Migraine

    Migraine effects more than 32,000,000 Americans, including 14,000,000 children and adolescents who are afflicted by this genetically inherited noncontiguous disorder. Migraine is a disabling headache that results in producing moderate and at times extreme pain in 90 percent of individuals afflicted by this disease. Migraine disrupts the lives of these individuals up to 99 percent of the time when they are not able to get appropriate therapy. This disorder is responsible for over 15 billion dollars of expenses to the United States alone.

    Recently there has been a greater understanding of the underlying neurologic mechanism of the disorder we call migraine. Migraine can present without aura symptoms, as well as with aura symptoms. The aura symptoms of migraine can be typical; a gradual onset over several minutes and then abates within an hour. Often the most common aura experience is that of a visual alteration. But migraine can present with many other forms of aura; difficulties with speech, loss of motor function, cognitive, and/or sensorial changes.

    Migraine can present in childhood with cyclical vomiting or abdominal pain symptomology without any headache symptoms whatsoever. Benign positional vertigo of childhood can present with significant dizziness, lightheaded sensation and continue in some individuals into their adult life with more typical associated migraine symptoms. Some forms of migraine can transform from episodic, a couple of times a month to just about everyday. Other forms of migraine can last for days, weeks, or months without ever stopping. Unfortunately there are forms of migraine that are associated infarcts, a cerebral stroke, these tend to occur more frequently in younger women and women who are on oral contraceptives who also smoke and have a history of migraine with aura as well.

     Migraine can be triggered by a seizure, although this is often rare. There are forms of migraine we call probably migraine because they haven’t fully developed, with time we usually see the development of the more common symptoms of migraine, which tend to be unilateral head pain, moderate, and avoid any physical activity which will worsen the head pain. The associated symptoms of migraine include nausea that can progress to vomiting, as well as light and sound sensitivity referring to as photophobia and phonophobia and in some individuals a heightened sense of smell, osmophobia.

    Further complicating this situation are symptoms of sinus headache that can be misdiagnosed, often times patients with migraine, more than 60 percent of individuals, will describe having a clear or white nasal drainage lasting for several days with symptoms consistent with migraine that occur for, on average, two to three days and then subside, occurring several times a month; over the course of months to years it become clearer that this is not acute sinusitis, but actually symptoms of a migraine with associated sinus components.

    Tension - type headaches sometimes also have aspects that are more consistent with migraine, even though they may have significant spasm and discomfort in the cervical or neck area, when their headaches are associated with nausea, photophobia and phonophobia that increase light and sound and disability of a moderate to severe nature, this is actually a migraine, often beginning more subtlety, but progressing to a more disabling headache. It’s important to recognize these sinus headache symptoms and these tension - type headache symptoms that are actually migraine because often times more specific migraine therapy is needed to control their headache.

    Let’s turn our attention to treatment options, all patients with migraine need to consider non-pharmacologic treatment options, as well as an acute treatment option; some individuals, those who have more than four headaches a month or even less when they’re severely disabling and not responding to acute therapy, will have to consider preventive pharmacologic therapy as well. The non-pharmacologic option that all patients should consider is to have a standard exercise program.

     To obtain and address proper BMI, we do know that with increased weight gain outside of a normal BMI results is a tendency to increased headaches and to the possibility of transitioning to more frequent chronic daily headache patterns. Dietary supplements, some of which have been studied, have been shown to assist in the prevention of migraine, specifically magnesium, using the chelated form in a dose range of 250 to 800 mg. Patients often find it easier to start with 100 or 200 mg initially, gradually increasing by 100 to 200 mg per week to a target dose of at least 400 mg and possibly as high as 800. Riboflavin, Vitamin B2, also has some data showing efficacy for the relief of headaches symptoms related to migraine; this medicine often is tolerated well when patients begin at 100 to 200 mg initially, gradually increasing by 100 to 200 mg each week to target does of 400 mg daily.

    CoQ10 also has been looked into in this regard with a target dose of somewhere in the range of 200 to 300 mg; patients can begin with 100 or 200 mg initially and gradually increase to 300 mg or possibly even 400 on a daily basis.

    Petadolic has also shown to be effective in the prevention of migraine beginning at 50 to 75 mg initially, gradually increasing over the course of one to two weeks to a target does of 150 mg daily; often this can be divided 75 BID, that’s once in the morning and once at night.

    It is also helpful for patients, as part of a general health program of neurovascular protection to consider a good multivitamin daily as well as to supplement with Omega 3 l daily as well.

    Proper sleep habits are also important, try to go to bed the same time every evening and get up the same time everyday as well as address any sleep disorder issues that may be present with your physician or allied healthcare professional.

    Stress management is also vital, sometimes biofeedback programs and formalized stress management programs can be helpful, but just taking some time to have a little bit of fun each day can be exceedingly beneficial.

    The acute therapy specifically for migraine can range from over the counter meds, which if effective, effective being complete relief of headache, pain and associated symptoms: nausea, vomiting, light and sound sensitivity, within two to four hours and the headache does not return within 24 hours, that’s the goal. Iif you are not able to obtain this with your present medications, consider other options.

     I wish I could say that in every patient this can be obtained, unfortunately, we’re not there yet. This is the reason we do so much research, in an effort to obtain complete relief of all symptoms in one to two hours of the onset of a migraine and no return of that headache for 48 hours, that’s our research goal, but that’s still a goal. For patients who do not do well with over the counter meds, possibly the consideration of prescription medication, specifically designed to target migraine, such as Triptans or Ergots, may prove beneficial. These medicines need to be monitored by your physician or allied healthcare professional since the side effect profile must be reviewed with the patient and they need to understand the risk / benefit ratio and these are not medicines that should be used in every single migraine patient.

    In adults, when they have equal to a greater than four headaches a month preventive therapy needs to be considered, especially if the acute therapy is not fully effective. In children and adolescents when you have two or greater headaches a month the patient needs to be evaluated for preventative therapy. There are FDA approved medicines for the prevention of migraine in adults, but at this time there are no FDA approved medicines, either acute or preventive, for adolescents or children. There are medicines that have been studies, both acute and preventive for migraine treatment in adolescents and children, but there is still limited data.

    Please review with your physician or allied healthcare professional all considerations of prescription meds, especially the off label medicines in children, adolescents and adults. There are migraine-specific medicines, FDA approved that have been studied well, but they too have side effects that need to be reviewed with the patient, since often times these side effects are experienced. When a side effect is experienced, please review that with your physician or allied healthcare professional and often times adjusting the does is all that’s needed. If this is not adequate enough to control the symptoms, another medication will need to be considered.

    The goal of preventive therapy today is the reduction of the number of headaches by 50 % over anywhere between a one and three month period once therapeutic levels of that medicine have been reached. The reason why we still do a lot of research in the area of prevention of migraine to find new and better medicines that are both more effective, as well as having less side effects potentially.

     For more information about migraine diagnosis, differential diagnosis, non-pharmicologic treatment, acute and preventive therapy; please speak to your doctor or allied healthcare professional and also consider the website www.americanheadachesociety.org as a potential resource for further education. There are several books that may help you with regard to further understanding, such as: Headache in Children Adolescents and Young Adult and Pediatric Headache.

    While many people suffer from this condition each year, there are simple steps that you can take to improve your quality of life. More information regarding these steps is outlined in Dr. Winner's "The 7 Steps to a Healthy Brain".