Delaware
Today Magazine
"Managing Migraines "
What does a migraine feel like? Multiply the worst headache you’ve ever had by ten. Add nausea and perhaps vomiting. Intensify the pain with an extreme sensitivity to light and noise, and any physical exertion. Imagine enduring hours, if not days of this, and you have an idea of the migraine experience.
Migraine affects 28 million Americans, and women three times more than men. And heredity plays a big part: if one parent has migraines, there is a 40 percent chance their children will.
Fortunately, current medications are able to help the majority of migraine sufferers.
“With the tools that we have available to us, generally migraine headaches can be fully relieved within two hours of initiation of treatment,” says Dr. Egilius Spierings, author, neurologist and headache specialist. “If you're receiving treatment but you're far away from that goal, I think it's important to continue the dialogue with your treating physicians.”
If your family doctor does not question you about specific headache characteristics, volunteer that information to assist him in matching your symptoms to the most appropriate medications. For instance, sharing the level of nausea you feel during attacks may prompt him to suggest a nasal spray or injection drug rather than an oral one.
“Many people that have migraines often have other kinds of headaches as well,” says neurologist John Townsend with Neurology Associates in Wilmington.
You are unlikely to find a treatment that is 100 percent effective for all of your headaches. Each treatment option has limitations and side effects. Before visiting your doctor, determine what you want to accomplish in treatment. Do you want a drug that is easy to administer? One that puts you to sleep or one that keeps you awake? Or those that better prevent headache recurrence?
Surprisingly, migraine pain does not come from the brain. Rather, the headaches come from activated nerves surrounding the skull, blood vessels, and head muscles. The inflammation and dilation of blood vessels cause the throbbing, pulsing pain.
And finding little relief elsewhere, migraineurs often find themselves visiting a neurologist.
“My job is often to reassure people that they don’t have brain tumors,” says Townsend. “Migraine is a neurological phenomenon. We used to think it was just a blood vessel thing. It’s clear the nerves around the blood vessels that originate in the brain stem are the true movers and shakers in migraine. There’s no cure, but the treatment for migraine is so much better.”
And that arsenal of treatment includes triptans, the newest family of “abortive” medications that go beyond masking the pain; they actually work to stop a migraine attack. By raising the level of serotonin in the brain, triptans reduce the dilation of surrounding blood vessels.
“For a patient that has an uncomplicated migraine symptom, triptans have the highest chance of eradicating the patient’s headache within a period of 1-2 hours,” says Townsend. “Seventy-five percent of people improve within two hours with triptans.”
Many consider triptans the best medications for moderate to severe migraine, cluster headache and menstrual migraine. But not all may partake of the wonder drugs. Because triptans constrict blood vessels, patients with uncontrolled hypertension, family history of coronary artery disease or heart attacks, uncontrolled diabetes or high cholesterol levels can’t use them.
Triptans have been on the market since the early 1990’s. Currently five triptans are available: Imitrex (Sumatriptan), Zomig (Zolmitriptan) -- manufactured by AstraZeneca, Amerge (Naratriptan) and Maxalt (Rizatriptan). The newest triptan, released in 2001, is Axert (Almotriptan Malate).
Potential side effects vary, but may include flushing, neck pain, muscle tightness, difficulty concentrating, rash, shortness of breath, heaviness in the chest and dizziness.
Imitrex is available in three formulations: as a tablet, a subcutaneous (under the skin) injection, and a nasal spray, making it the most frequently prescribed triptan. Axert is available in a tablet in two strengths. Maxalt is prescribed as a regular tablet or one that dissolves in the mouth (Maxalt-MLT). Amerge and Zomig are available in tablet form.
“Triptans represent a very effective treatment for migraines,” says Dr. William Sommers with Wilmington Neurology Consultants. “But a patient with mild attacks may do fine with over-the-counter (OTC) drugs like tylenol or aspirin.”
Several OTC drugs, including Extra Strength Excedrin, contain caffeine which can help relieve migraines when taken in small, well-timed doses. However, caffeine can produce drug rebound headache in some individuals.
Overuse of any analgesic drug – taking the medication more than twice a week – can also cause drug rebound headache. A vicious circle follows: as the medication wears off, the headache returns, prompting the sufferer to take even more medication. The only treatment for drug rebound headache is stopping the medication.
A combination of preventive and abortive medications may be safer and more effective. Preventive medications for headache include beta blockers such as propranolol (Inderal) and timolol (Blocadren), and antidepressants such as amitriptyline (Elavil/Endep) and nortriptyline (Pamelor).
Combination analgesics such as Phrenilin, Fioricet and Fiorinal – containing acetaminophen or aspirin and a barbiturate or narcotic drug – may be helpful to migraine sufferers with infrequent yet severe attacks. Although potentially habit-forming, they may be the only option for patients who cannot use the medications that constrict blood vessels.
Non-drug approaches, such as biofeedback, relaxation therapy and exercise can also be helpful in reducing migraine frequency.
Learning to identify and eliminate “triggers” will also help to reduce headaches. Foods like chocolate, cheese or alcohol, and food additives like sulfites, nitrates or MSG are often factors. Loss of sleep, missing meals, not exercising regularly and smoking can also cause headaches. Hormones are a common culprit: many women get headaches associated with their monthly periods or when using oral contraceptives or hormone replacement therapy.
Poor posture can also lead to headaches, and many migraineurs are visiting chiropractors in hopes of preventing headaches.
Chiropractors work on the assumption that when the nervous system is under proper control, the cells, tissues and organs of the body will resist disease and ill health. A common interference to the nervous system is the 24 moving bones of the spinal column, which can cause “vertebral subluxation complex” or VSC. Using special techniques, the chiropractor performs spinal adjustment to correct VSC, removing nerve pressure and spinal distortions.
“Medications go after pain relief, but the muscles remain stiff and tight. Manipulation restores mobility of spinal segments and restores blood flow,” says Gregory Yacucci with Colonial Chiropractic in New Castle. “Research has shown that when you put people through a course of treatment they are helped. Most people come in for other problems, but will often say, ‘My migraines seem to be going away.’”
Dr. Hal Bowen, in practice for 20 years with Bowen Family Chiropractic Center in Rehoboth Beach, says headaches are the third most common complaint in chiropractic after low back pain and head-and-shoulder pain.
“Headaches, particularly if they’re repetitive, relate to muscle tension in the neck. Chiropractic can offer some excellent results,” he says. “Most headaches are muscle tension type headaches, and most will respond to chiropractic treatment to some degree. After proper analysis is made, you’re going to see some results in a few weeks. If we don’t, we refer patients to a different kind of doctor, such as a neurologist.”
Before manipulation begins, a thorough case history is taken, as is a posture analysis and most likely X-rays.
“We don’t have diseases, we have patients who express symptoms, which are all different,” adds Bowen. “That’s why I think X-rays are so important; you see anomalies and you get a very clear picture of how the misalignment is configured.”
As a neurologist, Sommers says he feels chiropractic can be helpful. “I do have patients who have benefited from chiropractors,” he says. “What I tend to emphasize is that any treatment be limited to gentle, non-forceful manipulation of the neck.”
Younger people tend to respond quicker to spinal manipulations, so the younger you are the more favorable the progress, says Dover chiropractor Steve Goldschlager of Forrest Family Chiropractic. “It’s a longer haul for older patients. The reason chiropractic works so well is because we’re not removing symptoms, but getting to the cause of the problems,” he says. “Ninety-nine percent of the people who come in here come for migraines. We’ve had great success.”
