Living With Migraine And The Search For New Treatments
Image used under Creative Commons from Flickr user amanky
For those who suffer from migraine headaches, the pain can be devastating. Intense throbbing and sensitivity to light or sound often keeps people from their normal lives for hours or even days on end. The World Health Organization ranks migraine as one of the most debilitating diseases, and more than 10 percent of the population suffers from it. Yet migraine is not widely understood and is often misdiagnosed. But patients can find relief with the right treatments. As scientists learn more about the cause of migraines, doctors and patients have their sights on better medication. Diane and her guests discuss living with migraines and the search for new treatments.
neurologist at George Washington University Hospital.
author of "Living Well With Migraine Disease and Headache."
neurologist at the Mayo Clinic and chair of the American Migraine Foundation.
director of the National Institute of Neurological Disorders and Stroke at the National Institutes of Health.
Web Extra: Dr. David Dodick Answers Audience Questions
Is there a correlation between migraine and epilepsy? How are migraines diagnosed in children? Dr. David Dodick of the Mayo Clinic responded to these listener questions and more. Some questions have been edited for space and clarity.
Q: Is it common for children to experience migraines during puberty and then grow out of them? -- From Twitter user @A_Fountain
A: Migraine tends to be begin during adolescence, peak in the 20’s-40’s, and diminish thereafter. While the clinical course is highly variable and migraine can go into remission at any time, it is not common for migraine to remit in adolescence. In addition, the predisposition to migraine is believed to be genetic and therefore, the predisposition is lifelong, though for a significant proportion of individuals, the attacks tend to diminish over time.
Q: What is the correlation between stroke, birth control and migraine? -- From Twitter user @MigraineLand
A: The risk of stroke, particularly in women less than age 45, is increased two-fold in those who have migraine with aura. That risk is increased by up to 8-fold in women who have migraine with aura who also use an oral contraceptive pill. This risk is increased even further if the woman smokes. Therefore, all women with migraine with aura should be encouraged to quit smoking (if they smoke). In regards to the oral contraceptive pill, recommendations vary from never using the OCP in a woman with migraine with aura to using if aura is infrequent and limited to visual symptoms only. In general, for those young women with frequent migraine with aura, or aura that is prolonged (lasting longer than 60 minutes), or in those whose aura started or worsened after starting the OCP, it is recommended that alternative means of birth control be explored to minimize the risk of stroke.
Also, please keep in mind that while the relative risk of stroke is increased by a factor of 2 in those with migraine with aura, the baseline risk of stroke in young women without migraine with aura is very low (approximately 4 per 100,000 women). That means that while the risk is double, the risk of stroke is still very small (8 per 100,000 women) and even when the OCP is added, the risk is approximately 60 per 100,000. Those individuals with a family or personal history of blood clotting disorder (deep venous thrombosis, pulmonary embolus, should certainly avoid the OCP)
Q: Are there any studies that establish a correlation between fibromyalgia and migraines? -- From Twitter user @araaajoooo
A: Yes, fibromyalgia and other chronic pain disorders are considered to be “comorbid” with migraine. That means that they are more often associated with migraine than one would expect to occur by change alone. This is likely due to abnormal function of the internal pain modulating networks in the brain in migraine, and this dysfunction leads migraine sufferers to be susceptible to other chronic pain conditions.
Q: I get cluster headaches which are often mistaken for migraines. Is it because I am female, or are they that similar? -- From Twitter user @MJnTJ
A: Cluster headache does share some features with migraine. For example, cluster headaches are almost always unilateral (migraine is unilateral about 50% of the time), and cluster headaches may be associated with sensitivity to light (photophobia) and noise (phonophobia), and, less commonly, with nausea. However, cluster headache can usually be distinguished easily from migraine because cluster headache is almost always unilateral, side-locked (which means they occur on the same side), last a shorter period of time (30minutes to 3 hours; compared to the 4-72 hours of migraine), are associated with prominent tearing, reddening of the eye and nasal congestion, on the same side as the pain, and patients with cluster often need to pace during an attack while migraine sufferers generally like to be at rest and still. Cluster usually occurs once to three times per day for a period of months and then go into remission for months to years (hence the name cluster). Finally, in those with cluster, attacks that awaken individuals from sleep are very common. While cluster used to be considered a disorder that affected men 20-times more commonly than women, we now know what the ratio is much smaller and while cluster is still more common in men, the ratio is more like 3:1.
Q: Are most migraines onset due to triggers? What are common triggers? -- From Twitter user @JoanneDavidhiza
A: The extent to which triggers are present varies considerably from one individual to another. It is certainly time well invested to keep a diary to determine which triggers may be relevant for you. Common triggers include stress, relief from stress, sleep deprivation, alcohol, certain medications (e.g. nitroglycerin), overuse of analgesics, triptans, narcotics, certain foods (processed meats, aged cheese, monosodium glutamate, aspartame, caffeine), menstruation, exercise, high altitude.
Q: Are the mental health issues mentioned by your guests also a concern for those who have aural migraines? -- From Twitter user @Tom_Godell
A: Yes, the mental health issues are equally a concern for those who have migraine with aura. For those who have chronic migraine (headache more than 15 days per month), mental health issues are even more common. Rates of depression and anxiety for example are higher in chronic migraine sufferers than in those with episodic migraine (less than 15 headache days per month). This association is very likely due to similar underlying biology – in other words, the altered chemistry in the brain in depression and anxiety may be similar in some ways to migraine. This may explain in part why some antidepressants are effective for the prevention of migraine.
Q: Is there a comorbidity or other correlation between migraine and epilepsy? -- From Twitter user @MmrghHmph
A: Yes, migraine sufferers are twice as likely to experience epilepsy and vice-versa. This is very likely due to a similar underlying biology. In other words, epilepsy and migraine are both due to abnormally excitable brain cells and networks in the brain. And, in fact, several of the most effective medications for the prevention of migraine are antiepileptic drugs.
Q: What research is being done regarding long term impact of migraine on the brain and long term (20+ years) exposure to daily meds? -- From Twitter user @nikki_d
A: There have been a number of studies that have evaluated the long-term neurological effects of migraine, particularly with respect to cognitive function. A very recent and large study that evaluated over 6,300 women over the age of 65 at the time of the evaluation, and who had migraine with and without aura throughout their lives, found that cognitive decline was no more significant or rapid in those with migraine (with or without aura) compared to those without migraine. However, there is evidence that migraine sufferers are at an increased risk of stroke and brain lesions, particular those with migraine with aura. These individuals are at double the risk of stroke and up to 15-times more likely to develop brain lesions. It is not clear whether these lesions have an effect on these particular migraine sufferers over time compared to those without these lesions.
With regard to the long-term effects of migraine medications that are taken daily, while there are adverse effects associated with all medications, and the type and severity of adverse effects vary between patients and depending on the particular medication, there is no definitive evidence that there are serious long-term effects of preventive migraine medications taken daily for migraine. All of the preventive drugs taken for migraine are used long-term for other disorders such as epilepsy, depression, high blood pressure, and other disorders, so there is extensive evidence that the long-term effects of these medications taken for other purposes appear to be relatively safe long-term.
Q: Biofeedback machines, watching my state of mind and breathing techniques changed my migraines substantially. I had been a serious sufferer from 12 until 21 years old and still get them, but not nearly as often. Please discuss application of meditation and breathing techniques. Was this my imagination? -- From Facebook user Kathleen Galt
A: Biofeedback has been demonstrated to be effective and is recommended for the preventive treatment of migraine. By becoming aware of your body’s automatic responses to pain and stress, and learning to control those responses, some individuals are able to lessen your pain. Biofeedback monitors and measures your body’s involuntary physical responses to pain and stress, such as breathing patterns, heart rate, body temperature, and muscle tension. The monitors provide feedback to the patient during a session and with this information, individuals can better understand how their body reacts in certain situations and how they can modify these responses to reduce pain. These techniques are felt to exert control over the autonomic (‘involuntary’) nervous system and engage the internal pain modulation system in the brain and in these, and potentially other ways, have a positive impact on migraine.
Q: Is there any relationship between the brain disorder that causes migraines and trigeminal neuralgia? -- From Facebook user Donna Mitchell MacKinney
A: No, trigeminal neuralgia and migraine are felt to be distinctly different disorders. They each have a unique biology and are treated differently.
Q: I was wondering if you can have migraines that do not manifest as headaches? I had ear pains that literally gave me vertigo so bad that I had to use my medical leave. We were never able to figure out what caused the ear pain. -- From Facebook user Valerie Garza Estes
A: Migraine is a neurological disorder that can cause a wide variety of different symptoms, of which headache is one. However, other symptoms of migraine may appear without pain. In particular, the aura of migraine (e.g. visual disturbance may occur without pain), vertigo, and other symptoms may occur in the absence of headache. In children, abdominal pain, vomiting, and other symptoms may also occur in the absence of pain. The presence of ear (especially inner ear pain) with vertigo may be due to disorders other than migraine.
Q: I have suffered for over 30 years and now I am getting nocturnal migraines. Any idea why they are happening while I am sleeping? I have also suffered two episodes of cluster headaches in 1990 and 1996. Any input on what could have triggered my cluster headaches? -- From Facebook user Chris DeBottis
A: It's very common for cluster headache to occur during sleep and in fact, its also common for migraine to occur during sleep or upon awakening. While sleep sometimes provides relief of migraine, it can also sometimes trigger migraine. This may be due to inactivation of certain regions in the brain that may lead to activation of the pain pathways and other brain networks involved in generating a migraine attack. One should also beware that there may be sleep disordered breathing (sleep apnea), elevated blood pressure during sleep, and other disorders that can either trigger cluster headache or migraine during sleep. If patients whose attacks begin to occur during sleep, or occur exclusively or predominantly during sleep, a sleep evaluation, sometimes with overnight sleep studies (polysomnography) is recommended.
Q: My 5-year-old son has been suffering from weekly headaches for just over a year. They can be debilitating if we don't treat them with Tylenol or Ibuprofen immediately. His pediatrician has prescribed Periactin nightly. How are migraines diagnosed in children, and is there more we could be doing? -- From Marla via Website
A: Migraine is a clinical diagnosis, based on characteristics of the headache and associated symptoms. In other words, there is no blood test, x-ray, or brain scan that can make the diagnosis of migraine. These tests are used to exclude other disorders that can mimic migraine. While there may be some differences between migraine in children and adults (e.g headache may lasts shorter period of time), in general, the attacks are similar. Cyproheptadine (Periactin) is a commonly prescribed medication used in children to prevent attacks. There are a variety of treatment options, both pharmacological (drug) and non-drug treatments that can be used to effectively manage migraine in children. For those children who do are not responding to conventional treatment, and who are suffering from frequent and disabling headaches, one could consider a referral to a pediatric migraine specialist.
Q: I've heard that migraines are also associated with a higher incident of stroke. Does the latest research, which moves the disease from the vascular space to the neurological space, support that? -- From acdames via Website
A: Yes, there is now considerable evidence that women who have migraine with aura are at an increased risk of stroke. Even though the migraine aura and the migraine headache is now not considered to be due to constriction and dilation o f blood vessels, migraine may be triggered in some patients by alterations within the brain blood vessels (e.g. reduced blood flow, particles in the blood). Also, during migraine attacks, there may be secondary changes in the blood vessels that affect blood flow and increase the risk of stroke. For example, during migraine with aura attacks, there may be a reduction in brain blood flow as a result of changes in brain activity. Also, individuals with migraine, especially with aura, are also at an increased risk for other disorders (patent foramen ovale, arterial dissection) that may increase the risk of stroke.
Q: Could there be a correlation between gastrointestinal diseases and migraine headaches? You discussed in detail on the show the numerous neurological conditions that have a strong relationship to migraines, but is there any research being done about possible relationships between Inflammatory Bowel Diseases and migraines? -- From Schandra via Website
A: There is evidence of a relationship between migraine and irritable bowel syndrome. There is also evidence that gastric stasis (reduced movement or motility of the stomach) may be present during and in between migraine attacks. However, there is not yet convincing evidence that migraine is related to or more commonly associated with inflammatory bowel disorders that would occur by chance.
Q: What is the difference between migraine and Benign Paroxysmal Vertigo syndrome? If you have BPVS, will you become a migraine sufferer? -- From Facebook user Deborah Couch
A: Benign Paroxysmal Positioning Vertigo (BPPV) is an inner ear disorder and unrelated to migraine. However, paroxysmal vertigo (episodes of vertigo) may occur in association with migraine attacks, whether or not the migraine attack is accompanied by the headache. This has been termed migraine associated vertigo or vestibular migraine. In fact, in young women, migraine is one of the most common causes of unexplained episodes of vertigo.
Q: While going through peri-menopause, I started suffering from the most painful headaches that often came in the middle of the night and often induced vomiting. Is there a link between migraine and menopause? I have a younger sister who is now going through the same symptoms I had at about the same time in her life. -- From Facebook user Candy Allen-Smith
A: Yes, migraine is often affected by changes in hormonal cycles in women. For example, the onset of menstruation during adolescence, the menstrual cycle, pregnancy, hormone replacement therapy, oral contraceptive therapy, and menopause all may have a dramatic effect of migraine. However, there is considerable variation in the effect of each of these periods, including menopause, among individuals. Certainly, a significant number of women improve after menopause, but a substantial number of women worsen while going through menopause. The effect of fluctuating levels of female hormones during menopause appear to have an effect on the excitability of brain networks, including pain systems, that may adversely effect women with migraine and those genetically susceptible to migraine.
Q: Are ocular migraines related in any way to migraine headaches? Are they connected to any type of brain disorder, or something completely different? -- From Facebook user Suzanne Rose
A: The formal or accurate term for “Ocular migraine” is migraine aura without headache. The visual symptoms experienced by these individuals is the same as those who experience the visual symptoms associated with the headache. One can think of the visual symptoms and the headache as two of many symptoms of the migraine attack. Sometimes they occur together, sometimes they occur in isolation.
Q: I have had dizzy spells for months, which some doctors think are related to migraine. I have tried physical therapy with mixed success to "retrain" the brain. Do you think this approach makes sense? -- From Facebook user Barbara Carney-Coston
A: Yes, vestibular rehabilitation therapy is recommended for those with vesibular symtoms, whether related or unrelated to migraine. There are other potential approaches to treatment as well, and guidance from a neuro-otologist or migraine specialist may be useful if you do not make progress with physical/vestibular therapy.
Q: I still get the visual auras and as my migraines became less [severe], I began to have acute tinnitus. Is there a connection between tinnitus and migraines? I am 63. -- From Facebook user Virginia Ann Ullrich-Serna
A: Yes, there appears to be a relationship between tinnitus and migraine. A number of migraine sufferers report tinnitus during migraine attacks. However, age-related tinnitus can have other causes as well, the most common of which is sensori-neural hearing loss.
Q: I think I have visual migraine when I exercise vigorously or I'm dehydrated. I have jagged lines in my field of vision, but no pain or sensitivity. It happens one or two times a year. Is that a migraine? -- From Facebook user Janie Moretz
A: Yes, that is a migraine aura without headache. It has the same underlying biology as when these symptoms are associated with headache.
Q: My migraines seem to be triggered by hormones and seem to be getting worse as I approach menopause (I'm 45). Are there different approaches for hormonally-triggered migraines? Can I expect some relief after I go through menopause? -- From Facebook user Lisa Tait
A: As noted above, migraine may worsen while individuals are progressing through menopause and may improve after menopause. This of course is not true for all. While treatment approaches may be the same as for migraine that is not associated with hormonal changes, there may be very specific strategies for treatment that include hormonal replacement therapy. It is highly advisable however that you enlist your doctor’s advice and guidance regarding the pros and cons of hormonal therapy.
Q: Has marijuana shown any promise as a treatment for migraines? -- From Facebook user Lionel Hubbs
A: There is no evidence to support the use of marijuana for the treatment of migraine.
Q: If as much as 10% of the population suffers from migraines, why does the medical community lack basic knowledge of common symptoms and treatments? What will it take to put migraines on doctors' radars? -- From Erin via Website
A: That is an excellent question but complex to answer. A misunderstanding of the biological nature of migraine for centuries, an underestimation of the impact and suffering experienced by a substantial number of individuals with migraine, and the lack of education in undergraduate and post-graduate medical education of physicians and health care providers are certainly leading reasons. It’s also true that it takes approximately 15 years for advances in medical knowledge to make it into clinical practice. With the emergence of the internet and direct-to-consumer advertising, patients have and will continue to become more empowered and engaged in the management of their illness, and seek the most appropriate medical care for their condition. Also, as medicine moves toward reimbursement (“pay”) for performance rather than “pay-for-service”, physicians and health care providers will need to integrate evidence-based guidelines and best practices to ensure optimal patient outcomes.