September 18, 2017
If you’ve never had a migraine, I have two things to say to you:
1) You’re damn lucky.
2) You can’t begin to imagine how awful they are.
I had migraines – three times a month, each lasting three days — starting from age 11 and finally ending at menopause.
Although my migraines were not nearly as bad as those that afflict many other people, they took a toll on my work, family life and recreation. Atypically, they were not accompanied by nausea or neck pain, nor did I always have to retreat to a dark, soundless room and lie motionless until they abated. But they were not just “bad headaches” — the pain was life-disrupting, forcing me to remain as still as possible.
Despite being the seventh leading cause of time spent disabled worldwide, migraine “has received relatively little attention as a major public health issue,” Dr. Andrew Charles, a California neurologist, wrote recently in The New England Journal of Medicine. It can begin in childhood, becoming more common in adolescence and peaking in prevalence at ages 35 to 39. It afflicts two to three times more women than men, and one woman in 25 has chronic migraines on more than 15 days a month.
But while the focus has long been on head pain, migraines are not just pains in the head. They are a body-wide disorder that recent research has shown results from “an abnormal state of the nervous system involving multiple parts of the brain,” said Dr. Charles, of the U.C.L.A. Goldberg Migraine Program at the David Geffen School of Medicine in Los Angeles. He told me he hoped the journal article would educate practicing physicians, who learn little about migraines in medical school.
Before it was possible to study brain function through a functional M.R.I. or PET scan, migraines were thought to be caused by swollen, throbbing blood vessels in the scalp, usually – though not always — affecting one side of the head. This classic migraine symptom prompted the use of medications that narrow blood vessels, drugs that help only some patients and are not safe for people with underlying heart disease.
Furthermore, traditional remedies help only a minority of sufferers. They range from over-the-counter acetaminophen and NSAIDs like ibuprofen and naproxen to prescribed triptans like Imitrex, inappropriately prescribed opioids, and ergots used as a nasal spray. All have side effects that limit how much can be used and how often.
Neurologists who specialize in migraine research and treatment (“there are not nearly enough of them, given how common the affliction is,” Dr. Charles said) now approach migraine as a brain-based disorder, with symptoms and signs that can start a day or more before the onset of head pain and persist for hours or days after the pain subsides. Based on the new understanding, there are now potent and less disruptive treatments already available or awaiting approval, though cost will certainly limit their usefulness.
To be most effective, the new therapies may require patients to recognize and respond to the warning signs of a migraine in its so-called prodromal phase – when symptoms like yawning, irritability, fatigue, food cravings and sensitivity to light and sound occur a day or two before the headache.
Even with current remedies, people typically wait until they have a full-blown headache to start treatment, which limits its effectiveness, Dr. Charles said. His advice to patients: Learn to recognize your early, or prodromal, symptoms signaling the onset of an attack and start treatment right away before the pain sets in.
“It’s possible that a lot of therapies might be effective, including meditative breathing and relaxation techniques, that don’t help once the train is out of the station,” he said.
Even clinical studies of migraine remedies typically involve patients in the throes of an attack and thus often result in benefits to only a minority of people. Although triptans, for example, are among the most effective remedies, they completely relieve pain within two hours in only 9 percent to 32 percent of patients in published reports.
After a migraine attack subsides, there are often “postdromal” symptoms like fatigue, depressed mood and cognitive effects like poor concentration and understanding. The latter may prompt doctors to order needless brain imaging studies to rule out something more serious like a tumor or clot. (“Red flags” that warrant further investigation include sudden onset of a severe headache, especially in someone who never had one before, associated fever, or new onset of headache in someone older than 50.)
Both patients and doctors also often mistake migraine for a sinus condition, resulting in needless testing and ineffective therapy.
Conditions that can trigger a migraine in susceptible people include skipped meals, irregular intake of caffeine, erratic sleep habits and stress. Accordingly, Dr. Charles suggests practicing consistent dietary, sleep, caffeine and exercise habits to limit the frequency of migraines.
Women – myself included – often develop migraines just before and during their menstrual period. By keeping a headache-and-menstrual-cycle calendar, I discovered I also got a migraine when I ovulated. I recalled that my migraines had been at their worst decades earlier when I was on birth control pills, and realized that estrogen withdrawal triggered all my attacks. By then, I was near menopause, but by “filling in” with oral estrogen at the appropriate times in my cycle, I was able to prevent the headaches.
Preventive therapy “should be considered if migraine occurs at least once per week or on four or more days per month,” Dr. Charles wrote. Possible treatments include blood pressure drugs like beta-blockers; anticonvulsant agents like topirimate (Topamax); and tricyclic antidepressants like imipramine (Tofranil). In addition, botulinum toxin, or Botox, is approved by the Food and Drug Administration as a migraine preventive.
Most exciting, however, are new brain-based remedies that have few if any side effects. They include hand-held or headband devices, like the Single-pulse TMS (for transcranial magnetic stimulation) and the Cefaly t-SNS (for transcutaneous supraorbital neurostimulation), that transmit magnetic or electrical energy to nerves through the skull to the brain.
Nearing federal approval is an exciting new class of drugs that directly target the peptides believed to trigger migraine attacks. They include monoclonal antibodies given by injection or through a vein, and so-called CGRP antagonists taken by mouth.