Migraine FAQ
What is Migraine?
Most people think about a headache when they hear the word “Migraine”. The current science of migraine is far more complex. In actuality, it is more of a sensory processing disorder. That is why the light bothers you, and the sound bothers you, and people bother you. People often see sparkling lights or zig-zag lines. Migraineurs are more likely to have various types of motion sickness and atypical dizziness spells, and there are a thousand types of sensory and perception changes that can occur. Headache similar to migraine can come from many other problems especially tightness in the neck muscles, but the symptoms that make it migraine are the sensory processing and perceptual dysfunction. Chemically, it starts deep in the brain with a cascade of dopamine, inflammatory chemicals called cytokines, and a process called sensitization, where nerves become overactive and the signals coming from those nerves being amplified. A second pathway, called cortical spreading depression, leads to slowing of certain brain regions. None of this is considered dangerous, but the symptoms can be debilitating.
What if I don’t have a headache?
Many migraineurs have migraine symptoms such as light sensitivity, sound sensitivity, motion sensitivity, and dizziness even when they aren’t having a headache. The textbook migraine starts with a 20-30 minute aura (often visual spots or distortions) followed by a severe headache, nausea, light sensitivity, and fatigue, with a hung-over feeling for the rest of the day or even the following day. Patients who follow that pattern rarely need a neurologist because there are some very safe and easy to monitor medications often prescribed by primary care doctors. As a neuropsychiatrist, most of my migraine patients have some headache but the most frightening symptoms don’t occur with the head pain leading them to worry about seizure, stroke, or even that they are “going crazy”.
I used to have migraines, but this is different.
Migraine is a syndrome that naturally evolves throughout life. Many young people have abdominal migraines (stomach pain/vomiting syndromes) long before the headaches start. Some people will have years without any symptoms and then they will return in completely different patterns. Some people have visual migraines only for a few years, then classic headaches for a few years, and then a few years of dizziness and fatigue. The most common transitions are hormone related, with the textbook syndrome starting in puberty and the headaches improving or resolving at menopause. I don’t see many textbook cases, and have had patients who only had severe migraines before puberty and after menopause. Having atypical patterns, changing symptoms, and difficult to identify triggers really is more consistent with migraine than any other disorder.
Can Migraine be cured?
The simple answer is no. Migraine is a predisposition, and patients who have migraine will always have the potential to have these strange symptoms. However, there are many ways that patients can reduce the symptoms and even resolve them completely. Medications can definitely help, but alone medications are considered effective if they reduce symptoms by 50% or more. Most of the ways to reduce migraine have to do with working on overall health and looking for specific triggers. It isn’t fun, but migraine management often requires a lot of charting of symptoms, working on changing habits, treating other health problems, and slowly finding which foods, situations, and exposures are triggers for an individual. Medications can be a great bridge, but the best way to reduce migraine requires a lot of hard work on the part of the patient.
What can trigger migraine?
Nearly everything can trigger migraine. Problems with blood pressure (or dehydration) and blood sugar (especially skipped meals) are extremely common contributors. Getting over heated, including taking a hot shower and not allowing your body to cool off afterwards, can be a big trigger. There is a very long list of foods that may be triggers, but it is very unpredictable. Avocado, pineapple, and nuts are generally quite healthy, but I’ve had patients where a single peanut would cause a debilitating headache or severe dizziness. The body responds to physical and emotional stress in very similar ways, and toxic food and toxic people can both worsen a migraine syndrome.
How can I be sure it isn’t something scary like a tumor?
Being a Migraineur doesn’t prevent the development of other medical problems, and nearly any other disorder can trigger a migraine series. However, most of the common scary brain problems like tumor, stroke, and inflammation don’t have a headache as the primary symptom. By the time other medical problems cause severe headaches, they usually have a bunch of other symptoms and exam findings that are more worrisome than the headache. Rare, life threatening, severe headaches do exist but they often come on so severely and so quickly that people go straight to the emergency department and those problems can usually be ruled out quickly on a CT scan. More subtle, but serious, problems can lead to headaches that gradually worsen, and these need to be evaluated by a neurologist. In these cases, a good physical neurological exam including an eye exam are more useful than any imaging. However, the main message is that being a Migraineur doesn’t prevent new problems from arising, so keeping track of any new symptom and having an ongoing relationship with a physician is key to identifying any new medical problem in addition to your migraines.
What medications can help migraine?
Migraine medications come in two very separate categories. The most important thing with prescribing medications is having reasonable expectations, and then trying to utilize potential side effects to get additional benefits. The first is preventive medications which are taken every day with the goal of 50% reduction in symptoms. Tricyclic antidepressants (Amitriptyline, nortriptyline, imipramine, and clomipramine) at bedtime can be used at very low doses with additional benefits from side effects of drowsiness when insomnia is present. Sodium channel blocking medications (topiramate and zonisamide) have a very broad dosing range, meaning you can get benefits at low doses and slowly increase with greater and greater benefits. It also has unique mechanisms that improves headaches from many other causes. Side effects are unpredictable but temporary in most cases. Centrally acting beta blockers (mostly propranolol) block an individual adrenaline receptor and usually have very few if any side effects in otherwise young and healthy individuals. Incidentally, it can help tremor and certain physical symptoms of anxiety like butterflies in the stomach or lump in the throat when in an uncomfortable situation. Serotonin-norepinephrine reuptake inhibitors (venlafaxine, duloxetine, and milnacipran) can be uniquely helpful in migraineurs with chronic body pain, depression, and certain types of chronic dizziness. Newer medications have recently become popular as once monthly injectable options, but they aren’t inherently more effective than the older medications for the headaches and the “side benefits” are not as predictably useful. Botox injections every three months are also very effective when properly applied, but insurance companies balk at paying for these procedures unless a patient has failed a few other medications and has greater than 15 headache days per month. Abortive medications, taken only as needed and often harmful if taken more than 2-3 times per week, include serotonin modulating medications (sumatriptan, zolmitriptan, eletriptan, naratriptan, rizatriptan, and lasmiditan) can have very unpredictable effects on any individual but for most people one of them is very effective and has very few side effects. Dopamine blocking medications (metoclopramide, haloperidol, olanzapine, prochlorperazine) can also be very helpful especially when combined with benadryl which also prevents the main potential side effects of dopamine blocking medications. The point of all this is to say that there are dozens of medications that can either prevent or treat migraine and they can be a very helpful bridge to improve symptoms while working on habit changes.
So What do I do now?
I’ve put links to a few books, websites, and apps that can help you get started. The good news, and the bad news, is that there are a thousand potential triggers and treatments for any individual. It is good because you don’t have to fix everything; just keep working on your habits and looking for triggers to eliminate until you feel better. The bad news is that there is no one size fits all approach. Even individual treatment modalities, like chiropractic medicine or acupuncture, can be very helpful for one individual and not another. Even for the same individual, one chiropractor may even make things worse and another chiropractor can help enormously. A medication that helps in one stage of life can seem ineffective later, or visa versa. I often recommend people start by looking for obvious food or exposure triggers, keeping track of how any activities or medications affect their symptoms, optimizing their routine to promote good sleep and overall health, and develop a longstanding connection with a neurologist who you can discuss any changes to your symptoms with.