Minding Migraines

!–paging_filter–pIn 2003, Jane Bentley, a 53-year old kindergarten teacher from Tacoma, knew something was seriously wrong with her. Her symptoms started with strange visual effects. “It was like my peripheral vision would disappear and I would see these spidery cobwebs that I was sure were right in front of me,” she says. “I would literally put my hands out to get them out of my way and they weren’t there.” After about a month, she began experiencing searing headaches. “I thought for sure that I was dying,” she says.“It was the worst headache I could ever imagine.”br /Headaches became a daily struggle, leaving her wading through life feeling subhuman or lying in bed, unable to move. For the pain, she tried ibuprofen and even some leftover Vicodin from a previous root canal, but neither helped much. By the end of the school year, she had used up all of her sick leave with no relief in sight. Finally, her mother did some research and helped her find a specialist who diagnosed her with migraine, a syndrome that includes a collection of symptoms that can manifest in different ways.br /Bentley’s experience is similar to what we imagine when we hear the word “migraine,” but in addition to that searing headache, the condition also comes with a host of other possible symptoms, including upset stomach, unusual visual and other bodily sensations, and a heightened sensitivity to light and sound.br /The syndrome is often misdiagnosed and undertreated, leaving people with migraine, whose brains are hypersensitive to certain internal and external triggers, missing important work and social events in their lives. “What is really sad about this is there are so many people that are losing time from life, very important days and important family functions,” says Patrick Hogan, clinical director of Puget Sound Neurology in Tacoma. “Many of them are just using pain medicines without realizing that there are many other things that you could do.”br /At least 36 million Americans suffer from migraine, according to the Migraine Research Foundation; women are three times more likely to have it than men, and it is almost always passed down through families. Most patients experience the peak prevalence of the disorder between the ages of 25 and 55, but it can begin much younger, even in children. Sylvia Lucas, director of the Headache Clinic at the University of Washington Medical Center (UWMC), says Seattle is a particularly bad place to live for people with migraine headaches who are sensitive to barometric pressure drops. “I can write you prescription to move to Scottsdale, where there are fewer pressure changes” she says.br /Fortunately, doctors now understand better than ever what is happening in the brains of people with migraine and can target the condition with a host of treatments and strategies, all available in the Pacific Northwest. And exciting new treatments are in the works that may bring even more relief to sufferers of this debilitating condition.br /“A hundred years ago, we really didn’t know what was going on, and that is where the words ‘tension headache’ came from, because patients would feel the pain sometimes in the neck and shoulders or pain was felt in the forehead or face, and you’d call it a ‘sinus headache,’” says Lucas. “But there has been a lot of research showing the brain is where the perception of pain and headache happens.” br /Lucas says that while a migraine headache is activated in the upper brain stem, in a cluster of cells called the trigeminal nucleus caudalis, the pain actually may be a result of an inflammation occurring in the lining of the brain. She likens the pain of migraine to a heart attack sufferer feeling sensation in the left arm. The problem is with the heart, but the pain is felt elsewhere. “Pain in the head doesn’t really tell you where the working part of the headache is going on,” she says.br /Migraine pain is caused by the activation of the trigeminal nerve that releases a flood of inflammatory chemicals. Only about half of all migraine sufferers experience pain on just one side of the head. Sometimes the pain is located in the face leading people to mistakenly assume they have a sinus headache. “The trigeminal nerve often will go right to the front of the face around the eyes and it will cause draining of the nose and pain around the eye,” says Hogan. “Most people think they are having a sinus headache and will take decongestants.”br /Doctors still don’t really know why migraines happen to people; there doesn’t seem to be a good biological explanation for them. Eric Gierke, medical director of general neurology at the Swedish Neuroscience Institute at Cherry Hill, says that there appears to be a relationship between migraines and seizures. “With both of them, some stage of the event involves electrical changes in the brain,” he says. br /But doctors do know that migraines are activated by internal and external triggers, which tend to be unique for each patient. Lucas says that 60 percent of women have menstrual-associated migraine. “So a couple days before or a couple days after [menses] they’ll always get a migraine,” she says. “The estrogen drop is a very unique and potent trigger for women.” Other typical triggers include stress, changes in weather, lack of sleep, certain foods such as cheeses and caffeine, food additives such as nitrates (which you’ll find in cured meats) and monosodium glutamate (MSG), some food coloring and alcohol.br /Once a migraine is triggered, the patient may or may not have unusual sensations before they feel pain. Some experience what doctors call the prodrome, in which they may feel stomach upset, irritability or just a sense that something is changing. br /About 20 percent of migraine sufferers experience what is known as the aura, in which they see flashing lights or feel tingling sensations. Hogan says these experiences are caused by electrical waves spreading across the brain, like a rock thrown in water that sends ripples over the surface. “People start getting these flashing lights in one corner of the eye and as the wave spreads, the flashing lights are like a spot that gets bigger and bigger and bigger,” he says. “Or they will start getting tingling in one hand, and the tingling will spread up to their face and down their body in the same way that this wave is spreading across their brain.” Some people find they have trouble speaking or they can’t find the words for what they want to say. br /Gloria Langlois, a 50-year-old from Renton who works as a transplant program coordinator for the University of Washington, says she often knows when a migraine is coming. “My head gets hot,” she says. When the pain begins, it is in the back of her head and then it seems to travel around. “It will last two to three days, where I am in bed, in the dark, and I don’t want to talk. When I have one, I am totally disabled.” br /Because people experience migraine headaches so differently, treatment starts, Gierke says, with taking a patient history and learning their headache pattern. “If it’s 20 headaches a year or 20 headaches a month, you start with the pattern,” he says. “[For] people who really have migraines, it is hard to completely obliterate them permanently, but we try to get the pattern into a place where they have control over it, as opposed to the pattern having control over them.”br /Medication, lifestyle changes and avoiding triggers are all part of what local experts advocate for migraine management. nbsp;br /Triptans are a commonly used class of drug that constrict blood vessels and block pain pathways in the brain, effectively stopping a migraine headache in its tracks. “This is a treatment patients would take as soon as possible rather than waiting until the migraine is severe, because once it gets severe, the medicines may not work as well,” says Hogan. “The horse is already out of the barn.”br /If the trigger is especially potent for the patient, they may still need some additional pain medication, but Hogan cautions that trying to use pain medicine alone to treat migraine can have disastrous consequences. “Excedrin and other pain medicines are one of the major causes of converting episodic migraine, which occurs once in awhile, to almost daily migraine,” he says. Pain relievers can interfere with the pain messages the brain sends to receptors, making it worse. “It is called rebound migraine, and I see it everyday.” Hogan says there are exceptions with people who have low-grade migraine and take pain medicine once or twice a month. “But many people have tried to do that and they make it worse and worse.”br /Preventive medications include blood pressure drugs, antidepressants, seizure medications and injected botulinum toxin, or Botox, and are best for patients who have four or more headaches a month. These can reduce the frequency, severity and length of their migraines, says Hogan. “What all those medicines are doing is taking that hypersensitive migraine generator and blanketing it, making it less sensitive, even when it is exposed to whatever trigger is out there.” Dietary supplements, such as magnesium and riboflavin, are another preventive therapy option.br /In addition to taking medicine, Langlois has made lifestyle changes, such as exercising regularly, and looks out for triggers, which, for her, includes alcohol. “Even though I want to drink sometimes at parties, I stay away,” she says. “I can’t even have champagne because I’m so scared I will get a headache afterwards.”br /But some triggers are impossible to avoid. “November and December are always my worst time,” says Bentley. “Certainly at that time of year, stress is part of it with the holidays, but also that’s when the weather around here changes.” br /Even with all the treatments available, sometimes migraines can be difficult to manage. Tacoma resident Langlois says she takes four preventive medications daily and receives Botox injections every three months. Even though these have helped reduce her symptoms, she still gets debilitating migraines every month and lives in fear of her next one. br /But researchers are hoping that new treatments will provide more options for patients like Langlois. One promising avenue is a new class of drugs that targets calcitonin gene-related peptide (CGRP), a neuropeptide that is believed to play an important role in the pathophysiology of migraine. The UWMC Headache Clinic is participating in a multicenter study of CGRP that is sponsored by Seattle-based biotech company Amgen. The study is scheduled to begin by April; to qualify, people would have to have 15 or more headache days per month and not use narcotics for the treatment of their headaches. “It’s exciting that it is designed for the headache person,” Lucas says, “because everything else we’ve borrowed, like the blood pressure medicines, the antidepressants, the epilepsy drugs—even though they work very nicely as preventives—they are not specific to migraine.” br /Swedish’s Gierke notes that there are a number of new seizure medications on the market that may be useful for migraines as well. Currently, two of about a dozen seizure medicines are approved. “It’s not too hard to find anecdotal reports that one or another seizure medicine, such as topiramate or divalproex sodium, has been useful for somebody’s migraine,” he says, which makes it difficult to recommend one over another. “We’ve had good luck with some of the seizure medicines. I suspect we’ll see the same with the some of the other new ones.”br /Another promising research avenue is to find new ways to deliver already proven migraine therapies. Lucas says that in some cases, speed is of the essence. “There is some data saying that if you don’t treat a migraine more than one hour after it starts, your chances of being pain-free at two hours are less than 10 percent,” she says. “If you’re someone who wakes up with a headache or it peaks in a half an hour, then a pill is wasted on you.” These patients, along with those with rapidly escalating pain, are patients who might benefit from an injectable or inhaled form of medication, she says.br /For now, migraine sufferers like Jane Bentley continue to look for ways to reduce their attacks. Bentley is beginning a new exercise regimen and she continues to avoid certain food triggers, such as yellow dye no. 5 and MSG. She has also taken steps to reduce her workplace stress. Recently, she filed for disability from her school district and had all of the fluorescent lighting removed from her classroom. “That’s been huge,” she says. “It has made an enormous difference.” +/p