Migraine Disorder
Migraine disorder affects 12% of people in the U.S., mostly women, and its symptoms can be debilitating. But finding ways to keep life on an even keel can help prevent the pain.
The pain of a migraine headache is often described as an intense pulsing or throbbing pain in one area of the head. However, it is much more; the International Headache Society diagnoses a migraine by its pain and number of attacks (at least 5, lasting 4-72 hours if untreated), and additional symptoms including nausea and/or vomiting, or sensitivity to both light and sound. Migraine is three times more common in women than in men and affects more than 10 percent of people worldwide. Roughly one-third of affected individuals can predict the onset of a migraine because it is preceded by an “aura,” visual disturbances that appear as flashing lights, zig-zag lines or a temporary loss of vision. People with migraines tend to have recurring attacks triggered by a number of different factors, including stress, anxiety, hormonal changes, bright or flashing lights, lack of food or sleep, and dietary substances. Migraine in some women may relate to changes in hormones and hormonal levels during their menstrual cycle. For many years, scientists believed that migraines were linked to the dilation and constriction of blood vessels in the head. Investigators now believe that migraine has a genetic cause.
There is no absolute cure for migraine since its pathophysiology has yet to be fully understood. There are two ways to approach the treatment of migraine headaches with drugs: prevent the attacks or relieve the symptoms during the attacks. Prevention involves the use of medications and behavioral changes. The U.S. Food and Drug Administration (FDA) has approved erenumab (Aimovig) to prevent migraines in adults. The drug works by blocking the activity of calcitonin gene-related peptide, a molecule that is involved in migraine attacks. The FDA also has approved lasmiditan (Review) for short-term treatment of migraine with or without aura. The FDA also has approved ubrogepant tablets (Ubrelvy) for immediate treatment of migraine with or without aura. Drugs originally developed for epilepsy, depression, or high blood pressure to prevent future attacks have been shown to be extremely effective in treating migraines. Botulinum toxin A has been shown to be effective in the prevention of chronic migraine. Behaviorally, stress management strategies, such as exercise, relaxation techniques, biofeedback mechanisms, and other therapies designed to limit daily discomfort, may reduce the number and severity of migraine attacks. Making a log of personal triggers of migraine can also provide useful information for trigger-avoiding lifestyle changes, including dietary considerations, eating regularly scheduled meals with adequate hydration, stopping certain medications, and establishing a consistent sleep schedule. Hormone therapy may help some women whose migraines seem to be linked to their menstrual cycle. A weight loss program is recommended for obese individuals with migraine.
Relief of symptoms, or acute treatments, during attacks consists of sumatriptan, ergotamine drugs, and analgesics such as ibuprofen and aspirin. The sooner these treatments are administered, the more effective they are.
What is Migraine Disorder?
Migraines are usually thought of as severe chronic headaches, but for most sufferers, the experience of a migraine is more complicated than that. While head pain is a common symptom of one stage of a migraine episode, there are often other symptoms, such as visual and sensory disturbances, and side effects such as nausea and vomiting.
Migraines may last as little as a few hours, or they can hang on for days. Some sufferers experience attacks relatively infrequently, perhaps twice a month, but some sufferers have attacks daily or near-daily.
Symptoms
The experience of a migraine attack varies widely from sufferer to sufferer, but a common pattern has the attack divided into four distinct phases: the prodrome phase, the aura phase, the attack phase, and the post-drome phase. Not all sufferers experience all four phases, and the symptoms of each phase are different for everyone.
Prodrome Phase
The prodrome phase often occurs a day or two before the other phases, and it’s characterized by subtle symptoms that indicate an attack is coming on. These symptoms may include:
- Changes in mood, either positive or negative
- Increased thirst or urination, fluid retention, or constipation
- Unusual food cravings
- Stiffness in the neck
- Bouts of yawning
Aura Phase
The aura phase typically precedes the attack phase, but the symptoms of the aura phase sometimes continue after the attack begins. The symptoms may include:
- Visual disturbances such as colors, shapes, or flashes in your field of vision
- Impaired vision or vision loss
- Weakness, numbness, or tingling in the arms or legs or on one side of the body
- Problems speaking
- Auditory disturbances or hallucinations
- Uncontrollable twitching or jerky movements
Attack Phase
The attack phase is when the headache sets in. If left untreated, the pain may last anywhere from 4 hours to 72 hours. The pain is commonly felt on one side of the head, but it may encompass the whole head. The pain often throbs or pulses, as well.
Side effects during this phase often include nausea, vomiting, and extreme sensitivity to light and sound.
Post-Drome Phase
The post-drome phase begins when the headache ends and typically lasts for about a day. Sufferers usually feel lingering effects, including exhaustion, mood changes, or disorientation.
Starting in her 30s, Barbara Schulties began suffering from debilitating headaches, which she describes as “someone taking a hot poker to my eye.” Besides excruciating head pain, the Santa Cruz resident lists a host of accompanying symptoms: nausea, vomiting, dizziness, difficulty focusing, and hypersensitivity to light, noise, and even wind on her face.
“I can’t spell,” she says, describing a typical headache. “It’s very hard for me to visualize words.” Like 12% of people in the U.S., and 1 out of 3 women over a lifetime, Schulties suffers from migraine disorder, an inherited condition that affects the regulation of nerve signals in the brain.
“For some people, it’s absolutely a devastating condition that impacts every aspect of their life,” says Dr. Andrew Charles, professor of neurology and director of the Headache Research and Treatment Program at UCLA.
Though a throbbing, one-sided headache is the hallmark migraine symptom, it turns out that migraine is a complex neurological phenomenon. In the days and hours before a headache even begins — a period known as the premonitory phase — and an electrochemical storm begins brewing inside the migraine-af¿icted brain.
“In the premonitory phase, patients will feel tired and they might have some neck discomfort,” says Dr. Peter Goadsby, professor of neurology at UC San Francisco. Other premonitory symptoms include yawning, weariness, dizziness, irritability, thirst, food cravings, increased urination, and difficulty concentrating. Using brain imaging, Goadsby and colleagues recently identified specific areas of the brain that are activated in the pre-headache phase.
In 25% of migraine sufferers, headaches may be preceded by another neurological symptom: the aura. Often experienced as a blind spot or a spinning wheel of light that obscures vision, an aura can also cause numbness, tingling or a loss of words. Once a migraine headache sets in, any type of sensory input becomes unbearable — ordinary light, noise and smells become jabs of pain. Hours after the headache has subsided, many people experience lingering fatigue and foggy-headedness.
There is evidence that, between attacks, migraine-disordered brains function differently from normal ones. Studies show that migraine-affected brains have a decreased ability to habituate or get used to a stimulus. If you expose a normal person to a constantly flashing light, then measure the signals evoked in the visual part of his or her brain, the signals will get smaller with time as the brain gets used to the light. But if you expose a person with migraine to a flashing light, the signal will grow larger with time.
“That’s why migraineurs will notice small things that will irritate them, like a clock ticking in the background,” says Goadsby. “A migraineur gets irritated by things because [he or she] can’t get rid of them easily. A person that’s not migraine will just ignore things. The difference is quite stunning.”
Is it chocolate?
Every migraineur knows about triggers: things that seem to set off a migraine attack like a flame kindles a brushfire. And there are several chemical triggers that can fuel an attack in susceptible people, such as alcoholic beverages (particularly red wine, a common trigger among Caucasians), gasoline fumes, and nitrates, the last of which are found in cured meats. But identifying triggers is often complicated by confounding symptoms of the attack itself.
Many people crave sugary or savory foods during the premonitory phase, says Goadsby. “If they crave something sweet and they eat something sweet, then five hours later they get a headache, they’ll tell you that if they eat sugar they always get a headache.” But he explains that the craving is part of the actual attack and one of the first signs that a headache is on its way.
“Chocolate is a classic example of this,” adds Goadsby. “If you actually study this and you try to trigger people prospectively with chocolate, it just doesn’t work. But many people will tell you it’s a trigger, and I think that the explanation for that is this very well-described premonitory phase of migraine.”
What does trigger migraine attacks in susceptible people is change? It seems that the migraine brain exists in a delicate physiological balance, with any fluctuation in sleep pattern, dietary pattern, stress level, hormone level, caffeine intake, or even weather disrupting that balance and inciting an attack. Women are often plagued by migraine attacks just before their menstrual period when their levels of estrogen and progesterone decrease. (And they frequently experience a worsening of symptoms with the onset of menopause.) Like a dropped pebble causes disturbance in a pond, a missed meal, late-night, or extra hour of sleep can trigger a migraine attack that reverberates hours later.
Because stress is often attributable to headaches, many migraineurs are surprised when they suffer attacks over the weekend or at the beginning of a vacation. But it’s this “letdown” from normal stress levels that often initiates an attack, explains Charles. It’s not recommended that migraine sufferers avoid vacations, of course, but rather that they try to manage stress during normal life.
Manage the migraine
Though medication can help many people with migraine disorder prevent or treat attacks, people can minimize the frequency of attacks by adopting the theme of consistency in their lives, says Charles. Going to sleep and waking up at the same time each day, eating regular meals, moderating caffeine intake, and exercising regularly can all help.
Of course, not all attacks are avoidable, just as not all triggers, such as weather changes or a bout of insomnia, are avoidable. With this in mind, Goadsby recommends that migraineurs get to know their particular disorder. He suggests that patients keep a headache journal, where they record daily activities and symptoms so they can learn to identify potential triggers as well as premonitory symptoms.
“If you’re starting to get an attack, that’s definitely not a day to drink alcohol or stay up late. It’s a day to be a little bit cautious with yourself,” he says.
“I wish I would have understood that I have a chronic illness,” reflects Schulties, who now, after decades of suffering, has a greater degree of control over her migraine disorder. “I would have treated myself better when the warning signs were there.”
Goadsby emphasizes that such awareness can help migraineurs stem attacks. “Try to understand your disorder so that you get to be in the driver’s seat rather than the attack. Don’t let migraine be your lifestyle.”
Malte Urbschat’s “Phosphenes and Scotomas” describes his migraine aura symptoms. (Malte Urbschat)
New promise for migraine sufferers
New drugs, herbal remedies, and magnetic stimulation are among the options for migraine sufferers.
Migraine disorder is an elephant in the room of medicine, says Dr. Andrew Charles, professor of neurology and director of the Headache Research and Treatment Program at UCLA. “All physicians — anybody in any kind of medical practice — knows how common headache and migraine are as a presenting complaint, and yet we don’t really talk about it that much,” he explains.
Though migraine disorder affects 36 million Americans each year and is listed by the World Health Organization as the third most common disorder on the planet, it isn’t well represented in medical school curricula. It also receives relatively little research funding, with the National Institutes of Health dedicating only $18 million to migraine research, out of a budget of more than $21 billion. Most medications prescribed for migraine headaches were developed for other conditions, such as high blood pressure and epilepsy, and were serendipitously discovered to treat migraine. And most of them seem to follow the general rule of working for about half the patients half the time.
At the same time, new treatments are on the horizon.
Drug development
One promising approach targets a peptide called CGRP that is released from nerve cells and is thought to play a role in the pain mechanisms of migraine. Researchers are developing CGRP antibodies that can be injected beneath the skin, where they bind to CGRP and may prevent migraine attacks.
Now that scientists know that migraine is a neurological disorder rather than a vascular one, they are on the hunt for medicines that don’t affect the cardiovascular system and are thus safer for people with heart conditions.
Another drug in development is an inhaled version of dihydroergotamine, a medication that’s usually delivered intravenously in hospitals to relieve patients suffering from continuous migraine.
Supplements and herbs
The American Academy of Neurology recommends several complementary treatments, including the herb butterbur (Petasites hybridus), as effective for reducing the severity and frequency of migraine headache in some patients, though the report cautions that the safety of long-term butterbur use hasn’t been established.
AAN guidelines state that magnesium supplements are “probably effective” at preventing attacks. Side effects can include stomach upset. Riboflavin, known as Vitamin B-2, is also placed in the “probably effective” category.
Magnetic stimulation
A new paradigm in migraine treatment involves the search for non-drug, non-invasive therapies. Transcranial magnetic stimulation delivers a magnetic pulse to the brain, essentially hitting “reset” on electrochemical signals that run awry in migraine attacks. Studies show it is effective in patients experiencing migraine with aura, and the first hand-held, single-pulse device has been approved by the Food and Drug Administration.
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