Approximately 26 million Americans — 70 percent of them women — suffer from migraine, a type of headache that's often severe. Although any head pain can be miserable, migraines are in a class by themselves. These painful headaches may be preceded by a warning sign (aura) such as flashes of light, dizziness, or numbness and are often accompanied by severe nausea and vomiting and extreme sensitivity to light and sound. Migraine pain can be excruciating and may incapacitate you for hours or even days.
Fortunately, though, migraine pain management has improved dramatically in the last decade. If you've seen a doctor in the past and had no success, it's time to make another appointment. Although there's still no cure, there are medications that can help reduce the frequency of migraines and stop the pain once it's started. The right medicines combined with self-help remedies and changes in lifestyle may make a tremendous difference for you.
A migraine usually begins with an intense, gripping pain on one side of your head that may gradually spread. Migraines typically last from 4 hours to 72 hours, but the frequency with which they occur can vary from person to person. You may have headaches several times a month or just once or twice a year.
Not all migraines have the same patterns. Although there are several kinds of migraines, the most common are classic migraine — which is a migraine with aura — and common migraine, which has no aura.
If you're among the 10 percent of adults who have migraines with aura, you'll likely have warning signs about 20 minutes before the headache begins. These may include:
- Sparkling flashes of light
- Dazzling zigzag lines in your field of vision
- Slowly spreading blind spots in your vision
- Weakness, numbness or tingling in your face, hand or leg
- Difficulty seeing or speaking
Although a migraine without aura has no classic warning signs, you may have one or more symptoms of premonition several hours before your headache actually strikes, including:
- Feelings of elation or intense energy
- Cravings for sweets
- Thirst
- Drowsiness
- Irritability or depression
Migraine symptoms in children
Migraines typically begin in childhood, adolescence or early adulthood and often become less frequent and intense as you grow older. Although it's normal to think of adults as having migraines, children as young as age 2 can also have these headaches. In fact, it's estimated that between 2.5 percent and 22 percent of children experience intense headache pain. In addition to physical suffering, severe headaches often mean missed school days and trips to the emergency room, as well as lost work time for anxious parents.
Children's migraines are often accompanied by nausea, vomiting, increased sensitivity to light, diarrhea, increased urination, sweating and thirst. Visual auras aren't as common in children as in adults. If your child does have auras, he or she may also have premonition symptoms, such as:
- Yawning
- Sleepiness or listlessness
- A craving for migraine trigger foods such as chocolate, hot dogs, sugary snacks, yogurt and
bananas
Older children may have all of the signs and symptoms of migraine — nausea, vomiting, increased sensitivity to light and sound — but no head pain. These "abdominal migraines" can be especially difficult to diagnose.
The good news is that the same medications that are effective for adults also work for children. Your child doesn't have to suffer the pain and disruption of migraines. If your child has headaches, be sure to talk to your pediatrician. He or she may want to refer your child to a pediatric neurologist.
Although much about headaches still isn't understood, some researchers think migraines may be caused by functional changes in the trigeminal nerve system, a major pain pathway in your brain, and by imbalances in the brain chemical serotonin, which regulates pain messages going through this pathway.
During a headache, serotonin levels drop. Researchers believe this causes the trigeminal nerve to release substances called neuropeptides, which travel to your brain's outer covering. There they cause blood vessels to become dilated and inflamed. The result is severe headache pain.
Other studies using brain scans have shown that the volume and amount of blood reaching the brain drops during migraine attacks. This has led some experts to speculate that migraines occur when blood drains from the blood vessels in the center of your brain to outer blood vessels. Because levels of magnesium, a mineral involved in nerve cell function, also drop right before or during migraines, it's possible that low amounts of magnesium may cause nerves in the brain to misfire.
Whatever the exact mechanism of headaches, they don't just occur on their own — Something has to trigger them. Triggers can be almost anything, ranging from allergies and stress to sun glare and changes in barometric pressure.
For the nearly 65 percent of women who have migraines immediately before, during or right after their periods, that something may be changes in estrogen levels. Although the exact relationship between hormones and headaches isn't clear, hormonal fluctuations, especially during menstruation and pregnancy, seem to trigger headaches in many women with migraines.
Certain foods appear to trigger headaches in some people. Common offenders include alcohol, especially beer and red wine; aged cheeses; chocolate; fermented, pickled or marinated foods; monosodium glutamate (a key ingredient in some Asian foods, certain seasonings, and many canned and processed foods); aspartame and caffeine.
Other common migraine triggers include:
- Stress and fatigue
- Changes in weather, season, altitude level or time zone
- Changes in sleep patterns, including too much or too little sleep
- Bright lights
- Unusual odors
- Certain medications, including cimetidine (Tagamet), fenfluramine (Pondimin), nifedipine
(Procardia) and theopylline (TheoDur, Theo-24)
- Low blood sugar, changes in mealtimes, skipped meals or fasting
- Intense physical exertion, including sexual activity
- Tobacco, including secondhand smoke
If both your parents have migraines, there's a 75 percent chance you will too. If just one parent has migraines, you have a 50 percent chance of being affected. You also have a relatively higher risk of migraines if you're young and female. In fact, women are three times more likely to have migraines than men are. Headaches tend to affect boys and girls equally during childhood but increase in girls after puberty.
If you're a woman with migraines, you may find that your headaches are worse during menstruation or the first few months of pregnancy. And you may not be able to tolerate birth control pills or hormone replacement therapy (HRT).
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When to seek medical advice
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Try over-the-counter (OTC) medications such as acetaminophen (Tylenol, generics), ibuprofen (Advil, Motrin), aspirin (for adult use only — Don't give aspirin to children under 16 because of the risk of Reye's Syndrome, a rare but potentially fatal disease) or other self-care measures for a day or two. If you don't get relief, see your doctor. Even if you have a history of headaches, see your physician if the pattern changes or your headaches suddenly feel different.
Be sure to see your doctor immediately or go to the emergency room if you have any of the following signs and symptoms, which may indicate another, more serious medical problem:
- An abrupt, severe headache like a "thunderclap"
- A severe headache that isn't just on one side of your head
- Headache with fever, stiff neck, rash, mental confusion, seizures, double vision, weakness,
numbness, or trouble speaking
- Headache after a recent sore throat or respiratory infection
- Headache after a head injury, even a minor one, and especially if the headache gets worse
- A chronic headache that is worse after coughing, exertion, straining or a sudden movement
- New headache pain after age 55. This may be a symptom of a rare condition known as temporal
arteritis, which can lead to blindness or stroke if left untreated.
If you have typical migraine headaches or a family history of migraines, your doctor will likely be able to diagnose the condition on the basis of your medical history and a physical exam. But if your headaches are unusual, very severe or have come on suddenly, your doctor may recommend certain tests to rule out other possible causes for your pain.
You may have X-rays of your skull and sinuses, vision tests or magnetic resonance imaging (MRI) — a diagnostic imaging procedure that combines a strong magnetic field, radio waves and computer technology to produce clear images of your internal organs, including your brain. During an MRI, you'll lie on a special table while detector measurements are taken of your body from thousands of angles. This information is then processed by a computer to produce a three-dimensional representation of your head.
If your doctor suspects that your headaches are caused by an underlying medical condition, he or she may recommend that you have a spinal tap (lumbar puncture). In this procedure, a thin, hollow needle is inserted between two vertebrae in your lower back. Once the needle is in place, the pressure of the cerebrospinal fluid (CSF) is measured, and a sample of the fluid is withdrawn for testing.
The procedure takes about 30 minutes. You may have a feeling of pressure while the fluid is being extracted and a headache afterward because of a drop in CSF pressure. Lumbar puncture isn't without other risks, including a small risk of infection.
It's likely your headaches don't signal a serious medical condition. But in a small number of cases, headaches may be a symptom of a blood clot or brain tumor. Temporal arteritis, which usually affects those over age 55, is a rare, headache-related condition that may lead to blindness or stroke if not treated.
Sometimes even your efforts to control your pain can cause problems. If you take over-the-counter or prescription headache medications more than three times a week, you may be setting yourself up for a serious complication known as rebound headaches. Although these drugs can give you temporary relief, your body gets used to them over time. The result is that your headaches become worse or more frequent. You then use more pain medication, which traps you in a vicious cycle. If you're caught in the rebound headache trap, talk to your doctor. In addition, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) and aspirin may cause side effects such as stomach pain, bleeding and ulcers, especially if taken in large doses or for a long period of time.
At one time, aspirin was almost the only available treatment for headaches. Now there are drugs specifically designed to treat migraines. Several drugs commonly used to treat other conditions also may help relieve migraines in some people. These medications fall into two classes — those that reduce or prevent migraines, and those that stop pain once it's started.
Abortive drugs stop or decrease pain after a migraine starts. You may have better results from these medications if you rest or sleep in a dark room after taking them. They include:
- Mild pain relievers. Over-the-counter and prescription analgesics such as acetaminophen
(Tylenol, generics) and ibuprofen (Advil, Motrin), aspirin, or other nonsteroidal anti-inflammatory
drugs may ease mild to moderate migraines in as many as 50 percent of people. If OTC medications don't
help, your doctor may suggest a stronger, prescription-only version of the same drug. Be aware that
new OTC medications marketed specifically for migraines, such as Excedrin Migraine, Advil Migraine and
Motrin Migraine, contain the same amount of pain reliever as the original versions of these drugs and
aren't usually effective for people who are seriously disabled by their headaches. In addition, taken
too often or for long periods of time, NSAIDs can lead to ulcers, gastrointestinal bleeding and
rebound headaches.
- Triptans. Sumatriptan (Imitrex) was the first drug specifically developed to treat
migraines. It mimics the action of serotonin by binding to serotonin receptors and causing blood
vessels to constrict. Sumatriptan is available in oral, nasal and injection form. With tablets, relief
occurs in about 60 percent of people. Injections are effective in nearly 80 percent of cases because
more of the drug reaches the bloodstream. Relief may occur in as little as 15 minutes. Injections may
be inconvenient, however, and you may develop irritation at the injection site. Furthermore,
sumatriptan is expensive and its effectiveness limited — It relieves pain for about 5 hours. Since the
introduction of sumatriptan, a number of similar drugs have become available, including rizatriptan
(Maxalt), naratriptan (Amerge) and zolmitriptan (Zomig). Rizatriptan and zolmitriptan are effective in
between 60 percent and 80 percent of people and, unlike many other drugs, seem to offer relief during
menstruation. Side effects of triptans include nausea, dizziness and muscle weakness. Although rare,
stroke and heart attack also are possible side effects of these drugs. If you're taking the class of
antidepressants known as monoamine oxidase inhibitors (MAOIs), don't use triptans. In rare cases
people taking Imitrex have developed severe abdominal pain, cramping and bloody diarrhea (mesenteric
ischemia) that may require hospitalization or even surgery. To help your doctor determine what is
causing your symptoms, be sure he or she knows all of the medications you're taking.
- Ergot. Drugs such as ergotamine (Ergomar) and dihydroergotamine (D.H.E. 45) help relieve
pain by constricting swollen blood vessels in the outer area of your brain and in your scalp. But
because you can become dependent on these medications, they're usually only given for predictable
headaches, such as those that occur during menstruation.
- Metoclopramide (Reglan). This medicine is useful in relieving the nausea and vomiting
associated with migraines, but needs to be taken early in the course of the migraine or even during
the aura before the headache begins.
Prophylactic drugs help reduce the frequency and severity of migraines and may increase the effectiveness of abortive medicines during migraine attacks. In general, you use these medications only after you've tried other measures — including self-care — or if your headaches are disabling or occur more than two or three times a month. In most cases prophylactic drugs don't eliminate headaches completely, and some can have serious side effects. To be effective, they need to be taken every day, as your doctor recommends. Among these medications are the following:
- Cardiovascular drugs. Beta blockers and calcium channel blockers — commonly used to treat
high blood pressure and coronary artery disease — may help reduce the frequency and severity of
migraines. Why these drugs help prevent migraines isn't exactly understood. Side effects can include
dizziness, drowsiness or lightheadedness. Beta blockers can also raise blood sugar levels and mask
symptoms of low blood sugar in people with diabetes.
- Antidepressants. Certain antidepressants are extremely good at helping prevent all types of
headaches, including migraines. Most effective are tricyclic antidepressants such as nortriptyline
(Pamelor) and amitriptyline (Elavil). These medications may reduce migraines by affecting the level of
serotonin and other brain chemicals. You don't have to have depression in order to have one of these
drugs prescribed.
- Antiseizure drugs. Although the reason is unclear, some antiseizure drugs such as valproic
acid (Depakene) and gabapentin (Neurontin), which are typically used to treat epilepsy and bipolar
disease, seem to prevent migraines. Taken in high doses, however, valproic acid can cause side effects
such as nausea and vomiting, heartburn, diarrhea, cramps, hair loss and confusion. Side effects of
gabapentin may include fatigue, dizziness, blurred or altered vision, unsteadiness, and nausea or
vomiting. If you're pregnant, don't use antiseizure medications.
- Cyproheptadine (Periactin). This antihistamine specifically affects serotonin activity.
It's sometimes given to children as a preventive measure.
- Riboflavin (vitamin B-2). A high dose (about 400 milligrams of riboflavin a day) may
prevent migraines. Vitamin B-2 may work by correcting tiny deficiencies in the brain cells of people
with migraines. Large doses of this vitamin should be taken only with medical supervision.
- Magnesium. Infusions of the mineral magnesium can relieve migraine pain in some people. Ask
your doctor if this treatment may be right for you. Keep in mind that it's not known whether taking
oral magnesium supplements provides the same benefit.
Several self-care measures can help reduce the number and severity of migraines. In some cases you may be able to prevent headaches entirely. One or more of the following suggestions may be helpful for you:
- Keep a diary. A diary can help you determine what triggers your migraines. Note when your
headaches start, how long they last and what, if anything, provides relief. Pay special attention to
foods you ate in the 24 hours preceding attacks, any unusual stress, and how you feel and what you're
doing when headaches strike. If you're under stress, be sure to tell your doctor.
- Avoid trigger foods. If certain foods seem to have triggered your headaches in the past,
try avoiding them. These foods may include common culprits such as beer, red wine, aged cheeses,
chocolate, fermented, pickled or marinated foods, hot dogs, monosodium glutamate, aspartame and
caffeine. For some people, however, a cup of coffee may actually relieve migraine symptoms. Still, be
sure to eat regularly. Don't skip meals.
- Try muscle relaxation exercises and techniques. Biofeedback appears to be especially
effective in relieving migraine pain. This relaxation technique uses special equipment to teach you
how to monitor and control certain physical responses, such as muscle tension. Other relaxation
techniques, such as progressive muscle relaxation, meditation and yoga, don't require any equipment —
You can learn them in classes or at home using books or tapes. Or spend at least a half-hour each day
doing something you find relaxing — listening to music, gardening, taking a hot bath or reading.
- Exercise regularly. Aerobic exercise — about 30 minutes on most days — reduces tension and
can actually help prevent migraines. If your doctor agrees, choose any exercise you enjoy, including
walking, swimming and cycling. Be sure to warm up slowly, however, because sudden, intense exercise
can actually cause headaches.
- Reduce the effects of estrogen. If you're a woman with migraines and estrogen seems to
trigger or make your headaches worse, or if you have a family history of stroke or high blood
pressure, you may want to avoid or reduce the amount of medications you take that contain estrogen.
These medications include birth control pills and HRT. Talk with your doctor about the best
alternatives or dosages for you.
- Get enough sleep, but don't oversleep. Get the amount of sleep you need that provides
adequate rest.
- Rest and relax. If possible, rest in a dark, quiet room when you feel a headache coming on.
Place an ice pack wrapped in a cloth on the back of your neck and apply gentle pressure to painful
areas on your scalp.
- Quit smoking. If you smoke, talk to your doctor about finding ways to quit. Smoking can
trigger headaches and make any headache you have worse.
Living with migraines is a daily challenge. Headaches can be both incapacitating and unpredictable and may interfere with your job, your relationships with family and friends, and your overall quality of life. Although new treatments offer more options than ever for pain management, you may still get disabling headaches. You may also occasionally feel anxious or depressed. The following options may help you cope more easily:
- Counseling. A counselor or therapist can help you learn techniques for managing stress and
coping with pain. Family therapy may help the people in your life understand more about migraines.
- Support groups. Like many people with migraines, you may find that these groups are a good
source of useful information as well as support. Group members often know about the latest medical
treatments as well as self-care or complementary remedies. Your doctor may be able to put you in touch
with a group in your area. The American Council for Headache Education Web site also provides
referrals to support groups nationwide.
- Balance. Try to balance the use of medications with regular exercise, relaxation
techniques, such as biofeedback, and nutritious meals and adequate rest. Allow yourself at least a
half-hour every day for relaxation.
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Complementary and alternative medicine
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The following nontraditional therapies may be helpful if you suffer from chronic headache pain:
- Acupuncture. In 1998, the National Institutes of Health (NIH) issued a long-awaited
statement on acupuncture. Among other benefits, NIH researchers found that acupuncture could provide
relief from chronic headache pain. An acupuncture practitioner treats you using very thin, disposable
needles that generally cause little or no pain or discomfort. If you'd like to try acupuncture, ask
for a referral from someone you know who's had these treatments. You can also find referrals to more
than 8,000 licensed practitioners on the Acupuncture and Oriental Medicine Alliance Web site. The
American Academy of Medical Acupuncture Web site provides referrals to medical doctors who use
acupuncture in their practices. Although acupuncture can be extremely effective, keep in mind that you
may not experience immediate results from nontraditional therapies and may require more than one
session.
- Massage. Although massage is a wonderful way to reduce stress and relieve tension, its
value in treating headaches hasn't been fully determined. For some people, however, who have tight,
tender muscles in the back of the head, neck and shoulders, massage may help relieve headache pain.
- Herbs. In double-blind studies, the herb feverfew has been shown to provide headache relief
for some people. Before using any herb, check with your doctor to make sure it won't interfere or
interact with other medications you may be taking. Don't use feverfew if you're pregnant.
- Essential oils. Some studies have shown that lavender oil may offer migraine relief. You
may get results simply by smelling the oil, or you may want to rub it on the nape of your neck and
your temples. You can find essential oils in most natural food stores.
— September 25, 2001 —
