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Woodstock Times - Health | 11/25/2009 |
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by Aimee J. Frank
"It's crippling," said Lori McCabe. "For people who don't get migraines, they don't understand the severe pain you're in. They think it's a headache, like it can't be that bad. I'd sometimes rather give birth again than have one of those migraines."
McCabe, marketing coordinator at Health Alliance of the Hudson Valley, which includes Kingston, Benedictine and Margaretville hospitals, said she has lived with migraines since contracting viral meningitis during pregnancy six years ago.
McCabe has a lot of company. A recent study found that almost a third of people with migraines would prefer root canal, a broken nose and childbirth over another migraine headache.
A surprisingly large number of U.S. residents suffer from migraine. Data from two major studies has shown that the prevalence of migraine has remained constant since 1989. American Migraine Study I (1989) and American Migraine Study II (1999) found that one in every four households includes someone who suffers from migraine, with more than 18 percent of all women and six percent of all men affected. The prevalence is greatest between the ages of 25 to 55 years of age, with women experiencing migraine more commonly during puberty than men by three to one.
A migraine is not simply a headache or even a very bad headache. It is a very painful neurological event that Dr. Erin Elmore describes to her patients as a functional disorder, which is a medical abnormality or malfunction of a bodily organ or system for which no known physiological or anatomical cause exists. Elmore is an associate of Kingston Neurological Associates, with offices in Kingston, Northern Dutchess Hospital in Rhinebeck, and several other locations.
"I try to educate [patients] about the fact that migraine is not just a headache," said Elmore. "I tell them that it is a syndrome, a constellation of symptoms. A migraine can encompass a number of different symptoms, whether it is the headache itself, visual symptoms or visual auras, dizziness or vertigo, nausea, the sensitivity to light and sound. Those are all aspects of a migraine syndrome."
While the painful migraine headaches may not begin until late in life, leading migraineurs to report to doctors they have no history of migraines. Elmore said there are often other clues that patients have exhibited symptoms of the migraine syndrome. "People with migraines tend to be much more hypersensitive to shifting in movement," she said. "Oftentimes you ask them if they were ever car sick as a child, they say, Oh, my god, I can't ride in the back seat, or on park rides, things like that. There is a certain hypersensitivity to the nervous system you find in people with migraine headaches. This is the syndrome."
The experience of migraine
Until recently, the vascular theory of migraine was the predominant explanation of migraine headache attacks. The thought was that blood vessels in the head, reacting to certain triggers, constricted and dilated, changing the blood flow and oxygen to the brain, affecting chemicals that regulate pain, stimulating pain-sensitive nerves and resulting in a throbbing headache.
Medical researchers now believe that vascular changes are the result rather than the cause of other activities that lead to the headaches. Using functional MRI scanning, researchers can watch the brain of a person having a migraine to see which areas light up as a headache progresses. The results of this research have led scientists to a neuro-based theory of migraine headache, which they believe is caused by an imbalance in the control of pain transmission.
"They've been able to track some of the neuro-electric and metabolic events that can go on, such as an increase in certain types of transmitters that are released in greater quantities," explained Elmore. "It's triggered through a neuro-electrical event, which then leads to the release of neurotransmitters that can overly activate the neuro-system, such as the trigeminal nerve system, leading to a change in blood vessels that will dilate, become inflamed, and then that in turn can lead to more nerve activation. So you get yourself into this vicious cycle. These are the actual events that lead up to the pain of the headache"
Because migraine is a neurological event, migraineurs, as people with migraines are called, can experience myriad symptoms preceding a headache, or none. "I feel one coming on because my fingertips get numb and tingly and then my mouth and the inside of my lips get numb and a tingly feeling, like with Novocain, and then all of a sudden I get these blinding migraines," explained McCabe.
Not everyone who gets a migraine headache has this kind of preceding event, or aura. The Mayo Clinic found that approximately 20 percent of migraineurs experience some kind of aura. There are many different kinds of auras, from visual distortions to physical sensation or dysfunction. "You have positive features, such as seeing lights, spots, lines, waviness, or a negative feature, where you can have a transient loss of vision," said Elmore. Other pre-headache symptoms can include slurred speech, the spreading tingling sensation or numbness that McCabe experiences, vertigo - all of which can end in a migraine headache.
Just make it go away!
Because little is understood about what actually causes headaches, there are few tests that can be used to diagnose a migraine. An MRI is usually given to rule out a brain tumor or other abnormality, but the medical focus is on reducing the number of migraines in a patient and managing the pain when migraines occur.
"A migraine problem is probably a common final pathway, a symptom that comes from many different causes that produce the same symptom," said Dr. Sol Mora, a neurologist with the Mid-Hudson Medical Group in Poughkeepsie, Fishkill and Hopewell Junction. "That's why it's so complicated. There is more than one reason people get migraines."
Not all the traditional triggers known to cause migraine attacks, such as eating certain types of foods - cheeses, chocolate, wine or anything fermented - affect everyone, Mora said. Many women link regular hormonal changes such as the onset of menses to migraines. Many others don't get their first headaches until they are in their forties. In many people, skipping meals, too little or irregular sleep, and stress are as equally likely to produce migraines.
Since every migraineur is different, discovering what triggers migraine in an individual, how often headaches occurs, whether aura occurs, and which medicine or mix of medications will provide that person with relief appears more art than science. "Because the medications for keeping headaches away works so well, we don't go through [identifying triggers] any more. That's a second step, if we can't find a medication that prevents the headaches," said Mora.
Frequency of headache is usually the determining factor that doctors rely on when deciding whether and how to medicate a patient. When individuals experience only a few headaches a month, they are usually prescribed "abortive" medications, those designed to stop each headache before it becomes a full-blown blinding event. Many people find relief with such drugs as Advil or Aleve, especially when taken with caffeine. But the newer abortive medications, triptans in pill form, more effectively stop migraine pain within one or two hours.
Someone like Lori McCabe, who usually knows when a migraine is coming, can take a triptan drug before the headache starts and usually avoid the worst of the pain. For those who don't know when a migraine will occur, an injectible triptan is available for more immediate relief. Triptans act, in part, by constricting blood vessels, so can't be used by some people with cardiac and other health conditions.
For people who suffer from migraines frequently during the month, doctors use medication as a preventive strategy, selecting a daily dosage of one or more medications that are used to hold migraines at bay. The brand drug Topamax (or its generic version topiramate, originally used to treat epilepsy) was approved for migraine treatment by the U.S. Food and Drug Administration when found an effective migraine preventive for some. Another FDA-approved brand-name drug often prescribed to prevent migraines, Depakote or its generic version, was also originally for epilepsy and is approved for bipolar disorder. These drugs can have significant side effects in some people. Like beta or calcium-channel blockers, these medications work for some but not all migraineurs.
Doctors will try different medications at different strengths before they find what works for each patient. This was the case with McCabe's doctor. "He started me off with Fioricet, which didn't really work for me. Then he put on Topamax," she said. "I'd been on that for years. But sometimes I'd get such severe migraines that nothing worked so he'd have me go down to the ER and get morphine." Ms. McCabe no longer needs to take a topiramate for her headaches.
Take your meds
A World Health Organization study cited by the National Institute of Health listed disability ratings for 22 conditions, and the four most disabling, in order of severity, were active psychosis, quadriplegia, dementia and migraine.
Because most triptan medications cost between $40 and $60 per pill, and most insurance companies strictly limit a patient's monthly allotment, Mora said patients tended to hoard pills and not take them early enough during the onset of a migraine. "One of the most important things about treating the migraine is not to be too shy about using the medication," he said. "Because if they are really developing a migraine, the earlier you treat it the more successful the treatment will be. Once it gets to be full blown, it's much harder to treat."
Although the medications now available can significantly reduce or prevent migraine headache pain with few side effects, the WHO study found that approximately a third of migraine sufferers said they had never consulted a doctor for their problem. "People should not be resistant to seeing a doctor because these headaches can be, in the majority of cases, very amenable to medication treatment, and you don't have to suffer," said Elmore.++
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