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Presented by
Pennsylvania Neurological Associates, LTD.
Charles S. Yanofsky, M.D. |
Albert. W. Heck, M.D. |
Jon L. Vickery, M.D. |
Francis J. Janton, III, M.D. |
| Liana Laza, M.D. | |
Janice Morrow, Practice Administrator
108 Lowther Street
Lemoyne, PA 17043
(717) 774-2202
What is Migraine?
A Patient Guide
The bright lights of the brain extinguished one by one like lamps.
-James Joyce
He has seen but half the universe who has never been shown the house of pain.
-Ralph Waldo Emerson
Think about pain for a moment. What makes a person feel pain? If you’ve ever walked barefoot on a hot pavement and burnt your feet, was it your feet that felt the pain? We all know that the pain is apparently in the painful part but that it is your brain that mediates the painful sensation. Furthermore, scientists know that pain is felt by the highest centers of the brain, the cerebral cortex. To appreciate pain you have to be conscious or aware of the painful sensation. Why is this important?
It tells us the true meaning of pain and shows that pain is influenced
by many things - the same things that influence the cerebral cortex and the entire nervous
system. When you are in pain, you don’t consider this, of course. Pain is, most of
the time, a warning of imminent danger to the painful part. Keep your foot on that hot
pavement and you might get burned - you might damage that painful tissue. Your first
instinct is to withdraw and possibly to panic. In most cases this is adaptive, part of
self-preservation.
But many times pain occurs in the absence of injury to the painful part. Migraine is an example of this latter form of pain. When you see a physician for migraine, when your pain fits into that specific description, you and your doctor know that you will not have any tissue damage. Our scans almost never find anything abnormal. So you can relax with the comfortable assumption that you are out of danger.
So we’ve established that pain is felt by a mechanism of the conscious brain. Influence the brain and you can turn pain on and off. For example, it is possible to destroy tissue in the absence of pain. Think about a father running through fire to save his child, a Maharishi laying on a bed of nails, a surgeon cutting into tissue while you’re under anesthesia. Anything that alters your attentional focus or level of awareness will either heighten or diminish pain. These will be important considerations below. Certain drugs, narcotics, for example, intervene in various parts of the pain pathway to diminish pain. All of a sudden we are not talking about the painful part. Assuming there is no tissue damage, the painful area can be left out of the discussion!! That’s why very often in the realm of pain you end up seeing someone who specializes in treating the brain, a neurologist.
Yet for migraine there are excellent physical explanations for headache attacks. It is just that we're more hard pressed to find physical damage. And the problem is multifactorial. We have to ask what physically is causing the headaches and also what are the behavioral changes brought about by head pain and what are the emotional changes. Physical and mental elements have to be dealt with. In our practice we typically handle situations that are too complex to be addressed by general doctors and are more resistant to standard treatment. This is not to say that migraine is not a definite physical disorder. It is an organic ailment that has both physical and mental ramifications.
Migraine is one of the most common disorders in office practice. It affects more than eleven million Americans. In fact, where we look for it we find that almost everyone has some migraines or migraine symptoms. The person who seeks medical attention will often have more persistent or disabling problems. Migraine may possibly be considered an exaggeration of normal phenomena. For example, an important part of migraine is vasospasm, the squeezing down of arteries. Arterial muscle tone regulates blood flow and is always precisely controlled. Almost everyone experiences some dysregulation of their arterial tone (state of spasm) from time to time. Most persons have migraine headaches or even the visual changes once in a while, which is the reason why over the counter medicines such as Excedrine, and the like, are so popular. In medicine we define diseases by change we can see on tests and in looking at tissue under the microscope. True diseases have pathology, in other words, organ changes that define the diagnosis. In migraine, we have no such precise pathology, so it is a matter of debate that migraine can be considered a disease at all, or if it is rather some alteration or exaggeration of normal physiology. Another reason to relax. Migraine isn’t tuberculosis, if you get my drift.
Of all headache types migraines tend to be the most severe and disabling. The meaning of the word is literally "half a head", named for their tendency to affect predominantly one side of the head. Typically there is a severe pounding or pulsatile pain centered about an eye or one temple. There is nausea and vomiting at the peak of the attack and certain stimuli, especially bright light and sound, increase the pain. We say there is sonophotophobia a fear of sound or light because migraine sufferers, (migraneur or migraneuse) lock themselves in a dark quiet room in order to get some relief. If someone opens the door and a shaft of light enters the room, the hands go up and protect the eyes, or perhaps there is a wet cloth covering face and eyes. The sufferer can lay like that for up to a day or more and still be miserable after the headache attack.
Some sufferers know when a migraine is coming on. A specific aura is part of the headache attack. Most commonly this is a visual episode which can be spectacular. Suddenly vision is blocked by dark areas (scotomas) that may contain bright shiny even colorful regions or zig zag lines and spots that shimmer, jump and move (teichopsia, photopsia, fortification spectra that look like a herring bone or zig-zag lattice of a fort palisade). You can be reading a book and notice all of a sudden that some of the print is invisible. We refer to these as migrainous visual phenomena and they can be positive with the person seeing things that are not there such as bright colors or lights or fortification spectra that move around in one's visual field or expand and shimmer (see figures at the beginning and end of this document) or they can be negative, blanking out a portion or even all of a person's vision temporarily. These visions rarely, if ever occur outside of a migraine attack. If you have them you can be virtually assured you have migraine. Of course, there are exceptions to every rule. That's how some people know they are in trouble, about to get a headache. Visions will be followed by terrible head pains. This is a warning or aura that precedes a migraine attack in some minority of persons who have migraine.
As an aside, visual auras have been a topic of fascination for neurologists for a very long time. Visual episodes were noted in antiquity. More recently the famous neurologist-author Oliver Sacks has written extensively about them. Lewis Carroll, author of ALICE IN WONDERLAND, suffered from migraine and unusual visual distortions, heralding his headaches still known today as the "Alice in Wonderland syndrome". Undoubtedly these visions were employed in his writings. He might never have been the creative person he was if not for his migrainous visions. Undoubtedly migrainous visual phenomena are behind the miraculous apparitions in Macbeth, and Ezekiel’s brilliant visions in the Bible, and, very likely a good number of other religious hallucinations. We owe it all to migraine. To be fair, some of these visionaries had good imaginations, some had other disorders causing visual distortions and hallucinations such as schizophrenia, but some undoubtedly were migraneurs.
An aura may be non-visual. Some migraine sufferers lose the ability to talk and become confused or there may be numbness on one side of the body or weakness. A migraine attack can simulate a stroke. Usually the aura, visual or non-visual, recedes as the headache phase starts. After the pain phase there may still be a dull ache and various psychological effects that persist. Some people have high energy, others feel demoralized. The whole process can be serious and even disabling.
If a person has an aura, by which is meant a specific neurological event before that headache phase, that defines Classic Migraine. This is known nowadays more simply as Migraine with Aura. If there is no aura, then we are dealing with Common migraine, migraine without aura.
A migraine attack has three phases best defined by the status of blood vessels during a particular phase. First is the aura phase, which, as we have seen, not everyone has. At this time, arteries squeeze down or constrict (vasoconstriction). Some of the brain may not get a sufficient supply of blood in this phase. This is called tissue ischemia for technocrats. (Don’t worry, there is rarely, if ever, any permanent damage.) There will be a neurological deficit of some kind. In some instances and especially in the visual area in the back of the brain, brain tissue that is not getting enough blood reacts by being more active electrically. This is because lacking a sufficient energy supply, cells have more trouble controlling the flow of electrically charged ions and the tissue becomes hyper-excitable. That is probably why some people have visions or distortions. This is what is meant by positive visual phenomena. Most persons just have negative visual phenomena areas in their field of vision of relative blindness. For all intents and purposes aura = vasospasm.
Some studies relate these vascular stages to Serotonin. In the first or vasospastic phase of the headache, there is an overabundance of Serotonin. Some of this serotonin seems to come from platelets, blood clotting elements in the blood that contain a lot of it. Serotonin can act as a vasoconstrictor - a chemical that promotes vasoconstriction.
The second phase of a migraine headache is the pain phase. At this time arteries overly dilate. Cranial arteries are pain sensitive structures whose walls contain tiny nerve endings that go into the trigeminal nerve. As the pulse beat goes through a dilated sensitive artery, you may feel a pounding severe headache. Recall that arteries constrict in the earlier aura phase and that in this second phase they now dilate. That is why, classically, the aura ceases as you get into the pain phase, not always, but most often. This pain is often accompanied by nausea and vomiting defining a so-called, sick headache.
Almost imperceptibly the headache attack marches into the third or inflammation-muscle contraction phase. In this third phase, pain becomes more diffuse. There are inflammatory chemicals and cells, (white blood cells) that come into the nervous system and covering of the brain, the meninges. There is photophobia, fear or avoidance of light. The person wants to be in a dark room. There can be a clouding of thought or mental functioning and prolonged persistent misery.
Interestingly enough, some persons have yet a fourth phase, a post-headache phase during which there are temporary psychological changes. Some feel a sort of release, some fatigue, some people even a kind of elation. Connected with a full-blown migraine attack is a whole host of chemicals that scientists have only recently started to detect and define.
It is these three phases, the aura, the headache and post headache period and the discreet attacks of headache, ordinarily a pounding headache, worse on one side of the head, that distinguish migraine from other forms of head pain. The symptoms alone allow the doctor to make a diagnosis ninety nine percent of the time.
PHASES OF MIGRAINE ATTACK
I. Aura (vasospasm)
II. Headache (Compensatory Vasodilation)
III. Inflammatory-muscle contraction
IV Post-headache symptoms
Headache is rarely a sign of more serious disease. It happens that the brain itself is insensitive to pain. What is sensitive includes the blood vessels inside the head that are invested with nerves that transmit pain signals and various other parts composing the skull, the muscles which can contract near nerves and cause intense pain, and the meninges a three layered covering of the brain and external structures such as sinuses and facial tissues and sensory nerves. All of these can respond with pain.
You can relax about a headache being a sign of a brain tumor as well. A brain tumor ordinarily does not produce lot of pain unless it begins to affect other structures that are not part of the brain such as the meninges or blood vessels because due to the tumor's pushing or pulling on these other structures. The pain of a brain tumor is ordinarily more constant and less paroxysmal. Classically brain tumor pain is worst every morning. As Carbon dioxide levels are allowed to rise in sleep, and also with recumbancy, the intra-cranial pressure rises. Some more serious problems such as bleeding from an aneurysm or weak arterial blood vessel, and inflammations such as meningitis, may cause pain but not in the form of recurrent attacks such as those we experience with migraine. This means that persons with severe painful attacks only rarely have anything that is life threatening. In fact when we do tests and scans to look at the brain, in a person with typical migraine, which today means a CT scan, or an MRI scan, we almost never find anything abnormal within the head. A lot of people ask me about migraines and aneurysms. Aneurysms themselves actually are fairly common, but they seem to be no more or less common in migraneurs. Most aneurysms cause no problems or pain unless and until they burst and cause sudden bleeding in the head. As it turns out, only rare aneurysms rupture which is why an aneurysmal hemorrhage, called a sub-arachnoid hemorrhage, is pretty rare.
There are a number of kinds of classic migraine. Rarely some people get symptoms in the lower part of the brain or brainstem and may have vertigo and double vision even lose consciousness as a prelude to their headache. This is called Bickerstaff migraine mostly diagnosed in teenaged girls. Children sometimes get abdominal pain or cyclic vomiting. Rarely an adult may even have a stroke or some permanent damage done as a result of migraine. In other words there may be very significant manifestations apart from the headache and the problem is called Complicated migraine.
When there is no aura or warning headaches are classified as Common migraine. It's called common migraine, not surprisingly, because it is, far and away the most common type of migraine. A better name for this is migraine without aura. A person can also have an aura, ordinarily visual sensations, without a headache. Why not? They may just have a vasospastic phase without pain ("migraine without headache"). Persons with common migraine may have, in general, a far less typical attack than is described above. The headaches may not be on one side only and actually may be more like typical tension headaches.
Another type migraine is the so-called Cluster headache. This headache type is in men 80-90% of the time and is named because headaches tend to happen in clusters or groups over weeks to months and then the problem becomes inactive for a time. The pains are around or near one or the other eye always the same eye within a particular headache group. There is no pounding. Instead the pains are lancinating or like a knife blade being dug into the eye, associated with tearing of that eye, almost as if there is an irritant or allergy. In some you may be able to set your clock by pain that comes on at a certain time of the day or night. Due to tearing and nasal congestion they have been called histamine headaches in the past. Clusters rarely occur in women and I have rarely seen them occur in a non-smoker, interestingly enough. The pain is extremely severe a lot of the time. We don’t know if smoking cessation will eliminate them.
As we have seen the whole migraine attack is caused by blood vessels spasming and a person's normal response to this spasm. We can actually see changes in the blood vessels during a migraine attack. An angiogram is a test where x-ray dye is injected inside arteries to make them visible. A Doppler test uses ultrasound to look at blood flow. Both of these test show arteries spasming during the first phase of a migraine attack.
While many chemicals and hormones can affect the caliber of arteries, it appears a transmitter called Serotonin is most involved. Clotting elements in the blood called platelets contain a lot of serotonin. Serotonin is a signaling chemical in the brain that is distributed widely, involved with sleep and wake cycles, and emotion, especially depression. During a migraine headache in association with the aura, platelets dump their serotonin into the blood. The arteries spasm. Then quickly, the serotonin is cleared from the blood and the levels are actually lower than normal and the arteries open up during the second or pain phase of the headache.
Experiments with serotonin show that it will do very different things in different places. In the center of the brainstem it seems to induce some stages of sleep. In other areas it may control a person's emotional state even their appetite or cause vomiting. It makes the uterus contract and affects blood vessels. Scientists alter molecules to create drugs that preferentially affect these specific functions at specific sites. One drug may affect the uterus, for example, and not other areas. In other words there are slightly different receptors for the same chemical transmitter. Receptors are merely proteins in the cell membrane that bind to the serotonin in a certain way and then send a message inside the responding cell. The different receptors are actually different proteins and these are appropriately named. The specific serotonin receptors on blood vessels are called 1D receptors.
Finally after this traumatic event in the blood vessel, there is a third or inflammatory phase. White blood cells are attracted by other chemical signals and there is a more prolonged irritating inflammatory reaction. This is one reason why for some persons irritation and pain can persist even for days while the classic blood vessel spasm only lasts a much shorter time. If you look at the spinal fluid that bathes the brain by doing a spinal tap, you may find evidence of inflammation. Part of the evidence is in the form of white cells in the spinal fluid, signifying irritation of the meninges that cover the brain (meningitis). The signs of this meningitis include irritation from light, the photophobia I mentioned, and neck stiffness. The stiff neck also may be due to anxiety that tightens neck muscles.
The EEG or electroencephalogram has shed some light on migraines. We have found that patients have slowing of brain waves during a migraine attack. This slowing tells us that areas of the brain are not functioning well or are not as active. We expect this if the blood supply is cut off. There may be a gradually spreading pattern of slow activity over the surface of the brain which signifies a spreading pattern of depression of cerebral activity. It could be that this pattern of slowing has nothing to do with artery wall spasm. It may tell us about some of the control mechanisms coming from the lower areas of the brain, the same areas that signal higher areas to stay awake or go to sleep, namely the reticular activating system. As mentioned, these areas work partly through serotonin secretion. Brain scientists are divided as to whether the blood vessel change, which is the most obvious, causes migraine, or whether serotonin in the brain and the reticular activating system is the culprit.
The EEG also shows in some patients patterns that are similar to epilepsy. In fact on the EEG migraine and epilepsy can look very similar. There is a slightly higher incidence of epilepsy in migraine patients and we commonly see migraine occur in patients who have epileptic seizures. In selected cases, drugs used for epilepsy will help control migraine headaches. One very interesting thing that happens in migraine and some forms of epilepsy is called a Jacksonian march, named not as you might think, for Andrew Jackson the general, but Hughlings Jackson, the great British neurophysiologist. Abnormal electrical activity defines an epileptic seizure. It spreads over the brain. Specific parts of the brain control parts of the body. Body parts are represented over the brain. So as electrical activity spreads over the brain, the patient feels or moves parts of their body. Jackson noted that some seizure patients would start to shake in a specific place, say in one thumb, then the hand, then the mouth, over the arm, and so forth. The shaking would march over the body. Why? Because the electrical activity that caused the shaking, the epileptic seizure in other words, was marching over the cortex of the brain. It’s the best example of brain-body interaction. You can see this electrical activity move over the brain on an EEG or brain wave test which records brain electrical activity.
It turns out there you can see a similar march in migraine and in epilepsy. In migraine a numbness or weakness tends to spread over a hand to face to arm and this is called a spreading wave of depression because you can see a change happen simultaneously on the EEG and there is depression or decrease in function (hypofunction). The migraine spread of hypofunction may is very instructive though it is fairly rare. We don’t know if it is the cause or effect of the spasm of arteries but may have a lot to do with serotonin.
Another thing that affects migraine is hormones. I mentioned that these headaches are more frequent in women. They also have a tendency to occur just before a menstrual period. Birth control pills often increase headaches. Estrogen like drugs seem to increase platelet function and have widespread effects on the brain and neurotransmitters. During the second and third trimesters of pregnancy migraine headaches usually diminish.
Lots of times I've connected erratic eating and sleeping patterns particularly and depression with headaches. It is very hard to convince most people about this but it seems the common habit of not eating almost at all during the day, then consuming most of your calories at night, (an obese eating pattern) may bring on migraine headaches. In migraneurs it is very common to find something that is unbalanced in their lives. There may be not enough exercise or often, given some quirks in personality, too much. There is a great debate in medical circles as to personality types and migraine. Migraine is statistically related to both depressive and compulsive personalities. That’s not to say that every migraneur is compulsive or depressed, but many are.
Sleep is a big factor. Often sleep may vary as when someone is on a swing shift at work or there may be a sleep disorder with significant insomnia nocturnal sleep that varies with interspersed daytime sleeping patterns. This is important for several reasons. The brainstem, involved in migraine, also affects sleep. Depression and many emotional disorders are almost always tied to disturbed sleep. In fact all other things being equal doctors use sleep health and regularity as the most important single index of a person’s mental health. As we've seen, both sleep regulation and migraine have to do with serotonin. Serotonin is the single most important neurotransmitter connected with severe depression as well.
So what can be done? Ideally there is a combined approach to migraine involving physical and emotional modalities. It is critical to identify all factors that might be exacerbating headaches. On a routine office visit we usually prescribe medicines that ameliorate the symptoms. It is not possible to mention all of the medicines used to treat migraine because of their great number but here are some of the highlights.
There are basically two groups of medicines, those that prevent the headache and some used to treat the headache attack itself. In the as needed category narcotics are to be avoided, if possible. True, they are effective over the short run, but they tend to sedate and may be habit forming especially for a frequent or chronic headache. Narcotics fail to address the headache mechanism. They are useful to stave off severe pain as an emergency measure. Demerol injections are used in the emergency room. Many migraine combinations contain an agent that causes vascular spasm. This helps the pain phase of the headache. Caffeine and ergot derivatives (Ergots affect Serotonin) will cause some constriction of blood vessels during the pain phase. Caffergot, Wigraine, Fiorinal, Ergomar, and Bellergal are some proprietary preparations that either contain caffeine or ergot. DHE-45, heretofore available by injection only, will probably be released as a nasal spray. It is a very effective anti-migraine drug and an Ergot derivative. Ergots taken to excess can increase nausea and cause profound blood vessel spasm with tingling in the extremities and even blue or cold fingers and toes, or in rare cases angina or a heart attack ("ergotism"). For that reason we don’t like to use ergots in smoking men of a certain age. Ergots and vasoconstrictors are contra-indicated in older patients prone to angina, in persons with high blood pressure and in pregnant women.
Midrin is a mild combination that also causes blood vessels to constrict. Over the counter medicines almost always contain caffeine. Caffeine has been shown to increase the effect of analgesics such as aspirin, ibuprofen and acetaminophen (Tylenol).
It is important to address the issue of nausea and vomiting. That can impair the absorption of an oral medicine. Reglan and other antinausea drugs can be given or sometimes medicine can be used in suppository form. Other drugs are administered in other novel ways, under the tongue, via inhalation or intra-nasally.
Other agents prevent or prophylax migraine. They have to be taken as a regular dose daily and thus are only recommended in persons with frequent or very disabling headaches. If there are more than three significant headaches a month they are probably worth using. Some tricyclic antidepressants are of value especially when there is an accompanying sleep disturbance or depression. These include among others Elavil and Tofranil. These are old medicines and we now have a whole class of anti-depressants that act specifically on Serotonin, the serotonin reuptake inhibitors, called SSRI’s. These drugs block the neuron releasing serotonin from taking it up and degrading the chemical, in essence prolonging serotonin’s effect. They have much fewer side effects than older anti-depressants. We say they have a cleaner effect, because they act so much more specifically on serotonin itself, and less on other transmitters as the older medicines tend to do. Examples are Prozac, Paxil, Zoloft and others.
A lot of doctors use these newer drugs for migraine prophylaxis, not because they are treating depression (these are all antidepressants) but because they want to affect serotonin. The problem is that these drugs most of the time don’t seem to work. In some persons they may even increase headaches!! In situations where they do work, they seem to do so because the headache is a "depressive equivalent", an symptom accompanying depression. The whole topic is very tricky. Part of the confusion might relate to the fact that serotonin has different effects in the various phases of a migraine attack, also that there are so many responses that serotonin affects, so many different serotonin receptor types as we’ve discussed above. On the other hand some of the older antidepressants have a more "tried and true", reliable, ant-migraine affect. These include the older drugs mentioned above as well as nortriptylene, and trazodone which also have less side-effects.
They really work in a lot of cases even if a person is not overtly depressed and neurologists use them very frequently. Patients come back to the office sometimes because the pharmacist or someone else tells them they are being treated for depression which they are not.
One very effective preventive medicine is Inderal (propranolol). It is well tolerated but may worsen asthma, decrease one’s energy level or even cause depression. Verapamil is another drug used primarily for persons with heart disease that is almost as effective yet seems to be better tolerated than Inderal. Some antihistamines, especially Periactin and some anticonvulsants, particularly Depakote, work well in some cases. Depakote (Valproate) is a very effective preventive medicine, but has some disturbing side effects, such as tremor, and may cause a person to put on weight. Steroids such as Prednisone are used occasionally for severe unrelenting headaches. And Lithium may be used for Cluster type headaches.
This is a wide array of drugs that seem to have little in common. Many affect serotonin in some way. When the Serotonin receptor is broken into subtypes different drugs affect different receptors so exactly how they work is problematical. Sumatriptan (Imitrex) has proven to be an excellent drug and a life-saver for a lot of migraine sufferers. It stimulates Serotonin 1D receptors so common on the walls of blood vessels. DHE-45 has as similar effect on Serotonin receptors. See special discussion: "The Triptans" on this website http:triptanslink
Some newer approaches include Catapres (Clonidine) patches and pills, a blood pressure drug that affects alpha adrenergic receptors (related to adrenaline). Clonidine is also used to lessen drug withdrawal and seems to interact with many other neurotransmitters. Neurontin (Gabapentin) used for seizures, which has been effective in many types of chronic pain is also a promising agent. This may affect GABA, another neurotransmitter. A number of longer acting Sumatryptan -like drugs are under investigation.
Figure 4: Classes of foods affecting migraine
It is also important to mention non-pharmacologic treatments. There are dietary considerations. Long lists of foods which affect migraine have been published. These include foods rich in Tyramine (red wines, cheeses, chocolates), and nitrites that dilate blood vessels, and even MSG has been implicated, also Nutra-Sweet (Aspartame) in a few instances. A lot of people ask about Caffeine. Caffeine is important only if the dose is varied a lot but it does not seem to be a factor if used regularly. I have seen some rare patients who cured of their migraine when "dried out" from caffeine. This is rare, but it’s important to know that some people who cease using caffeine entirely may stop having headaches. Caffeine causes vasospasm, and vasodilation as well in different arteries. Constant use may in some way, "up-regulate", increase the sensitivity, of muscular artery walls. Caffeine and smoking cessation are worthwhile considerations in chronic migraine.
My experience over the years is that these lists of foods play only a minor role. These specific foods are important only in selected individuals and they are few. It doesn't make sense to go crazy eliminating certain foods.
What is important is dietary indiscretion, non-regular consumption of food, binge eating and starvation, erratic sleep. Moderation and regularization of eating, relaxation, and exercise is critical. This figures in with the personality profile of migraneurs. Sometimes they seem to enjoy delayed gratification, periods of self-denial, which are variably followed by binges. They are monks or stoics, some, but by no means all of them. They need to regularize and moderate their lifestyles.
Another thing that happens very often is that a person will start out very early in life having typical migraines. Over years, the headaches slowly change. They are not as typical migraine type headaches. Slowly, imperceptibly, attacks become less migraine-like and there aren’t actually discreet attacks of pain. Migraine degenerates into a pattern that is designated chronic daily headaches. Since pain is almost a constant burden for these people, they use medicines almost constantly, often in great quantity, especially men, who don’t like to see doctors as much and self-medicate with caffeine-containing over the counter agents. They cycle between pain, drug-popping, drug withdrawal, and more pain as in the figure below. A lot of times I find that these persons have such an intense fear their pain will recur and they will be without medicine probably recalling their old typical migraine attacks, that they absolutely can’t be without a medicine or they will panic. Many of them can’t believe that what we need to do is dry them out, almost discontinue all prn drugs, and nine times out of ten they improve remarkably. These folks are in a state of almost constant withdrawal in their headache-medical cycles. They have an analgesic abuse syndrome. One medicine that is frequently abused in this way is Fiorinal or Fioricet. That’s why we try to avoid it. This preparation contains caffeine and also butalbital, a barbiturate which can, in rare cases, cause addiction. Lots of migraineurs use Fioricet every day. They are almost never butalbital addicted. The quantities they are using are far below the physically addictive ranges for barbiturates. What they crave is the caffeine or the combination of caffeine and barbiturate.
Figure 5: The chronic daily headache, analgesic abuse cycle.
Sometimes other modalities such as counseling, biofeedback etc will be important. Migraine is a disorder with a broad spectrum. For some just prescribing the right medicine will have a dramatic effect, but for other situations the approach has to touch the soul as well as the body.
If you suffer from migraine, I would urge you to look at more than medicines that can be used to stave off or decrease pain. A multi-faceted approach may involve some soul-searching, counseling, changing one’s life-style, which is difficult to do but well worth it. Some kind of counseling may well be in order in refractory cases and the active participation of the sufferer which may not be so easy. A migraine "check-list" follows below incorporating non-medicine related factors that are well worth looking at.
Revised 4/17/99. © 1999 Charles Yanofsky
See also "The Triptans," an addendum to this guide.
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