Migraine Headache

Perspectives for Better Neurological Care
: C. Robert Adams, M.D.; Board Certified Neurologist

Migraine Headache Problems

(See other articles “Headache Management & Migraine Headaches)

Migraine headache is a common problem which affects over 20% of the population, at least some time in their life. Migraine headaches are a phenomenon of altered blood flow to the head. In many instances there is increased blood flow to the sides of the head, the temple area, behind the ears, and sometimes in the front of the face. Blood flow in the head is sometimes “shunted” or taken away from areas of the brain and diverted to the scalp, sinus areas, ears, and so on. This diversion of blood flow from the brain sometimes causes symptoms resembling a stroke. In particular, there can be loss of vision to one side or sometimes complete blindness in one or both eyes. On occasion, there is numbness and tingling of the face and of one arm and in extreme cases a severe paralysis on one side of the body which may last for twelve to up to twenty-four hours. Visual warnings of flashing lights and arcs of color may precede a migraine. More subtle manifestations of migraine can be associated problems of irritability, personality change, sleepiness, nausea, vomiting, and abdominal pain. Migraine headaches can last from a few hours to up to several weeks or longer. In some individuals, migraines becomes more of a “ continuous” problem with a perpetual increased blood flow to the area of the ears and sinuses which tend to cause persistent sinus congestion and a feeling of ear stuffiness. The discomfort of a migraine can vary in intensity from no pain at all, to a severe excruciating pain which incapacitates the individual and forces them to curl up in a ball in a dark room away from loud noises.

The cause of migraine headaches remains uncertain although there appears to be an inherited or familial contribution in many cases. Many individuals troubled by migraine headaches have had prior problems with motion sickness or car sickness and this suggests an undue sensitivity of their nervous system to external stimuli or change. Factors that can precipitate migraine include ingestion of alcohol, going without adequate sleep, fasting, or skipping meals, and changes in hormonal status as with menstrual periods or menopause, bright sunlight, and on occasion certain foods. More common possible irritating foods include chocolate, nitrates, (as in hot dogs), and aspartame (Nutrasweet). However, foods other than many types of alcohol are not a common precipitant of migraine. Migraine headaches tend to come somewhat unpredictably, not necessarily during times of stress. Migraine as a ”let down” phenomenon, when a person is most relaxed and otherwise happy.

Migraine can imitate many other varieties of headaches, thus causing some confusion as regards diagnosis or classification. Some migraine headaches are associated with marked pain in the back of the head and cause a feeling of tightness and stiffness in the neck. They are sometimes misunderstood as being a stress or muscle contraction type of headache. A bad headache can of course cause secondary reactive muscle tension and neck and shoulder tightness. Conversely, an arthritic, sore stiff neck which might get stirred up after physical activity or trauma can “transform” into a migraine. Migrainous pain in the facial area can feel like a “sinus” headache. Many people have a mixed type headache with some migraine component and some tension or stress type headache contributing. Tension or stress type headaches can usual be handled by simple type analgesics as aspirin or Tylenol and by trying to take a break from demanding stressful activities or the inciting irritant. More persistent and unresponsive type of stress or tension headache can sometimes be seen in the setting of more serious underlying depression or unresolved family problems that need address. More often, headaches cause stress rather than vice versa.

Migraine attacks can be nearly continuous for prolonged periods. In these protracted cases, it is important to consider the possibility of other disease in the brain such as a tumor, pseudotumor, hydrocephalus or malformations of blood vessels as aneurysms. If appropriate, x-rays as CT scans or MRIs can be done to check out the brain, sinuses, neck and head structures, although these tests are usually of little help in dealing with or treating most headaches.

Treatment for bothersome migraine headaches should initially include attempts to eliminate any factors which obviously bring them on. Unfortunately, this is usually not enough to eliminate severe headache syndromes and most assuredly does not decrease the intensity of headaches when they do occur. Hypnosis, relaxation techniques, biofeedback, and even supportive psychotherapy are usually helpful. Chiropractic and physical therapy measures can be palliative though not usually curative.

A person with a migraine tendency is unfortunately afflicted with a disorder that is most often beyond his or her control. In particular, it often does very little good to confront the person with the headache suggesting that they have a headache just because they were not able to tolerate stress, or have a weak constitution. The pain of migraine and other vascular type headaches can incapacitate the strongest, most well conditioned weight lifter as well as the elderly frail individual with many other medical problems.

Medications or drugs probably offer the most direct and effective relief of migraine headaches. In most circumstances when compared to other more indirect means of treatment. Two approaches need to be considered in lessening the symptoms of headaches with medications. The initial abortive approach is to try and “stop the headache in its tracks” by giving medication that gets rid of the headache as it comes on. Unfortunately, migraine headaches are sometimes stubborn in responding even to strong medications and the best one can hope for is to be tranquilized or calmed such that they can sleep until the headache has passed. “Sleeping it off” is not always an option when someone has to continue functioning and does not have the opportunity or leisure to lie down and take a nap. Recurrent use of oral narcotic medications or of intramuscular shots should be avoided with migraine headaches. There is a tendency for narcotics to wear off quickly with return of a rebound headache such that more narcotic pills or shots tend to be craved. The class of drugs known as triptans (Imitrex, Maxalt, Relpax, etc.) can work miraculously some cases of acute onset severe headache.

The second approach of treating migraine or vascular headache syndromes with drugs includes a prophylactic regimen with an individual taking medications every day to try and prevent the headaches from occurring in the first place. Agents such as propranolol (Inderal), verapamil, topirimate (Topamax) and valproic acid (Depakote) have been helpful if taken on a regular daily basis. If headaches do “break through” with prophylactic treatment, there is hope that they will be less intense and shorter lasting than they would have been if the individual would not have been on the prophylactic rug. Benefit from taking the drug has to be weighed against side effects, inconvenience, and expense with having to be on daily treatment. In general, it is useful to institute drug treatment, either in an abortive or prophylactic regimen, if headaches are severe and frequent enough to decrease the quality of life in the individual who is afflicted.

There is hope and treatment success for the vast majority of migraine headaches sufferers. Caution should be made in the setting of lack of response to empiric treatment to look at alternative etiologies that might be very serious or merit other approaches.