Britt Talley Daniel MD
Migraine is a genetic, inherited condition involving the brain, the trigeminal nerve, and cranial blood vessels which consists of symptoms of episodic headache with intervening periods of normal health. It is familial in occurrence and about 80% of patients who have migraine will have someone in their family with it. Migraine occurs in women about three times as often as men. The American Migraine study found that18% of women have migraine, while 6% of men have it. Migraine is said to be the most common chronic human health problem for women. People with migraine often have motion sickness (60%) either in childhood or adulthood. They have a sensitive brain and affected individuals may get attacks following exposure to bright sunlight, flashing lights or patterns, heat, nervous excitement, or fasting. Women often begin with headaches at menarche, when they have their first period, and they may keep this pattern until menopause. About 70% of women with migraine get headaches during the monthly estrogen withdrawal which occurs just before they start to bleed. They may have little headache during pregnancy, only to have the attacks return with resumption of the menstrual cycle. These same women may have an increase in frequency, intensity, and type of migraine attacks with the use of birth control pills or estrogen. The other 30% of women with migraine may notice no particular relationship to their menses or estrogen levels. These are likely different genes for migraine. Migraine attacks may be precipitated by relaxation after stress—the weekend, holiday, or vacation headache. Headaches may come from oversleeping, anxiety, or depression.
There are two types of Migraine
1. Migraine without aura, according to the 2004 International Classification of Headache is diagnosed by a headache pattern fulfilling the following criteria:
A. At least five attacks fulfilling B-D.
B. Attacks lasting 4-72 hours (untreated or unsuccessfully treated).
C. At least two of the following characteristics:
1. Unilateral (one sided) location.
2. Pulsating (throbbing) quality.
3. Moderate or severe intensity (inhibits or prohibits daily activities).
4. Aggravation by walking stairs or similar routine activity.
D. At least one of the following:
1. Nausea and/or vomiting.
2. Photophobia (sensitivity to light) and phonophobia (sensitivity to sound).
Migraine without aura used to be called “common” migraine because it is the most prevalent type of migraine, consisting of about 70% of all attacks. Typically the patient has one sided headache (migraine comes from a French word that means half of head or hemicrania), nausea and vomiting, photophobia (fear of light), sonophobia (fear of sounds), and goes to sleep in a quiet, dark room. This is often called sick headache, sinus headache, heat or sun headache, menstrual headache, letdown headache (a headache that comes during a weekend, vacation, or holiday), cold front or weather change headache (from a drop in the barometric pressure), or nocturnal headache (middle of the night, end of a dream headache.) The patient may not know he has migraine but comes for treatment and diagnosis of headache.
2. Migraine with aura. This used to be called “classical” migraine and consists of an aura, usually followed by headache. 30% of migraine attacks are like this. The aura may be visual, such as seeing wavy lines, spots, or holes, or half of things. The aura may also consist of slowly spreading numbness in one hand or the face on the same side, or a temporary disturbance of language (aphasia.) The aura symptoms may be frightening and much more concerning than the headache. The patient usually knows he has migraine when they come in and mainly want treatment. Aura may occur without headache.
The patient with migraine needs to understand that although the condition cannot be cured, since it is part of the genetic makeup, effective treatment exists. Adequate rest of seven to eight hours of sleep a night, a short nap at midday and regular hours for going to sleep and arising, including the weekend, may help set the individual’s internal biologic clock. Fasting, missing meals, oversleeping, alcohol, bright sunlight, and heat should be avoided. Daily caffeine in beverages or medication should be eliminated. Regular aerobic exercise taken three or four times a week may help relieve anxiety and stress and help the headaches. For some patients relaxation training or formal psychological counseling may be helpful. Prescribed medication should be taken early on in the course of the headache without delay, attempting to “nip the headache in the bud,” before it is fully developed. Migraine should be treated early and when it is mild. Extra supplies of medication should be stashed away at work, in the car, and at home. If a headache comes on at night during sleep, the patient should take his dose of medication, and attempt to return to sleep. In general sleep is one of nature’s best treatments for migraine and the individual who ”changes his life,” stops an activity, goes home from work, takes his medication and lies down in a quiet, dark room will fare well. The idea is to “learn to live” and “give into” the condition rather than ignore it and have the headache win.
Analgesic, pain killer, or narcotic type medications usually fail to treat migraine successfully. Taking Lortab (a typical narcotic) and going to sleep for the rest of the day is not successful treatment. A program of outpatient self management wherein the patient takes his medication and stops the headache is desired. The patient who has to go to the emergency room or the doctors office for repeated injections is somewhat of a treatment failure. For patients who experience more than 3-4 migraines a month, chronic preventive therapy may be helpful.
Lifestyle treatment plan for Migraine
Decaffeinate yourself either slowly by decreasing by one cup of coffee or two colas every three days or do it quickly-cold turkey. The reason is that caffeine is a vasoconstrictor and too much can cause medication overuse headache. Caffeine is confusing to some patients because they know that it may be used to treat headache, but need to learn that if taken daily it can cause frequent headaches.
Eat Three Meals a day. A small breakfast will suffice. Remember breakfast means “break the fasting of sleep.” If you don’t eat and without your knowing it, your pituitary gland will sense your low blood sugar and send out a hormonal signal that will cause vasodilatation of your cerebral arteries and start your “hungry headache” migraine.
Exercise aerobically for 20 minutes, 3 to 4 times a week. Aerobic exercise means that you do an activity that gets your heart rate at a certain desired target range and keeps it there for the entire workout. Consult tables for your age heart range at bookstores, the YMCA, or your local fitness center. The more aerobic the exercise, within heart rate limits for age, the better. You can treat migraine, anxiety/panic disorder, depression, tension headache, and sleep problems with aerobic exercise. There are hundreds of scientific articles over the past 20 years proving that exercise works for headache therapy. Aerobic exercise is aerobics, jogging, cycling, swimming, rowing, cross-country skiing, and stair-stepping. It is usuall not walking, lifting weights, stretching, or playing most games, like tennis or racquetball. If you are already exercising and still have bad headaches, consider increasing your exercise program. Exercise is something you can do for yourself to take control of your headaches. It takes determination, time, and effort. Some migraine patients get a “work out headache” if they get hot. If this happens to you then try to work out so you don’t get so hot. Exercise in front of a fan or in air conditioning. Take ibuprofen, Excedrin, Midrin or a half of a Tryptan drug before you work out. If you still get a work out headache, then try swimming.
Set your sleep/wake cycle to rise and go to sleep at the same time every day-even through the weekend. Avoid oversleeping Saturday morning or falling asleep for that seductive two hour nap on Sunday afternoon. Set an alarm for 10-15 minutes for a short, energy restoring nap.
Try to destress your life. Talk over your daily life problems with your friends, family, preacher, priest, or rabbi. Develop a support system to sustain you in life, built up of key people that are there for you when you need them. Plan time to relax and spend on hobbies or interests. Normal people have hobbies which is something you do for fun and relaxation, that is creative and not goal or money-making oriented. Children and family are not hobbies. Leave that depressing, stressful job, or get counseling and try to change a personal relationship that is causing problems.
Medication to be taken when the Migraine starts.
Aspirin (5 grains)with caffeine (60 mg) (Excedrin,Vanquish), Excedrin Migraine also has acetaminophen, 2-3 at onset, then repeat every hour X 2. Limit to 2 treatment days a week. Rebound potential.
Nodolor generic for Midrin (Tylenol for pain & a mild tranquilizer for muscle relaxation; isoheptadine for vasoconstriction of a migraine headache) The dose is 2 at onset and then 1 every hour to 5. Limit to 2 treatment days a week. Max 15/month. Rebound potential.
Cambia (diclofenac) an NSAID (nonsteroidal antiinflamatory drug) approved by the FDA for acute treatment of migraine. Dose is 1 at onset, may repeat in 4 hours. Rebound potential.
Migranol now generic DHE-45 Nasal spray 4mg/ml. One spray (0.5 mg dihydroergotamine) to each nostril is taken at onset and the dose may be repeated X 1. The half life is 10 hours. This drug may be used for medication overuse headache.
DHE-45 for Intramuscular injection 1 cc at onset of a migraine. Has to be drawn up from a bottle like insulin and injected in the muscle. May repeat in 6 hours. Used for treating medication overuse headache. Look to YouTube to learn about IM injections.
General triptan rules—don’t use with a personal or strong family history of coronary artery disease or uncontrolled hypertension. Limit the dose in children, the elderly (over 65 years old.), and patients with basilar artery or long aura symptoms.
Don’t mix the triptans or take with ergotamine within 24 hours.
Common triptan side effects: chest tightness or pressure, near fainting, neck/back pain or burning, warm or hot feeling, dizziness, or drowsiness.
Imitrex (sumatriptan) most effective when given via a gun type injector. The medicine comes in a vial with a needle and is loaded into the injector like a bullet. The medicine is then injected subcutaneously by pushing a trigger. This is a very slick, high tech system. The dose is 1 injection (6mg) at the onset of a migraine, with one repeat dose within 24 hours (max 12 mg/24hrs). An oral pill exists also: 25 mg (for kids) or 50, 100 mg (for adults). The usual dose is 50-100 mg at the onset of headache (max 200mg/day). An Imitrex nasal spray is also available as 1-10 mg squirt per nostril per migraine. For Imitrex the highest drug levels are obtained with the shot, medium drug levels with the pills, and low drug levels with the nasal spray. Rebound potential. Limit to 2 treatment days/week.
Treximet (sumatriptan 85 mg/naproxen 500mg). Studies show this may be more effective than Imitrex alone. Rebound potential. Limit to 2 treatment days/week.
Alsuma an epi pen type injection, 6mg sumatriptan, may repeat in 1 hour, rebound potential, Limit to 2 treatment days/week.
Sumavel DosePro transdermal injection of 6 mg sumatriptan may repeat in 1 hour, rebound potential, Limit to 2 treatment days/week.
Zomig (Zolmitriptan) should decrease the dose by 50% if taken with Tagamet (Cimetidine). Comes as a 2.5 mg or 5 mg tab to be taken one as needed for migraine, trying the 2.5 mg dose size first and moving up to 5 mg (max 10mg/day). Also comes as a dissolvable tablet 2.5/5 ZMT and as a nasal spray 5 mg. Rebound potential. Limit to 2 treatment days/week.
Maxalt (Rizatriptan) comes as a MLT (melt in your mouth) 10 mg wafer and 5/10 mg tablets. Both are absorbed in the stomach and the MLT, which some patients consider more convenient, is absorbed slower than regular Maxalt. Should reduce the dose by 50% if taken with Inderal (Propanalol). Max 30 mg/day. Rebound potential. Limit to 2 treatment days/week.
Axert (Almotriptan) Comes as a 6.25 and 12.5 mg tablet. Take at onset, may repeat in 2 hours. The only triptan approved for ages 12-17 years old. Rebound potential. Limit to 2 treatment days/week.
Relpax (Eletriptaan) —20 and 40 mg tablet. The 40 mg tablet seems to work the best. If there are no good results the 40 mg tablet may be repeated at 2 hours. Contraindicated with Antifungals, Macrolide Antibiotics, and Protease Inhibitors. Rebound potential. Limit to 2 treatment days/week .
Amerge (Naratriptan)—2.5 mg tablet which is the initial dose. May repeat in 2 hours. Duration 6 hours as opposed to 2-3 hours for most of the other triptans, except Frova. Rebound potential. Limit to 2 treatment days/week.
Frova (frovatriptan) 2.5 mg tablet It has a very long duration (26 hour half-life) and lasts four times longer than any other triptan, drug of choice for menstrual migraine. Taking birth control pills or Inderal may increase blood levels of Frova. Treat with an initial 2.5 mg dose, may repeat in 2 hours. Rebound potential. Limit to 2 treatment days/week.
Chronic or Preventive Therapy (taken daily)
Preventive Therapy of Migraine
Beta Blockers–Inderal (Propranalol) Comes as LA (Long Acting) an oral capsule 60, 80, 120, or 160 mg once a day, or as an oral tablet 10, 20, 40, 60, 80, and 90 mg given in divided doses. The initial dose is 40-60 mg and the typical dose is 40-240 mg/day. Blocadren (Atenolol) Comes as an oral tablet 25, 50, 100 mg given in divided doses. The initial dose is 25 mg and the typical dose is 50-100 mg. Common side effects—fatigue, depression. Serious side effect–bradyarrhythmia. Beta Blockers are contraindicated in patients with asthma or severe COPD, 2nd and 3rd degree AV block, severe sinus bradycardia, and Raynaud’s syndrome.
Antidepressant—Elavil (amitriptyline) Comes as an oral tablet 10, 25, 50, 75, 100, and 150 mg given usually at bedtime. The initial dose for migraine is 10 mg and up to 30 mg may be used. Side effects come with antidepressant psychiatric doses of 100-150..Pamelor (nortriptyline) Comes as a 25 mg oral tablet and oral capsule 10, 25, 50, 75 mg. The initial dose is 10 mg and the typical dose is 25-150 mg given at bedtime. Common side effects—weight gain, constipation, and sedation, cardiac dysrhythmias.
Depakote (Divalproex sodium) Comes as a delayed release oral capsule 125 mg, oral tablet 125, 250, 500 mg, and oral tablet extended release 250, 500 mg. The initial dose for migraine is 250-500 mg and the typical dose for migraine is 750-1500 mg given in divided doses. Common side effects alopecia, weight gain, nausea, and tremor. Serious side effect pancreatitis, liver failure, and thrombocytopenia. Depakote should never be given to fertile women since it carries a class D risk for pregnancy.
Topamax (Topiramate) Comes as an oral capsule 15 and 25 mg and oral tablet 25, 50, 100, and 200 mg. Doses for migraine the usual final dose is 100 mg and the drug is titrated up weekly starting with 25 mg and increasing the dose by 25 mg/week to decrease the risk of side effects to 50 mg taken twice a day– Common side effects—paresthesiae, weight loss, cognitive/psychiatric side effects including cognitive dysfunction, word finding difficulty, somnolence and fatigue, acute myopia and secondary angle-closure glaucoma (patients should be cautioned to seek medical attention if they experience blurred vision or ocular pain), oligohidrosis and hyperthermia—decreased sweating and increased, metabolic acidosis with lowering of serum bicarbonate levels (especially children in hot weather), and kidney stone formation.
In case of pregnancy all regular drugs for Migraine prevention and acute therapy should be stopped as during pregnancy the only medications most women may take are vitamins and iron. The patient should check with their obstetrician to see what drugs he or she allows for pain during pregnancy. Usually this is Tylenol and caffeine. Rarely patients with very severe migraine may be given one of the preventive drugs, except Depakote which has an X rating for pregnancy and which should never be considered for a patient who is fertile. Also rarely triptans may be used safely during pregnancy and are commonly used by headache specialists.
Chronic sinusitis is not validated as a cause of headache or facial pain unless relapsing into an acute stage. Migraine and tension-type headache are often confused with rhinosinusitis headache because of similarity of location of the headache. A group of patients can be identified who have of all the features of migraine without aura and clinical features of facial pain, nasal congestion and headache triggered by weather changes. None of these patients have purulent nasal discharge or other features diagnostic of acute rhinosinusitis. Therefore is necessary to differentiate headache attributed to rhinosinusitis from so-called “sinus headaches”, a commonly made but nonspecific diagnosis. Most such cases fulfill the criteria for migraine without aura with headache either accompanied by prominent autonomic symptoms in the nose or triggered by nasal changes. Sinus CAT scan is required to differentiate migraine in the sinus areas from acute rhinosinusitis.
Patients with what they call “sinus headache” usually localize the pain to behind the eyes, the forehead, or the cheeks. Many of these patients have no purulent nasal discharge, a cardinal requirement of acute rhinosinusitis, an infection in the sinus areas. This myth about sinus headache has been taught to Americans by TV ads since the 50’s by the pseudoephed industry. This misconception doesn’t exist in Europe. It is a marketing idea made up in America to sell pseudoephedrine type drugs to the unwary consumer.
Allergy and Migraine
Allergy and migraine are separate medical problems sometimes existing in the same person. The word “allergy” is not listed in the index of the 2013 International Classification of Headache. Allergic symptoms may be an aggravating factor for the occurrence of migraine attacks. Many different chemicals cause vasodilation and therefore aggravate migraine and is why MSG, chocolate, tyramine in aged cheese, and nitrates in hot dogs may result in migraine headache. There is a relationship between the ingestion of such a chemical and headache, but the headache comes because of vasodilation caused by the offending chemical, not from an allergic reaction.
Medication Overuse Headache
Medication overuse headache or rebound headache is very common and occurs usually in migraine patients who overtreat with caffeine, NSAIDS, barbiturates, and triptans. In general only 2 treatment days per week are allowed. One may have fewer headaches by taking less headache medicine. The only way to treat rebound headache is to completely get off of the daily drugs for several weeks or months and the headaches will lessen.
Medications or Food that may aggravate Migraine
Antihypertensive drugs-such as Reserpine (Brand name- Ser-ap-Es, Hydropres),
Hydralazine (Brand name-Apresoline), and Nifedipine (Brand name-Caalan).
Birth control pills, estrogen patches, IUDs, or intramuscular contraceptives Coronary vasodilators for angina-Nitroglycerin, Nitrates
Antacids Tagamet (Cimetidine)
Decongestant overuse-pseudoephedrine (Advil sinus, Dristan)
Analgesic overuse-Excedrin, Tylenol, Advil
SSRIS-Selective Serotonin Receptor Inhibitors-for treatment of Depression, Anxiety and Panic Disorder-Prozac (Fluoxetine), Paxil (Paroxitinel).
Benzodiazepine withdrawal Xanax (Alprazolam), Valium (diazepam), Ativan (lorazepam)
Certain foods-listed below
Aged Cheese-cheddar, Brie, Camembert, Gruyere, Stilton (tyramine)
Bananas, figs, and raisins
Beer, wine (especially red wines), champagnes, vermouth, hard liquor
Dairy products such as ice cream, milk, yogurt, whipped and sour cream
Fermented and pickled foods such as pickled herring
Most citrus fruits like oranges, grapefruit, and lemons (Octopamine)
Nuts, peanuts, peanut butter
Soya products, vinegar
Pods of broad beans-lima, navy, pea pods
Yeast containing products such as fresh breads, sourdough, and donuts
Avocados, Anchovies, Onions, and Sauerkraut
Pork, Pizza, chicken livers
Caffeine in coffee, tea, and colas, and over the counter medications such as Excedrin and BC Powder,
MSG (Monosodium glutamate) which is found in Chinese food, Accent seasoning, Lawry’s Seasoned Salt, canned soups, snack chips, some processed meats and nuts, and TV dinners.
Saccharin or aspartame found in diet sodas, drinks, and foods.
Sulfites found in shrimp and processed potatoes, store bought potato mix.
Benzoic acid which is a food preservative.
Nitrates used as a preservative in bologna, salami, pepperoni, and hotdogs.
Aspartame, a table top sweetener, used in foods and drinks (NutraSweet).