There’s no mistaking a migraine headache — the excruciating
head pain, nausea and sensitivity to light and sound. The incapacitating
attacks can last for hours or days and are sometimes frequent enough to
cause moderate or severe disability.
“Fortunately, the list of both acute relief and preventive treatments
continues to grow. Although there’s no cure for migraines, usually
the right medicines, combined with self-help remedies, work fairly well
for many sufferers,”
Alan Zacharias, MD, of Associated Neurologists said during a free online health lecture.
“Careful joint decision-making with your doctor is needed. Together,
you can often find ways to treat your migraine attacks and make them less
frequent and severe.”
Watch a recording of Dr. Zacharias' lecture
on "Controlling Migraine Pain."
Migraine is a Chronic Illness
Migraine headaches are considered a chronic illness, although many people
don’t think of them that way. Roughly 15% of women and 5% of men
suffer from this recurrent and often lifelong condition.
According to Dr. Zacharias, migraines usually start in adolescence or early
adulthood and tend to become less frequent as we age. “Interestingly,
in childhood it's more common in males than females, but after menstruation
there is a significant change. So, we know there's a hormonal component
that carries on throughout life until menopause,” he said.
The frequency with which migraines occur varies from person to person.
While most sufferers experience attacks once or twice a month, more than
4 million people have chronic daily migraine, with at least 15 migraine
days per month.
“In general, migraine becomes less frequent with age and often there's
a genetic component,” said Dr. Zacharias. In fact, about 90% of
migraine sufferers have a family history of migraine.
Symptoms of an Attack
Dr. Zacharias said that during a migraine attack, you may experience:
- Disabling throbbing or pounding head pain that is usually one-sided. The
pain usually lasts more than 2 hours, if untreated.
- Nausea, vomiting and sensitivity to light or sound.
- Confusion and irritability.
Dr. Zacharias explained, “You don't have to have all of those
for us to say it fits the criteria for migraine but quite typically some
will have at least one of those features.”
Migraine auras, which are a series of sensory disturbances, can happen
shortly before or during a migraine attack. These usually cause visual
disturbances such as flashes of light or wavy zigzag vision.
“This happens in about 10 to 15% of patients and last about 30 minutes.
Visual auras are the most common. You can also feel numbness or tingling
in the face or hands that slowly spreads over many minutes. Additionally,
with auras you might experience a disturbed sense of smell, taste or touch
and have problems with language,” Dr. Zacharias said.
Factors and events that can set off an attack are called migraine triggers.
- Hormone changes during the menstrual cycle
- Lack of sleep
- Stress and anxiety
- Alcohol (often red wine)
- Perfumes and strong odors
- Bright lights
- Fermented cheeses and cured meats
- Caffeine (too much or withdrawal)
- Weather changes
“Triggers are highly individualized. Your specific triggers might
not be entirely clear. To pinpoint them, keep a migraine diary or log,
which can lead to insights into your triggers,” Dr. Zacharias said.
He added, “What's being understood now is it may be that we crave
some of these items, such as chocolate, as the early manifestation of
our migraine — that the craving may be part of the migraine itself
rather than an actual trigger.”
Physiology of Migraine
Scientists used to believe migraines were caused by a constriction and
dilation of blood vessels. They saw migraines as being primarily a vascular
disorder. “The constriction phase is when you might get the aura
and the dilation phase is when you might wind up with the intense headache.
It’s still partially true but we've shifted.”
Instead of purely vascular theory, he said there’s a new neurovascular
hypothesis. “We now know that a migraine is triggered deep within
the brain structures, predominantly in the brainstem and through portions
of the trigeminal nerve and its nucleus in the neck, and then moves upward.
Electrical discharges of neurons then spread out and create what we refer
to as a sterile inflammation,” said Dr. Zacharias. “Various
neurotransmitters and proteins then wreak havoc and cause pain, hypersensitivity
to light and sound, variation in blood vessel size and the suppression
of neuronal activity so you can’t feel or think very clearly during
However, the exact cause of why these changes in the nerve pathway occur
is not fully understood, Dr. Zacharias explained.
Treating an Attack
Migraines can be managed with a doctor's help. Dr. Zacharias said
your treatment plan may include some or all of these methods for stopping
Caffeine and sleep: Migraine sufferers often report that a strong cup of coffee or restful
sleep can improve the headache.
Over-the-counter drugs: NSAIDs (nonsteroidal anti-inflammatory) drugs such as acetaminophen and
ibuprofen or combination NSAID-caffeine pills can help. Benadryl can also
have a calming effect to sight and sound disturbances.
Traditional prescription medications: Two types of medications doctors often try first are triptans and ergotamine,
which work by balancing the chemicals in the brain. However, Dr. Zacharias
said that both of these types of medications have some side effects that
limit their use and contraindicated for those with heart disease or high
Prescription lidocaine nasal: Nasal spray or drops applied directly to nerves in the back of the nasal
cavity appears to offer significant relief to migraine sufferers.
Newer prescription medications for patients with cardiovascular risks: Dr. Zacharias described newer agents that tend to have fewer side effects
and lack the cardiovascular concerns seen with some earlier agents. These
include CGRP inhibitors or “gepants” and Ditans.
For people with extreme migraine pain, your doctor might prescribe powerful
“rescue” drugs such as barbiturates, narcotics and IV infusions
of anti-seizure medications.
Dr. Zacharias then discussed alternatives to medications for both preventing
and relieving migraine pain, which include:
- Vagal nerve stimulation
- Supraorbital nerve stimulation
- Transcranial magnetic stimulation
- Brachial electrical stimulator: Nerivio Migra
What to Do First for an Attack
“I get asked this a lot. Do I go to Advil first or to a triptan?”
said Dr. Zacharias. “Most prescription drugs for migraine attack
work best when taken right away, when symptoms first begin, which is why
I usually recommend going straight to the big guns. It’s best to
treat the migraine at an aggressive level with your prescription medication,
because once you pass a certain threshold, it’s hard to go back.”
He added that this recommendation is always tailored to patient preference
and any known illnesses or chronic conditions.
“When you only treat attacks, they come back. The goal is to figure
out a prevention ‘cocktail’ to give patients sustainable relief,”
said Dr. Zacharias.
Prevention strategies can include the following:
Supplements such as magnesium citrate (400-600mg), riboflavin (400mg), feverfew (50-300mg)
and CoQ 10 (300mg) have the most supportive data for effectiveness, according
to Dr. Zacharias. However, the FDA only regulates prescription medicines
and not vitamin and mineral supplements. "Because of this, it's
important to research supplement manufacturers to make sure they have
a long track record of safety and quality,” he warned.
Prescription medications, taken daily, can help prevent attacks. “Many of these medications
were designed to treat other health conditions such as depression or epilepsy.”
Some examples are antidepressants, seizure medications, blood pressure
medications and botulinum toxin.
Relaxation techniques such as biofeedback and cognitive behavioral therapy can help calm down
the nervous system without drugs. Biofeedback involves learning how to
monitor and control your body's responses to stress, which lowers
heart rate and eases muscle tension. The goal of cognitive behavioral
therapy is to change patterns of thinking or behavior that may increase
or maintain headaches. There’s strong evidence that these options
can reduce the frequency of attacks.
“Treatment for prevention of migraines can work for one person but
may not work for another. About 60 percent of patients get a 50 percent
reduction in frequency of migraine,” Dr. Zacharias stated. “Sometimes
we’ll need to use more than one treatment approach for prevention.”
Migraine and Stroke
Dr. Zacharias warned that there is a small increase in the risk of stroke
with migraine for those who smoke or take birth control pills and especially
for those who experience migraine with aura.
He said to see your doctor immediately or go to the emergency room if you
experience any of the following signs and symptoms, which may indicate
a stroke instead of a migraine:
- The worst headache of your life.
- Severe nausea and vomiting from the start of the headache.
- One sided weakness, numbness or persistent visual loss.
- Failure to respond to any treatment after 12 hours.
“Also, aura symptoms that last longer than one hour can also signal
a stroke and should be evaluated,” Dr. Zacharias cautioned.
To make an appointment with neurologist
Alan Zacharias, MD, call Associated Neurologists at (303) 415-8800.
Click here to view or download a PDF of slides shown during Dr. Zacharias' lecture on “Controlling Migraine
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