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The main thing to know is that migraines can be very complicated – not only in their causes but also in their treatment. Sometimes it’s a multi-factoral approach. The first medication I try may or may not be helpful and we may have to meet multiple times in order to actually help you. Sometimes I may also ask you to put forth some effort in making sure that your lifestyle is not a cause and making sure that you’re keeping a headache diary to see if I’m helping or not. We also need to make sure that we’ve ruled out some of the other common headache disorders and make sure that those are not mimicking migraine and I don’t need those medications to treat what you currently have. I may ask you to do some diagnostic testing and treatment options as a trial to rule out other headache disorders. The most common one I’m asked about is medications and I break that down into two categories: abortive medications (which people think of as “what can I take right now because my headache is killing me?” and then prevention or prophylactic therapies (which are something you take every single day to ideally decrease the frequency and severity of the headaches.)
Abortive medications would be Triptans – these are the kind of gold standard. Things such as Imitrex, Maxalt, Zomig, there’s 9 different Triptans on the market. Even if you failed one, it doesn’t mean that you would fail or have a side effect to another and it may take a while to figure out which one is the best for you. Other options: maybe nonsteroidal anti inflammatories – things you have in the cabinet: Ibuprofen, Naproxen, aspirin, things of those nature. However, you have to be careful about those medications as they can cause a bounce-back or rebound headache if you use them too often. Most commonly, I see people prescribed Fioricet or Fiorinal (the generic name is Butalbital with other ingredients along the list.) You have to be very, very cautious with this medication because it has multiple medications in it. It’s the most common medication that can cause a bounce-back or rebound headache. I’m not saying that patients are addicted or dependent on this medication, but the brain gets used to having those chemicals and it can actually make the headache worse long term. Actually, so can Excedrin. Other options for treatment include physical therapy, which can be sometimes beneficial – it kind of depends on the patient and where their pain is at. I get often asked about manipulation or chiropractic treatment, which is fine, except that we don’t like fast manipulation of the neck (so only gentle manipulation) and I’m very cautious about manipulation the neck whatsoever because it depends on arthritis and other conditions of the neck. I’m very cautious to ever recommend that. Fast manipulation of the neck can actually increase your risk of stroke. I also do some therapies here in the office, sometimes if you’re having a very bad migraine just to try and break that headache cycle. Those can include a short burst of steroids that I may prescribe. Those may include coming into the office for an injection such as Toradol or an Imitrex injection or even a nausea medication. Those may also include coming in for nerve injections, so sometimes I’ll actually give a shot in the various places that you’re having pain and try and actually numb up that nerve temporarily.
Testing for migraines is variable. It may depend on what we’re trying to rule out, more than actually diagnosing the migraines. Sometimes we’re trying to make sure that there’s nothing else that could be causing the headaches or head pain more than anything else. Such as strokes, tumors, blood, fluid, stuff like that in the brain. I do a variety of diagnostic testing. Some of it is very basic just to make sure there’s no problems with kidney function, thyroid function, you’re not anemic, any of those things that may not necessarily cause headaches, but it certainly is going to aggravate them or make them worse. Basic testing of the brain, including usually an MRI of the brain – usually with contrast to make sure there’s nothing obvious causing the headaches – strokes, lesions, brain tumors, things like that.
I may or may not do an MRA of the brain and/or the neck, which is blood vessels – to check the blood vessels of the brain and neck. That depends on the history the patient gives me. I sometimes do an MRI of the cervical spine (the neck spine), again – it depends on the history the patient gives me. If their headaches tend to come from the neck upward or are triggered by certain neck movements, I may consider doing that. I may consider doing a lumbar puncture depending on the history the patient gives me or the type of headaches they’re having – positional, stuff like that. If it’s an atypical headache or there’s a very strange presentation, I may consider doing an EEG. The diagnosis is made basically by clinical exam and ruling out any other possible causes to headaches or head pain.
The risk factors for migraine are typically: being of childbearing years, being female, obviously (since 75% of the people that have migraines are women), genetics – if you have two parents that have migraines, you have a 60% chance of getting migraines. If you have one parent, I think it goes down to about 40%. But again, it may or may not actually occur – something has to turn it on. If you have some sort of trauma, neck or head injury, the risks increase. Although that’s not necessarily 100% – it kind of depends. Decreased sleep can sometimes turn on migraines as well. Lifestyle habits, such as not drinking or eating consistently.
There are lots of organizations available to help migraine patients, but mostly it’s just for education. There is American Headache Society, which is a national group of providers that are interested in helping patients and they have a provider website as well as a patient website. There’s National Headache Foundation, again – mostly patient education on that website. If a patient ends up getting botox, Allergan (the company that makes Botox) has a website available for patients to read about. Even Mayo clinic has a great website about headaches.
The causes of Migraines are very difficult to tell. We don’t fully understand them. Part of that is because enough research doesn’t go into migraine and headaches in general – I can’t just say migraines. We used to believe it was all vascular, meaning too much blood was rushing up to the head. We now realize it’s only a tiny portion of it and it’s mainly a chemical or neurotransmitter. A chemical P (or substance P) is released into the head and that basically turns on the nerves and causes more pain. There’s a small portion of blood flow issues, but we don’t fully understand all the causes related to it. We also don’t fully understand everything that turns off in a migraine.
Home remedies are huge and all-encompassing. It is anything from just putting ice on the back of your head or the area that may hurt during a migraine attack to some of the herbal remedies that are actually recommended by American Headache Society. Those herbal remedies include things you may have heard about or read about. Those include Magnesium, Vitamin B2 (which is also called Riboflavin), Coenzyme Q10, Feverfew (which coincidentally was not found to be effective, but everybody asks me about it), Butterbur Root – a whole variety of them. I have a very specific handout that I give patients if they’re interested in herbal remedies and the specific dosing and everything recommended by American Headache Society.
In addition, massage was found to be helpful (although cost can sometimes be prohibitive.) This, again, is a prevention measure, so you have to plan on basically doing this anywhere from once a week to once every two weeks depending on where your pain is. If there’s a lot of neck pain associated with the migraines, then that has to be a planned prevention method that you’re doing on a continuous basis. Same thing with acupuncture. Acupuncture was found to be effective, but it’s a prevention method. So it has to be done usually in the very beginning, almost as a titration, done about once every week for about two or three months and then decreased to once every two weeks or maybe once every three weeks. But it is a planned prevention medicine that has to be almost continued constantly.
Prevention options: there’s four standard categories. Some of them have FDA approval and some don’t, and that’s mainly because we use them clinically but the companies that had the drugs either didn’t seek FDA approval or the medications are just too old to have bothered to go to the FDA for FDA approval. You may hear of antidepressants, most specifically tricyclic antidepressants – very low doses. These are very commonly used to treat migraine. At night, amitriptyline or nortriptyline, usually. Beta blockers – Propranolol is probably my favorite but you may hear of Atenolol or Metoprolol. Again: pretty low doses because in higher doses those can have side effects. Seizure medications, so these are anti-seizure medications that have some properties (again, at lower doses) to help with migraine. Typically Topiramate, Depakote, or sometimes Gabba Penton. And then the last one (and this is actually typically my last choice, although it works fantastically) is botox. The reason is that it’s fairly invasive. It requires multiple injections and multiple appointments.
Preparing for your appointment: I ask a large variety of questions and sometimes patients are a little overwhelmed with the complexity of my questions, but I tend to ask when the migraines actually started, at what age, what type of headaches you may have, including any variety of different types of headaches. I may ask how frequent they are, where the pain is located, if anything obviously triggers them, if anything obviously makes the headaches better, what kind of medications you take, what kind of medications you may take to help the headaches if you’ve tried anything in the past to prevent them ( including even in the past 10 years or more.) If you’ve had any testing, if you’ve had any past medical history including even a head injury that may have triggered the headaches. I also want to know about your family’s history. I would love it if patients brought a medication list, including the medications they’re currently taking and the medications they’ve tried and failed in the past. That would help me tremendously so that I don’t repeat history and make them try medications over and over again that they’ve already failed. I would love it if they brought me a headache journal telling me what their headaches are like over the past two, three, four months. I don’t need anything complicated. Just write down: “It’s a 7 out of 10.” “It always hits in the morning.” “It always hits when I’m exercising” or something like that. Or “it always hits around my menstrual cycle.” Some sort of pattern so that I can figure that out.
The latest research on Migraines is a little bit sad. There’s not enough research being done in migraines. The money is not going into migraines compared to all of the other disease processes. So there’s not much being done from a prevention standpoint. There is some research going into a board of medications and, in fact, a new medication came out last week – it’s not actually a new medication but a new delivery system. It’s a Triptan (like we talked about) but in a patch form, so that should be interesting. A lot of the medications that are being studied now are different types of abortive medications to work on those neurotransmitters that we talked about that cause some of the migraines.
Headache is certainly one of the most common come pain complaints that afflicts humans. There are many, many causes. Stress – the so-called tension headache. It often turns out that tension headaches are more complex, but certainly people under a lot of stress or pressure often experience headaches. Migraines are very, very common. This is essentially a malfunction of the nerves in the surface of the brain and the cortex of the brain, and at times the malfunction can even be observed or witnessed by the patient because they may get what we call an aura – flashing lights in their vision or waves of out-of-focus vision. Sometimes they get other sensations that are a sign that the nervous system is malfunctioning and that often will trigger a cascade effect that will lead to the patient having a fairly severe headache.
For patients who have migraines fairly often (let’s say: once a week – often in our field, we’ll look at whether or not they have 4 days a month of significant migraines that really impact the quality of their life) then for these patients, they’re smarter to get on medicines that prevent the migraine as opposed to using the medicines to treat it once it’s happened – to what we call abort the migraine or abortive medicine. Primary care doctors, neurologists, pain doctors – lots of doctors can help patients find medicines that might prevent the migraine. There’s a variety of medicines that are used for this. One of the nice things about preventing the migraines is that it doesn’t trigger these rebound headaches that can occur with the short acting abortive medicines. For the rare headache (once a month, maybe twice a month) abortive medicines are okay, but when they’re used frequently, they really have the problem of developing these rebound headaches – increased vulnerability to a headache as soon as the good effects have worn off. Included in this are Tylenol, Ibuprofen, Naproxen, Aleve, Fioricet, Fiorinal, the Triptan medicines, medicines like Imitrex, etc. There are many different medicines that are short acting for the purpose of aborting the pain of a headache, and if they’re used very sporadically, they too can be good, but when they’re used frequently, they increase the headache problem.
Often patients with headaches are concerned that they might have a tumor or some other problem in their brain that is causing the headaches. Doctors will judge whether or not this is necessary based on a variety of of symptoms and and what we call signs. If the patient has any signs that there is a neurologic malfunction (which the doctor will pick up on examining the patient) then the patient will need an MRI of the brain. If there’s a real new change that there are headaches that are much more severe or the patient never used to have headaches and now suddenly has headaches, then often the doctor will make the decision that they should check and make sure everything is fine with a brain. But many patients have had sporadic headaches throughout their life and if there’s no real change, then there’s not going to be a need to get an MRI.
One of the most troublesome causes of headaches is what we call “rebound”. The patient may be using medicines to treat headache – aspirin, Motrin, sometimes it may be a more sophisticated medicine prescribed by their doctor – but so many of these medicines will cause the patient to become more vulnerable to a headache after the immediate benefits of the medicine have worn off. So we find that patients who use a lot of these short-acting, pain-relieving headache medicines often drive themselves to get more and more headaches. What started as a once-a-month migraine may (over a period of a few years) evolve into daily headaches, driven by their use of medication. It’s not only the typical medicines. Caffeine can do it also, and it’s not the caffeine itself, but again, it’s when the caffeine wears off and people have essentially caffeine withdrawal and they get a caffeine withdrawal headache. There are people who have caffeine in the morning and by the evening they’re having a headache because they’re in caffeine withdrawal. Helping patients discover these problems and modify their diet, modify their use of medicines, is often tremendously helpful in reducing the amount of headache that they deal with.
Headache is one of the pain conditions that really can respond wonderfully to a healthy lifestyle. Everything your mother told you to do – she was right. Eat three square meals a day – don’t skip meals. If you have big gaps between meals, you might need to have a snack. Exercise regularly. Exercise at approximately the same time of day every day. It doesn’t have to be a lot. Even 20 minutes of exercise makes a difference. Sleep regularly. Having a fluctuating sleep schedule is a real trigger of headaches for patients who are susceptible to headaches. Having a regular sleep schedule is really important for the patient who is prone to headaches. You want to avoid variation of the sleep schedule – both the bedtime and wakeup time.
My name is Amy Tees. I’m a nurse practitioner at Center For Neurosciences. I work under Dr Noland. I do general neurology, but I prefer to see migraine patients – it’s my sub-specialty. I also have migraines, which is part of why I chose to work in the sub-specialty. I have been doing this for about 10 years. I was a neurotrauma ICU nurse at TMC prior to doing this, which is part of what drove me into this profession as well. I am married and I have two children. I work pretty hard – I don’t have a lot of hobbies aside from reading and both of my children play sports, so we are constantly all over the place with our children, watching them play sports. My husband is a firefighter in town and I kind of lead a crazy, harried lifestyle. I got my undergraduate degree from the University of Arizona in 1997. I worked as a nurse for quite a few years and then I went back to school and got my master’s degree from the University of Arizona as well and graduated in 2004. I do have a certification in family practice, but I don’t practice in family practice anymore. I did for quite a while. There is no certification in neurology.
A migraine is not easy to define, but there is the basic definition, which changes every few years. American Headache Society and International Headache Society has defined that for us and you’ll hear different ways it’s defined and sometimes that’s even confusing for patients. A migraine with aura, migraine without aura, a typical migraine, or even hemiplegic migraine – all these different topics and it just kind of defines as to what are the associated symptoms, or the things that go along with the migraine. But the defining thing is pain. It doesn’t have to be one sided or both sided. We used to kind of believe that – it can be both or one sided. We define that as typically throbbing type of pain or a pulsating type of pain. It has to be fairly disabling. It’s not what people would call a low-grade pain, it has to be fairly disabling where you don’t feel like you can really go on with your day.
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