If you’re taking OTC meds before you have pain, you are probably overusing them. This is true with prescription painkillers, but the problem can be more serious: You could end up with a rebound headache and an addiction.
Rebound headaches can resemble migraines or become mixed into your migraine attacks, so it’s hard to tease the two apart. The best way for a doctor to tell whether you have chronic migraine versus rebound headaches is to get you to stop taking medication. But do not do this on your own. Stopping any medication or drug cold turkey isn’t advisable unless you have your doctor’s approval. When you do stop the meds, you will probably get a headache as a result—which can lead to a migraine. If you find, after a few days, that your headache stops and you begin to get fewer headaches, then your problem was probably medication overuse.
But if, after a few days or weeks off the medication, your headaches continue at the same frequency and intensity, you probably have chronic migraine, defined as migraine that comes more than fifteen days a month.
Cluster Headache—These are rare but extremely painful headaches that come on in clusters or groupings, and affect men much more than women, by a ratio of 10 to 1. A person may go months or even years without them, and then suddenly get a series of headaches every single day for several weeks or longer, before the headaches disappear again for months or even years. See Ch. 6.
Thunderclap Headache—This headache feels like a sharp blow to the head and appears without warning. If you get a sudden, violent headache, seek medical attention immediately. You could be suffering a stroke or some other very serious medical problem. Call 911—especially if the headache is accompanied by a stiff neck or you become drowsy.
Kinds of Migraine
Chronic Migraine—If you get migraines fifteen days or more a month, you have what’s called chronic migraine. It’s important to know how many migraines you get because it may determine the best kind of treatment for you.
Episodic Migraine—Migraines that come every once in a while, several times a month or less, are called episodic.
Evolved or transformed migraine—If you used to get episodic migraines but now get them every day or almost every day, your migraines are called evolved or transformed migraines. The biggest factor in migraines transforming from episodic to chronic is lack of good-quality sleep, recent studies show. See Ch. 12.
Ocular or Ophthalmic Migraine—If you have strange visual changes—flickering lights, zig-zag or other patterns before your eyes—without a headache, you may have an ocular or ophthalmic migraine. About 3 to 5 percent of migraineurs experience aura—visual or otherwise—without a headache. An ocular migraine, like any migraine without a headache, is called a migraine equivalent. Ocular migraines generally are not dangerous, but if you’ve never had one before, you must tell your doctor.
Abdominal Migraine—Abdominal migraines appear mostly in children. They include stomach pain—and, sometimes, vomiting, pale skin, or flushing (reddish skin)—but usually no headache. They typically appear in children who have a family history of migraine. When the child is older, the stomachaches may stop and be replaced by a migraine headache. How can a physician tell if a child’s stomachaches are migraines? Since there’s no easy diagnostic tool, they eliminate other causes for the stomach problems such as flu or a bowel obstruction.
Classic Migraine and Common Migraine—If you get migraine headaches preceded by aura (changes in your vision, hearing, sense of smell, or perception), you have what we used to call classic migraines. Only about 20 percent of migraineurs get classic migraines. If you get migraine without aura, this was called a common migraine. We now use the simpler terms: “migraine with aura” and “migraine without aura.”
Some Pretty Unusual Migraine Types
“All of a sudden, I started feeling really sick. My heart started racing. I got weak and started to feel like I would pass out. My eye felt like it was fluttering, and I felt like I was going to lose my bowel function. I lay down on the floor, and then my arms and legs went into an involuntary V position above my body. It was a terrible feeling, really scary.”
—Samantha, 26, nurse
Samantha has what’s called “complicated migraine” because her attacks include symptoms located in specific parts of her body. Other focal symptoms might include paralysis, numbness, speech difficulty, double vision, or a fixed pupil in the eye. The feeling that she was going to lose control of her bowels is part of her body’s autonomic nervous system—the “fight-or-flight” reaction—responding to a migraine attack. The first time this happened to Samantha, she and her doctors were very worried, since the symptoms could point to a stroke, seizure, or heart attack. But an MRI revealed no brain bleed, and doctors were puzzled. Samantha was referred to me when her primary care doctor wasn’t sure what was happening to her. Once I diagnosed her with complicated migraine, she could not take triptans. Instead, I prescribed a beta blocker, which she takes every day.
Complicated migraines are a subtype of migraine, which affect less than 1 percent of migraineurs. There are a number of other subtypes, some of which are quite odd. But all, fortunately, are quite rare. They include:
Basilar Migraine—This type of migraine includes headache plus at least two of these aura: vertigo (being off balance or dizzy), ringing in the ears, decreased ability to hear, unsteady or clumsy motion of the limbs (called “ataxia”), visual symptoms in both eyes such as double vision, difficulty in speaking or getting words out, tingling or numbness in the skin (called “paresthesia”), inability to move (called “paresis”), or decreased level of consciousness. This type of migraine is more frequent in adolescent girls and young women. Children with basilar migraine can lose all ability to move, in what’s called basilar migraines with limb paralysis. If you or your child have these symptoms, you should call 911 to make sure it’s a migraine and not a stroke or other serious medical problem.
Migraine Aura Without Headache—You get no head pain but get aura such as tunnel vision, flashing lights, or other strange visual changes; vertigo (dizziness); or changes in your hearing. Migraine aura without headache occurs in about 3 to 5 percent of migraineurs. If you get visual aura only, with no headache, this is called ocular migraine (see above).
Benign Paroxysmal Vertigo of Childhood—This type of migraine occurs in children, with symptoms of anxiety, dizziness or vertigo, rapid and involuntary eye movement (called “nystagmus”), or vomiting.
Hemiplegic Migraine—These migraines, which affect less than .01 percent of the population, cause temporary paralysis or weakness on one entire side of the body (which is why they’re called “hemi,” which means “half”), along with speech, visual, or other sensory changes. They may include more frightening symptoms such as coma, seizures, or ataxia, a severe lack of muscle coordination. If you get this kind of migraine, you cannot use triptans. See Ch. 2.
Familial Hemiplegic Migraine—Some families pass down the genetic mutations that cause hemiplegic migraine. Geneticists have identified mutations in three different genes related to this kind of migraine but believe there may be more yet to be discovered.
When to Call a Doctor—Beware of Change
More than 95 percent of headaches are harmless, at least in terms of your overall health, and rarely a sign of something really dangerous like a tumor, aneurysm, or stroke. If your headaches have remained the same for a long time, it’s unlikely there’s anything seriously wrong with you.
But beware of change.
If you experience a noticeable change in your headache pattern—if you start to get them more often or the symptoms are different—notify your doctor immediately. If your headaches used to come once a month during your period but now come every week, call the doctor. If the pain was throbbing but now feels like a fullness in your head when you bend over, call your doctor. If you suddenly get a severe headache you’ve never before experienced, call your doctor. You need to make sure there isn’t something more serious going on.
Migraineurs, who ar
e used to severe head pain, must be especially vigilant to note a change in headache pattern. It’s easy for us to ignore the signs of something more serious because we are used to severely painful headaches. If you suddenly get the worst head pain of your life, you need to call your doctor or head immediately to the ER to make sure there isn’t something more serious and potentially dangerous going on.
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Special note about children: Any child who has recurring headaches—especially if they occur at night or first thing in the morning—should see a doctor right away. These can be symptoms of tumors. “Waking-up” headaches are always really worrisome for children—although it’s tricky to make a diagnosis because sometimes it’s nothing more serious than your child trying to avoid school.
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Emergency! Call 911 if…
Change in your headache is a “red flag” that means you should call your doctor. There are other headache “red flags” you should know because they can indicate more serious problems. Contact your physician or an emergency department right away if you experience any of these symptoms:
Your headache comes on very suddenly and is extremely painful—this could indicate an aneurysm (bleeding in your brain).
You faint or black out during the headache.
You get a headache along with a stiff neck—this could indicate meningitis, an inflammation of the membrane covering the brain, which can be fatal if not treated immediately.
You get a headache along with a fever—this, also, could indicate meningitis.
You can’t see or have other visual problems during the headache—this could indicate bleeding in the brain, or a blood clot, tumor, or abscess.
You can’t talk or have slurred speech during a headache—this could indicate bleeding in the brain, or a blood clot, tumor, or abscess.
You can’t walk or have paralysis during a headache—this could indicate bleeding in the brain, or a blood clot, tumor, or abscess.
You feel numbness or tingling on one side of your body during the headache (although numbness in your scalp or face just before a migraine is generally harmless).
You get the headache after a blow or knock to your head—this could indicate an injury to your brain.
You get the headache after physical exertion, coughing, or bending—this could indicate a brain tumor (although physical exertion during a migraine also is usually painful).
You have convulsions.
Your headache slowly but definitely gets worse over a period of weeks or months—this could indicate a brain tumor.
Change isn’t always something serious, however. Your migraine pattern may change over time. But always tell your doctor if your headache pattern changes—in number of headaches, type of pain, symptoms, or other factors. Your doctor needs to make sure these changes in your migraine don’t point to something more serious.
CHAPTER 2
The Migraine Brain: How It’s Different—and What That Means for You
“My brain is like a delicate instrument that has to be carefully calibrated.”
—Nonnie, 31, temp worker
“I am so susceptible to everything! I always have to be on guard to avoid getting a migraine.”
—Bethany, 32, graduate student
The human brain is a complex organ that hates change and craves sameness. Some organs, such as the liver or kidneys, are pretty flexible when it comes to the abuse we heap on them. The brain is not. It isn’t as tolerant or easygoing, and it doesn’t like to stray too far from its comfort zone. Still, the average person’s brain doesn’t react too dramatically to minor irritations or interference. It may get a bit annoyed, at worst. If the average person is sleep-deprived, for instance, he or she may become groggy or get a mild headache or may have no reaction at all.
That’s generally not true for people prone to migraine. Your brain is as high-maintenance as they come. Like a thoroughbred racehorse or diva, it’s hypersensitive, demanding, and overly excitable. It usually insists that everything in its environment remain stable and even-keeled. It can respond angrily to anything it isn’t accustomed to or doesn’t like.
Thirty million Americans share this type of hypersensitive brain. I call it the Migraine Brain.
A Migraine Brain is always on alert, ready to overreact to any stimulus it finds displeasing. That could be red wine or changes in the weather or stress. It could be dust or strong perfume or lack of sleep. The irritants that trigger a migraine vary from one person to the next and can be almost anything, from aged cheese to fluctuating hormones to low blood sugar. These triggers don’t merely upset your brain, they can cause it to careen out of control with a biochemical chain reaction that may result in anything from severe head pain to vomiting to dizziness, or, in rare cases, paralysis.
In Chapter 4, you’re going to figure out your personal list of migraine triggers so you can avoid them whenever possible, and be ready with a migraine attack plan when you can’t. But first, let’s take a closer look at what it means to have a Migraine Brain.
Cortical Spreading Depression—the New Science of Migraine
Let’s say you drink a glass of red wine in a smoky bar after a really stressful day at work, and each of those stimuli happens to be a migraine trigger for you. Your Migraine Brain reacts, sending chemical and pain signals throughout your brain and body. You end up with a pounding headache and huddled over the toilet in the women’s room. What, exactly, is happening in your body?
For many years, migraine was was believed to be a problem with the vascular system (your blood vessels and the circulation of blood to body organs). Many doctors thought that migraines were caused by vasodilation—blood vessels in the brain expanding and pressing on pain-sensitive structures. But this theory wasn’t perfect. It didn’t explain many of the characteristics of migraine attacks, such as nausea and aura.
In recent years, our understanding of migraine has progressed a great deal. We now know it is a complex neurological disease that involves much more than the vascular system. The vasodilation theory was probably backwards: migraines aren’t caused by blood vessels expanding; rather, blood vessels are thought to expand as a result of a migraine attack.
The new science of migraine recognizes that migraine disease involves many aspects of your physiology, including your central nervous system, neurotransmitters and other chemicals in your brain, electrical impulses, your inflammatory response, a nerve in your face and head called the trigeminal nerve, and other systems. The latest research points to “cortical spreading depression” as the physical reaction that begins a migraine attack. It isn’t a depression at all but in fact is just the opposite, a superexcitability of the brain. Cortical spreading depression is a dramatic wave of electrical “excitation” that spreads across the surface of the brain, also called the cerebral cortex, when something antagonizes or upsets it. The cerebral cortex is responsible for many complex functions in the body including processing sensory information, executing voluntary movement, and handling the functions of language, thought, perception, and memory, which is why these functions can be affected during a migraine attack. For example, the spreading excitatory wave can be the cause of visual aura or tingling up your arm, while the cortical “depression” that follows can cause blind spots or numbness.
Cortical spreading depression was first described in 1943 by a Brazilian scientist named Aristide Leao, who, in a series of experiments, opened the skulls of rabbits and pricked their brains with a pin. When he did so, he observed actual waves of electrical reaction emanating outward from the site of the pinprick. But a pinprick is not the only stimulus that evokes cortical spreading depression. Every brain, if antagonized (such as by a medication, chemical imbalance, or some other stressor), can be susceptible to cortical spreading depression. It seems that people with migraine disease have a low threshold for cortical spreading depression (CSD), and it doesn’t take a very strong stimulus to set off CSD in the Migraine Brain. This susceptibility to CSD appears to be inheri
ted, but we also suspect it can be induced through extreme circumstances.
Researchers have found that CSD seems to explain many if not all aspects of migraine. At first, they believed CSD was related only to the aura phase of migraine, but we now believe it may well be the underlying basis for most things migraineurs experience during an attack.
The CSD model of migraine also explains why certain drugs—some of which were developed for other conditions such as epilepsy or depression—work to prevent migraine. These drugs aren’t similar to each other in their chemical properties, but they do share a common feature: they appear to raise the threshold for aggrivating CSD. In other words, these drugs may make your brain less excitable. In an experiment at Massachusetts General Hospital, researchers found that daily doses of selected migraine drugs reduced the frequency of CSD by 40 to 80 percent.
Here’s how we now believe migraine works: A migraineur’s central nervous system is overly sensitive to certain stimuli. When it encounters something it doesn’t like—a change in weather, let’s say, or fluctuations in estrogen levels—it sends a “red alert” to your overly excitable Migraine Brain, which reacts by setting off cortical spreading depression. In CSD, a wave of electrical excitement moves rapidly across your brain. (Don’t get worried about the electrical activity here—it doesn’t mean you’re in danger of electrocution.) During CSD, nerve cells in your brain become depolarized initially, then hyperpolarized, causing “depression.” In short, cell membranes, the outer protective layer of each cell, become unstable, allowing changes in the usual chemical balance. This instability spreads to other nearby cells in a chain reaction.
The Migraine Brain Page 5
