. He is a partner with Neurology Associates of New Haven, 60 Temple Street, New Haven, CT.

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