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 health lecture held in Erie, Colo.

“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.”

Migraine is a Chronic Illness
Migraine headaches are considered a chronic illness, although many people don’t think of them that way. More than 30 million Americans, roughly 12 percent of the U.S. population, suffer from this recurrent and often lifelong condition. Three-quarters are women.

The frequency with which migraines occur varies from person to person. They can be rare or strike several times a month. Nearly 5 million sufferers experience at least 1 migraine attack per month, while almost 10 million experience 4 or more per month, which significantly impacts daily living.

According to Dr. Zacharias, migraines usually start in adolescence or early adulthood and tend to become less frequent as we age. “But this is not the case for everyone,” he said.

He described migraines as a neurovascular disorder. “Various neurotransmitters and proteins wreak havoc in the brain causing ‘hypersensitivity’ and pain. But the exact cause of why they occur is not fully understood,” Dr. Zacharias explained.

Migraines have also been linked to genetics. People who get migraines may have genes that control the functions of certain brain cells. “In fact, about 70 to 80 percent of people with migraines have other members in the family who experience them too,” Dr. Zacharias stated.

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

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.

“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.

“Yet most people experience migraines without aura.”

Migraine Triggers
Factors and events that can set off an attack are called migraine triggers. They include:

  • Hormone changes during the menstrual cycle
  • Lack of sleep
  • Exercise
  • Stress and anxiety
  • Alcohol (often red wine)
  • Perfumes and strong odors
  • Bright lights
  • Chocolate
  • 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.

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 an attack:

  • 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.
  • 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 should not be used if you have heart disease or high blood pressure.
  • 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.

For people with extreme migraine pain, your doctor might prescribe powerful “rescue” drugs such as barbiturates, narcotics and IV infusions of anti-seizure medications.

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.

Prevention Strategies
“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.”

Emerging Treatments
Dr. Zacharias discussed two emerging treatments: neuromodulator devices and calcitonin gene-related peptide (CGRP).

  • Neuromodulator devices, or neuromodulators. "These are an option outside of medications used for both preventing and relieving migraine pain,” according to Dr. Zacharias. “Treatment involves holding a device up to your head, which emits a pulse of electric or magnetic stimulation that targets the nerves involved in a migraine.” Treatment is usually done at home with a rented or purchased device available by prescription.
  • Calcitonin gene-related peptide (CGRP). Researchers have discovered that CGRP, a small protein found throughout the brain and body, is detected at high levels during a migraine attack. CGRP treatment targets and neutralizes CGRP or its receptors and disrupts the disease process.

    Dr. Zacharias said, “The FDA recently approved this very new CGRP therapy, which is specifically designed to prevent migraines before they start. It is self-administered through subcutaneous injections, just beneath the skin, either monthly or quarterly.”

    He added, “The real upside of CGRP therapy is that there are minimal side effects. Just local reactions. It’s pretty safe.”

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.

View his PowerPoint slides from the free health lecture on “Controlling Migraine Pain.”

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