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Britt Talley Daniel MD
7777 Forest Lane Suite B-220
Dallas, Texas 75230
Migraine Aggravating Factors/Triggers
Many patients refer to “migraine triggers” but ICDH II differentiates between a migraine trigger which is something that causes an attack within 24 hours, like red wine inducing a migraine, and an “aggravating factor” like stress which builds up over weeks to produce migraine.
Chabriat, et al,[i] wrote in 1999 in Headache on “Precipitating factors of headache. A prospective study in a national control-matched survey in migraineurs and non-migraineurs.” They screened prospective factors in a migraine and non-migraine group of patients who kept a diary for a 3-month period. The most frequent precipitating factors in both groups were:
“fatigue and/or sleep, stress, food and/or drinks, menstruation, heat/cold weather, and infections in both groups.”
Kelman[ii] writing in Cephalalgia in 2007 on “The triggers or precipitants of the acute migraine attack” listed stress at a frequency of 79 % and food at 26.9 %. The table of frequency of individual migraine triggers from his article was:
Trigger Frequency
Stress 79.7%
Hormones (in women) 65.1%
Not eating 57.3%
Weather 53.2%
Sleep disturbance 49.8%
Perfume or odor 43.7%
Neck pain 38.4%
Light (s) 38.1%
Alcohol 37.8%
Smoke 35.7%
Sleeping late 32.0%
Heat 30.3%
Food 26.9%
Exercise 22.1%
Sexual activity 5.2%
Kelman is not going by ICDH-II here which refers to stress as an “aggravating factor”, not a “trigger.” However, his list is interesting and I keep a copy of this article in my office to hand out.
Another observation here is that many patients will focus on the different foods that may aggravate migraine and not recognize stress in their lives which is the most aggravating feature of migraine.
(972) 566-4556
Allodynia with migraine and medication overuse headache
Allodynia comes from the words “allo” which means “other” and “dynia” which means “pain.” Clinically it refers to pain produced by a non-painful stimulus, such as touch. Allodynia is an uncomfortable heightened sensitivity to touch. Normally it doesn’t hurt to touch the head or the brow or the temple, but during the late stages of a migraine or during medication overuse headache, a simple touch to the head or temple may be perceived as painful. This is like a sunburn. Normally if I touch my arm it doesn’t hurt but after a sunburn at the beach, my arm is painful to touch. This is what allodynia is like.
Allodynia can be divided into: tactile allodynia-pain from touch or light pressure like a belt or bra strap, mechanical allodynia-pain from motion across the skin such as light massage or the touch of fabric, and thermal allodynia-pain from heat or cold that makes the limbs feel needle like, sharp pain.
The pain of allodynia can be provoked by combing or brushing the hair, shaving, showering, wearing glasses, or earrings. The pressure of a strand of hair may feel like the jab of a hot knife. Allodynia is the migraine patient who notes on the third day of headache suffering that it hurts her to brush her hair or lay her head on the pillow.
Allodynia occurs mostly in long duration episodic migraine attacks or in patients transformed to medication overuse headache by overtreatment of headache with analgesics. The duration of migraine is 4-72 hours, as defined by the International Classification of Headache 2004. Migraine is generally an episodic, paroxysmal disorder occurring at most 2 times a week. One can easily see by doing simple math that multiplying 72 hours or 3 days by 2 equals 6 days. This is why periodic migraine rarely occurs more than twice a week. Daily headache or headache 3 or 4 days a week is usually Chronic Daily Headache (CDH), a syndrome defined as >15 headache days a week. About 70% of persons with CDH have a common headache syndrome from overtreating with analgesics, caffeine, or triptans called Medication Overuse Headache. Also read my article on the subject of Medication Overuse Headache on this blog.
An attack of migraine has 4 stages: 1) trigeminal activation, 2) neurochemical release, 3) arterial vasodilatation, 4) central sensitization of the thalamus in the brain. In general patients with an attack of migraine are at stage 3 in two hours and after two hours they are in stage 4. Thus, patients with long-duration (headaches lasting more than several hours) episodic migraine attacks spend most of the time in stage 4 central sensitization. The general thinking is that all patients with medication overuse headache are continuously in stage 4 central sensitization. Both of these circumstances can produce allodynia.
With episodic migraine the allodynia clears when the headache ends and the offending neurochemicals are metabolized and excreted. The same thing occurs during treatment of medication overuse headache when the patient is detoxed off of analgesics, caffeine, or triptans. In time the offending neurochemicals are metabolized and consequently the headache clears.
BTD 10/29/09.
Britt Talley Daniel M.D.
(972)566-4556
Rules for acute treatment of Migraine:
This refers to the medication you take for the headache you have now.
1. Treat at onset. This means that all medication should be taken at the very first beginning of the headache. Don’t wait, thinking it’s not going to be “one of those.” It very well may be a bad headache coming on. Treat early. Carry your medication wherever you go. It is self defeating to have a migraine start at the office when your medication is home in the bathroom. Migraine is like a fire in your brain and no one would sit and watch a fire burning on the kitchen stove; they would put it out. Migraine has 4 stages and by 2 hours the typical patient is at stage 3 with trigeminal activation, neurochemical release, and arterial vasodilation fully developed. After 2 hours the tryptans don’t work as well. Treat early and when the headache is mild.
2. Take the right drug. In general, for severe migraine patients this is going to be a triptan. Yes, many patients with mild migraine can treat their headache with Excedrin, a NSAID, or some low level drug like Midrin, but the severe headache patients—the type that end up in the Doctor’s Office—will need a triptan. Only triptans can give 2 hour pain free data after treatment. Also usually the Triptans will treat the whole migraine syndrome—headache, nausea, vomiting, photophobia, sonophobia—and they will work anytime during the headache. However, as stated above they work better when taken early on the migraine attack.
3. Take enough of the right drug. This is a dosing situation which varies from patient to patient. Elephant rifle load for migraine remains injectable Imitrex which works the fastest, in 10 minutes, and gives the highest blood levels. Either oral Imitrex 50-100 mg, Treximet, Maxalt 10 mg, Zomig 2.5-5.0 mg, Axert 12.5 mg, or Relpax 40 mg should be taken at onset of the headache. All of the triptans may be repeated in 2 hours and that then is the full dose for 24 hours, except for Maxalt where 3 pills may be given in 24 hours. Also a new idea is to combine a triptan with the NSAID naprosyn. This is what is in Treximet, the new drug that replaced Imitrex. Several migraine treatment papers have show that a triptan taken with 500 mg of naprosyn (2 Alleve) works better than just the triptan alone.
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