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Article by Dr. Singh

Migraine Is a Real Headache

By  Dr. Ravinder Singh, MD

Gurvinder Kaur was having a really bad day. She woke up with a mild headache. Even though she wasn’t feeling well, she got ready for work. She had been under stress lately at work, as her boss had given her a project which had taken much longer than anticipated. At home, her mother-in-law had been getting on her case about not spending enough time with her children. At work, she had been so engrossed in her project that she forgot to eat her lunch. She had noticed before that if she did not eat her meals at specific times, she would develop a splitting headache. Such was the case today. At approximately 2 PM, she developed a terrible headache on the left side of her head. She felt as if someone was hitting her head with a sledgehammer. She just wanted to find a quiet spot and lie down. Bright light seemed to bother her eyes. She also started feeling nauseated. She remembered that her doctor had given her a medicine called Imitrex, but as soon as she took it, she vomited. She finally decided that she had to go home early and rest. Her doctor had given her another medication that she could put under her tongue, without having to swallow it, but she had left it at home. It seemed that her headaches kept getting worse as time went on, and she was getting really frustrated because of the pain and the disability that it was causing.

This is a typical scenario of a person suffering from a migraine headache. Migraine is a very common disorder, affecting approximately 23 million Americans. It is very common in the South-Asian community. It affects more women than men, and usually starts in childhood. More than 80% of people suffering from migraine headaches suffer from some form of headache-related disability. The number of people suffering from headache has increased steadily over the years, due in part to the increased incidence of stress in our society. Well, enough about statistics, let’s examine what a migraine is and what we can do about it.

Definition of a migraine:

A migraine is a very bad headache that tends to recur. However, it is the typical characteristics of the pain, which differentiate it from the other common type of headache, known as Tension-Type Headache (TTH).

Characteristics of migraine headache

1. Pain usually on one side of the head

2. Throbbing, pulsation pain

3. Very sensitive to bright lights (photophobia) and noises (phonophobia)

4. Worsened by head movement

5. Appearance of an "aura."

6. Nausea and/or vomiting

There are many forms of migraine headaches. The two major varieties are Migraine with aura and migraine without aura. The aura is the occurrence of neurological symptoms 10-30 minutes before the classic migraine attack. One may see flashing lights, zigzag lines or may temporarily lose vision. Other symptoms of classic migraine include speech difficulty, confusion, weakness of an arm or leg and tingling of face or hands.

The common migraine - a term that reflects the disorder's more frequent occurrence in the general population - is not preceded by an aura. Some people do experience a variety of vague symptoms before common migraines - mental fuzziness, mood changes, fatigue, and unusual retention of fluid. During the headache phase of a common migraine, one may have abdominal pain and diarrhea, increased urination, nausea and vomiting. Both types of migraine can strike as often as several times a week or rarely as once every few years.

Scientists and physicians don’t really know what causes headaches. However, experience and research has shown that for some reason, patients with migraine headache have an increased sensitivity to the environment. Hence, bright light, sounds, and movement can increase the pain level. In addition, many substances can trigger the migraine response. Headache triggers can be things one eats, smells, hears or sees. Some of the more common triggers are listed below:

• Stress and time pressure, major hassles, major losses, anger and conflict.

• Smells and fumes, tobacco smoke, light glare or dazzle, weather changes.

• Monthly periods, birth control pills, estrogen therapy.

• Too much, too little or interrupted sleep.

• Hunger, fasting, specific foods or beverages.

• Excessive activity.

• Certain medicines.

A word about food triggers. Many different types of foods have been linked to migraine such as aged cheese, MSG, caffeine, chocolate, aspartame (found as a sweetener in many processed foods) etc. People who are familiar with migraine will recognize that this is a very short list of food items that can potentially trigger a headache. This is because any food can trigger a headache. Some people are sensitive to certain foods, while others may not be sensitive to the same foods. It is up to the patient and the doctor to determine what foods may be the triggers in that particular patient.

Just as the external environment (what we eat, see, feel and hear) has triggers, so does the internal environment (hormonal changes). Hormones seem to influence migraine development. This is especially true for women. Women may have menstrual migraines, which can disappear during pregnancy. Other women develop migraines for the first time when they are pregnant. Some are first affected after menopause. Scientists report that some women with migraines who take oral contraceptive (birth control) pills (OCP) experience more frequent severe headache attacks. A smaller number of women experience less frequent, less severe migraines with OCP. Women who do not have migraines may develop migraines as a side effect when using OCP.

Treatment of migraine headaches

Now we come to the most important part for patients. It is helpful to understand the causes and impact of the disease, but what is most important for the patient is how to get rid of the headaches.

There are many approaches to reduce the pain of migraine. The most common methods of preventing and controlling migraines and other headaches include:

• Drug therapy

• Biofeedback training / relaxation

• Stress reduction

• Elimination of certain foods from the diet

• Elimination of allergies to trigger substances

• Regular exercise, such as swimming or vigorous walking

• Temporary relief can sometimes be obtained by using cold packs or by pressing on bulging arteries found in front of the ear or the painful side of the head.

• Acupuncture / NAET

Most doctors tend to resort to drug therapy without addressing the other strategies, which are equally important. Let’s discuss drug therapy first, and then we will explore the other approaches. Drug therapy is divided into 2 major categories:

• Abortive: To abort or relieve the symptoms once the headache is already present. This is also known as acute therapy.

• Preventative: To prevent the headaches from occurring in the first place. This is also known as prophylactic therapy.

Abortive therapy is designed to get rid of the acute pain, once the headache starts. There are many medications that can achieve this purpose. The most effective medications, and the most commonly used, are medications that belong to a class of drugs known as the triptans. These are drugs such as sumatriptan (Imitrex), zolmitriptan (Zomig), rizatriptan (Maxalt) etc. There are more than 10 triptans that are currently used for migraine relief, in addition to other non-triptan medication, such as ergotamines and over-the-counter medications such as Advil, Motrin, Aleve etc. Our patient, Gurvinder Kaur, was prescribed Imitrex for her headaches, which worked well, when she could take it and keep it down. She was also given a prescription for a special form of Zomig tablets which do not need to be swallowed, and should be taken when the patient feels nauseated or is vomiting and cannot keep any medication down. These tablets are placed under the tongue and are absorbed directly into the blood stream. There are also triptans in the form of nasal sprays and injections. The doctor can determine which approach is best suited for a particular patient.

The aim here is not to provide the reader with an exhaustive list of abortive treatments, since the decision to prescribe one of these medications resides with the treating physician. The main point here is that there are many drugs that are very effective in quickly resolving the pain. However, not all doctors are experienced in treating headaches. If a person is suffering from frequent headaches, that person needs to find a headache specialist, as the different treatment approaches, including alternative strategies, are very effective in significantly reducing the acute pain and disability from headaches.

Preventative therapy is designed to decrease the frequency, duration and severity of headaches, and prevent them from occurring. This type of therapy is recommended for people who suffer from migraine headaches more than 3 times per month. The types of medications used for this purpose usually do not provide instant relief like the abortive medications. In addition, these medications need to be taken on a daily basis, as they “strengthen” the nerves which are instrumental in causing the headaches, and make them less responsive to the triggers. The drugs used for this purpose are typically used for other purposes. For example, Elavil is an anti-depressant, Depakote is a seizure medication, and Inderal is a blood pressure medication. All of these medications are used as preventative treatments for headache. Gurvinder Kaur’s doctor has no experience with preventative strategies, and so the patient was sent to a headache specialist for optimizing her therapy, as she was having headaches almost 2-3 times per week.

Equally as importantly as drug therapy are the non-pharmacologic approaches. An important trigger for both TTH and migraine headache is stress. Stress management is an essential part of the treatment regimen, which is largely ignored by many doctors. This is not something that can be easily treated with a pill, at least not without potentially serious side effects. The patient needs to find adequate means to combat stress. Some strategies include certain stress-reducing exercises, biofeedback, yoga, meditation, and many others. An experienced physician can usually design stress-reducing strategies for individual patients.

Avoidance of triggers is another important strategy. However, this is less satisfying to me as a physician, as it depends on being able to identify triggers reliably. In some cases, it is easy, such as with chocolate, but in other cases, even if the offending substance can be identified, it might not be easy to avoid it. In these cases, acupuncture can be very helpful.

Another technique that many physicians including myself, have found very useful in identifying triggers and eliminating them without having to avoid them is a technique known as NAET (Nambudripad’s Allergy Elimination Technique). This is particularly effective, natural, safe technique, which does not involve drugs, injections or herbal treatments. (For more information about this technique, readers are directed to read a book, Say Goodbye to Illness by D. Nambudripad, or contact the author of this article). This technique has been particularly helpful with many patients who desire to get rid of migraine headaches without using any drugs. There are also very successful homeopathic approaches that have been found to be very effective in treating headaches naturally.

A natural formulation of the herb feverfew, magnesium and riboflavin (one of the B-complex vitamins), known as Migrelief, is also being used more and more, especially in the prevention of headaches. All of the 3 ingredients of Migrelief have been shown independently to be effective in decreasing the incidence and intensity of headaches. The effects of the formulation will become most apparent within 60 to 90 days.

In short, migraine is a very common problem, resulting in much disability. However, patients with this condition need not resign themselves to a lifetime of suffering. Using a multi-faceted approach, which combines both Western and Eastern medicine, is likely to be more effective, as patients are increasingly embracing alternative strategies. The judicious use of medications and the appropriate “alternative” treatment will likely have a longer lasting effect than relying solely on one approach, whether it is medications or acupuncture.