Migraines, Part I
This is a very personal topic for me, as I have had cluster headaches and migraines my entire life. While I was double checking a statistic for this blog, I came across a term that I’d never heard before: migraineur. Such a romantic sounding word to define a person with migraines. But when in Rome… As a migraineur, at times my headaches dictated my entire life, what I did and when I did it; or more accurately, if I did it. My cluster headaches are horribly disabling, like fireworks going off in one side of my head; bunches of them exploding at random intervals- in clusters- hence the name. Best medical intel indicates this barrage lasts 4 to 72 hours, though mine have always been a helluva lot closer to the latter than the former. And I swear that migraines and clusters somehow alter the spacetime continuum, tearing a hole in the fabric of time such that every minute lasts an hour. In any event, suffice it to say that every minute of a cluster or migraine is the Longest! Minute! Of! Your! Life! If you’re having difficulty imagining what that pain might feel like, consider yourself lucky. Most people (physicians included) don’t realize how consequential and life altering migraine can be. Migraine is the 3rd most prevalent illness on the planet and the 6th most debilitating illness on the planet, yet also the most misunderstood, underestimated, mis-/un-diagnosed, and mis-/under-treated neurological disorder, especially in relation to its symptoms and ability to incapacitate afflicted people, people. While most migraineurs have “attacks” or episodes once or twice a month, more than 4 million adults experience chronic daily migraine, which is defined as having at least 15 migraine days each month. Though it’s usually unintentional, medication overuse in treating episodic migraine is one of the most common reasons why episodic migraine becomes chronic daily migraine.
Migraine Fast Stats
-Affects 12% of the US population = 39 million people in US, 1 billion globally.
-Affects 18% of all American women, 6% of all men, and 10% of all children.
-Onset can occur at any time, but most commonly falls between ages 18 and 44.
-Approximately 90% of migraine sufferers have a family history of migraine.
Migraine and Gender
-Migraine disproportionately affects women, as 85% of chronic migraine sufferers are female, affecting 28 million women in the US.
-Fluctuations in estrogen levels are often responsible for increased severity and frequency of migraines.
-Before puberty, boys are more affected by migraine than girls, but adolescence sees an increase in the risk and severity of migraine in girls such that by adulthood, three times more women suffer from migraine than men.
-Very often undiagnosed or misdiagnosed
-Evidence suggests association with infant colic, possibly an early form of migraine.
-Occurs in kids as young as 18 months.
-50% of first migraine attacks occur before age 12.
-Occurs in 10% of school-age children 7-14 and 28% of adolescents 15-19.
-Migraines are hereditary: studies have shown that a child with one parent who suffers from migraines has about a 50% risk of developing migraines, but if both parents have a migraine diagnosis, a child’s risk of developing migraines jumps to 75%. If just a distant, non-parent relative suffers from migraine headaches, the risk for any genetically related offspring to also develop migraine is 20%.
-Childhood aged boys suffer from migraine more often than girls, but as adolescence approaches, the incidence rate increases faster in girls than in boys, and by adulthood, females with migraine outnumber males by three to one.
Costs of Migraine
-Migraine is a public health issue with major social and economic consequences.
-More than 157 million workdays are lost each year in the US due to migraine.
-US industry loses $36 billion per year due to absenteeism, lost productivity, and medical expenses caused by migraine.
-US headache sufferers receive $1 billion worth of brain scans each year.
-Over 90% of sufferers are unable to work or function normally during migraine, claiming at least a 50% reduction in overall productivity.
-24% of people living with migraine disease report headaches so severe that they have sought emergency room care.
-Medical costs of treating chronic migraine itself equal approximately $6 billion annually, but sufferers spend nearly seven times that treating the conditions often associated with it including depression, anxiety, and sleep disturbances.
-Healthcare costs are 70% higher for a family with a migraine sufferer than a non-migraine affected family.
Headaches vs Migraines: Who’s Who?
Headache refers to any pain within the head, face, or neck. This pain may be centralized to one focus or area, or it may be diffuse and emanating throughout all areas. While many people consider all “bad” headaches to be migraines and/ or use the two terms interchangeably, this is inaccurate. As I’ll explain next, migraines are a type of primary headache, so that means that all migraines are headaches. But the reverse, that all headaches are (or can be) migraines, is not true.
Headaches: Three Main Categories
Category 1) Primary Headache
Category 2) Secondary Headache
Category 3) Painful cranial neuropathies and other (facial) pain
Primary Headache: Refers to a headache that occurs on its own. The three major types of primary headaches are migraine, tension, and cluster.
Secondary Headache: Refers to a headache that is caused by something else, such as ‘medication overuse headache’ which is caused by using migraine medication over a long period of time. This is also known as rebound headache, a very disabling headache that is basically the result of taking meds for frequent migraines over an extended time period, even when taken as directed. I have a chronic daily migraine patient that at one time had 22-plus migraine days per month, and she got locked into a gnarly rebound headache. They’re super painful and the only way to treat them is to discontinue the causal migraine med… and that’s a problem if that’s the only thing that’s ever helped. Thankfully, these days we have more options for both preventing migraine and treating it when it rears its ugly head. But I’ll tackle all of that next week. For now, continuing on with migraines.
Painful Cranial Neuropathies and Other Facial Pain: Refers to headaches/ pain arising from, or related to, nerve abnormalities in the upper part of the head and neck. For example: a whiplash injury or disk injury with nerve damage (ie neuropathy) leading to inflammation and pain.
As opposed to “bad” headache, migraine is a neurological disorder whose accurate diagnosis requires the presence of specific symptoms and certain qualities.
Requisite Migraine Symptoms
Migraine attacks are accompanied by one or more of the following disabling symptoms: visual disturbances, nausea, vomiting, dizziness, extreme sensitivity to sound, light, touch, and smell, and/ or numbness/ tingling in extremities or face.
-(Mostly) occuring on one side of head
-Pulsating pain quality
-Moderate to severe pain intensity
-Made worse with physical activity
-Nausea and/ or vomiting
-Sensitivity to light (photophobia)
-Sensitivity to sound (phonophobia)
Migraine: Ancillary Symptoms
The presence of one or more disabling symptoms (listed above) are required for diagnosis of migraine, but many other ancillary symptoms can be (but aren’t required to be) associated with migraine. These can include abdominal pain, fever, dizziness, and fatigue.
Many things under the sun can trigger a migraine. Triggers are very individualized, they’re not the same for everyone; what’s more, what causes or triggers a migraine in one person could relieve it in another.
Migraines are commonly triggered by environmental factors, and these can be external factors like eating certain foods or taking certain medications, or internal factors like stress or blood sugar changes.
Triggers may be hormonal, behavioral, physical, emotional…they vary, but there are common themes. Below are some of the usual suspects, along with ways to avoid them.
Certain light patterns, loud sounds or strong smells
Alcohol: Red wine is a common and well recognized migraine trigger, but other alcoholic drinks can also cause migraine.
Weather changes: Even small changes in barometric pressure can cause migraine, especially those associated with storms and hurricanes. If weather is a trigger for you, ask your doctor about the possibility of taking medication at the first sign of atmospheric change.
Bright light: It’s believed that light “turns on” certain cells that can trigger pain. Wearing sunglasses indoors can increase your eyes’ sensitivity to light, so save your shades for outside. You can also try wearing FL-41 boysenberry-tinted lenses, which have been shown to minimize the triggering effect of light.
Caffeine: Caffeine is unusual in that both its presence, and its withdrawal, can trigger a migraine; and it is a common component of prescription and over the counter migraine remedies. If you have migraine, your best bet is to not vary your regular coffee/ tea routine and caffeine intake, even on weekends.
Processed meats and cheeses: Some people may be sensitive to tyramine, a substance found naturally in some foods: especially aged and fermented foods like some cheeses, kimchi, smoked fish, soy sauce, caviar, cured meats, and some types of beer.
Computers: Poor ergonomics and the screen’s bright light can combine to trigger a migraine. Practice good posture and take frequent stretch breaks.
Dehydration: Not consuming enough liquids causes blood volume to drop and decreases blood flow to the brain, which can trigger migraine. Low electrolyte levels and/ or the loss of electrolytes are also common culprits. Aim to drink at least eight 8-ounce glasses of water a day.
Hormonal changes: Migraines affect women disproportionately, which could be partly due to fluctuations in estrogen levels. Talk to your doctor about whether you should take NSAIDs a few days before menstruation.
Hotter temperatures: The risk of migraine jumps almost 8% for every 9-degree Fahrenheit increase in temperature. Stay hydrated and consider avoiding outdoor activities during the hottest seasons and/ or times of the day if you’re sensitive.
Anatomical Migraine Triggers
Rather than an environmental trigger, these are four distinct external sensory nerve regions in the neck and face that can act as anatomical migraine triggers. Patients who are subject to one or more of these triggers will feel as if migraines are emanating from these specific areas. The common trigger areas are 1) the area above the eye/ forehead, 2) the neck, 3) the nose (felt behind the eye), and 4) the temple(s).
Two long term treatment options act against these trigger points:
-Botox injections will relax all of these trigger sites except for the nose.
-Trigger point surgery will physically release these nerves.
More on these next week.
Nearly one in four American households includes someone with migraine. This exceptionately high incidence rate means that every American knows someone who suffers from migraine (whether they’re aware of it or not) or they themselves struggle with it. Despite this high incidence rate, migraine is misdiagnosed more frequently than it is accurately diagnosed, most often as tension headache or sinus headache. Seriously? Misdiagnosed as often as it’s accurately diagnosed?! Scary, no? Blows my mind… but check out this this cute little factlet: 60% of women and 70% of men with migraine are misdiagnosed… period, end of story. But getting an accurate diagnosis is critical for arranging the right treatment, as some medications indicated for specific migraine types can actually be dangerous to people with other migraine types.
The science behind migraines can get complex people… we are dealing with the brain after all. But understanding exactly what’s occuring during a migraine can help in receiving the proper diagnosis and treatment options, as when it comes to migraine, it’s always better to err on the side of caution. Why? Aside from the fact I mentioned above, about how certain type-specific medications can be dangerous if utilized incorrectly… Well, if a migraine is not properly diagnosed and treated, an individual will typically experience recurrent and increasingly severe symptoms, including extreme head pain, fatigue, nausea, vomiting, and increased sensitivity to light and sound. Not only do the symptoms of the migraine become more severe when left untreated, the migraine tends to become more difficult to treat as it becomes more prolonged. In addition, the neurological disorder as a whole tends toward the progressive, such that subsequent instances of migraine and associated symptoms generally become more severe with time. But even setting aside the health and medical implications, there’s simply no reason to suffer pain needlessly and allow your life to be totally disrupted in the (horrifyingly) special way that only migraines can. Primary care physicians are often responsible for a preliminary diagnosis of migraine headaches, but it is strongly suggested that patients suspected of having migraines see a neurologist for a full workup, including a neuro evaluation and imaging studies if/ when indicated. Knowing exactly which type of migraine you have is essential to finding the safest and most effective treatment for you.
What’s Up with the Migraine Brain?
What’s happening in the brain to create such an excruciating storm? A migraine typically starts with a trigger, which is often incoming sensory information that wouldn’t bother most people… maybe opening the door to a bright sunny day or walking into Starbucks with the intense smell of coffee beans roasting. But a migraine brain is essentially damaged, so it doesn’t respond to stimuli the way a “normal” non-migraine brain does. So during a migraine, these incoming stimuli feel like an all-out assault.
Simple mechanistic view of a migraine brain: upon presentation of a trigger, the migraine prone brain produces an oversize reaction to that trigger, and its electrical system immediately starts (mis)firing on all cylinders. All of this electrical activity causes a change in blood flow to the brain, which in turn affects the brain’s nerves, causing pain and other associated symptoms. About 25% of migraine sufferers have an associated visual disturbance called an aura, which usually lasts less than an hour. In 15-20% of migraine attacks, other disabling neurological symptoms occur before the actual head pain, while in some other cases of migraine, these neurological symptoms occur without any actual head pain. More on these specific phenomena to come.
Migraine: Progression of Stages
Migraine attacks can progress through four distinct stages: prodrome, aura, attack, and post-drome. It’s important to note that not everyone with migraine goes through any or all of these stages.1) Prodrome Stage
Beginning one to two days before a migraine, some subtle changes that may warn of an impending migraine include:
-Mood swings, depression to euphoria
-Increased thirst and urination
-Frequent yawning2) Aura Stage
Reversible symptoms or sensations of the nervous system that might occur before or during migraines or other neurological events. They’re usually visual symptoms, but they can also include other types of disturbances as well. Each symptom usually begins gradually, builds up over several minutes, and lasts for 20 to 60 minutes before fading away.
Examples of migraine aura include:
-Visual phenomena, ie bright spots, flashing lights, and zigzag lines
-Pins & needles sensations in extremities
-Weakness or numbness in face or single side of the body
-Auditory symptoms: noises/ music
-Uncontrollable movement,shakes/jerking3) Attack Stage
A migraine usually lasts from 4 to 72 hours, depending on its severity and if/ how it’s treated. Migraine frequency varies from person to person; may occur rarely or strike many times each month.
During a migraine, you will likely have:
-Pain on one side of your head, but can occur on both sides.
-Pain that throbs or pulses
-Sensitivity to light, sound, smell, touch to varying degrees.
-Nausea and vomiting4) Postdrome Stage
After a migraine attack, you might feel drained, confused, hung over, and moody for up to two days. Some people report mood swings from elation to despair. Sudden head movement may briefly bring on pain once again.
Traditional migraine treatment involves a combination of medications, lifestyle changes, and potentially, alternative therapies like acupuncture. Migraine medications are usually divided into three groups: preventative, abortive, and rescue.
Preventative medications: Captain Obvious says that preventative meds are generally taken daily in an effort to avoid getting (aka prevent) a migraine, as they are intended to reduce the frequency and severity of migraine attacks.
Abortive medications: Abortive meds are generally the first-line, acute medications meant to be taken when someone gets a migraine. Unlike pain medications that only mask the pain for a few hours, abortive medications work to stop the migrainous process itself and end the associated symptoms, and they are most effective when taken as early as possible in a migraine attack.
Rescue medications: Rescue meds are often pain medications, and are intended to be used if and when abortive meds fail, or when abortive meds might be contraindicated due to allergy, side effects, or pregnancy in some cases. Other types of rescue meds can be used to help people relax and get through a migraine by reducing nausea for example. Rescue meds don’t have the ability to abort a migraine, but the idea is they may mask the pain for a few hours while the migraine runs its course.
While most migraineurs experience “attacks” or episodes once or twice a month, more than 4 million adults experience chronic daily migraine, which is defined as having at least 15 migraine days each month. Though it’s usually unintentional, medication overuse in treating episodic migraine is the most common reason why episodic migraine becomes chronic daily migraine. About 25% of migraine sufferers have an associated visual disturbance called an aura, which usually lasts less than an hour. In 15-20% of migraine attacks, other disabling neurological symptoms occur before the actual head pain, while in some other cases of migraine, these neurological symptoms occur without any actual head pain. More on these specific phenomena to come.
Migraines are like ice cream… they come in a variety of different ‘flavors’ that ‘taste’ different to each of us. The basic ingredients may be the same, but the symptoms and severity vary widely by person, age at time of attack, and length of time they’ve been experienced. It’s always possible to have multiple migraine types, so talk to your doctor about your symptoms if you’re uncertain.
According to the ICHD-3 the International Classification of Headache Disorders, there are seven types of migraine, with diagnostic criteria based on scientific evidence. It should be clear by now that not everyone will have ‘typical’ migraine, so please view this information as a guide only, and not as a replacement for physician evaluation. Note that some references created different divisions.
ICHD-3 Seven Migraine Types:
1. Migraine without Aura
-Formerly called common migraine
-First & most widespread type of migraine
-Main symptoms: throbbing pain that starts on one side of your head (as opposed to starting behind the left eye where most migraines tend to start), moving around tends to make the pain worse, and it’s normal to feel nauseous, dizzy, and sensitive to light and sound.
-Duration 4 to 72 hours
-Prodrome brings: difficulty speaking or reading, increased urination, irritability and depression, food cravings, frequent yawning, muscle fatigue or tight or stiff muscles in the neck and shoulders, nausea, constipation, or diarrhea, poor concentration, sensitivity to light, sound, touch, and smell, and trouble sleeping.
-After the 4 to 72-hour headache attack, hits, postdrome with “migraine hangover” can make you: feel moody, feel sensitive to touch, especially in areas where the headache was focused, feel tired, have stomach issues
Here’s some more info about how the common migraine progresses.
2. Migraine with Aura
-Formerly called classic migraine, focal migraine, complicated migraine, aphasic migraine, migraine accompagnee.
-Main symptoms: visual disturbances before migraine begins, followed by common migraine symptoms
-Duration of visual disturbances: ranges from a few minutes to a full hour, usually before the actual migraine attack starts.
-Duration of migraine: 4 to 72 hours.
-25% of people with migraines also experience aura.
-Aura can cause visual disturbances, neurological symptoms, and unpleasant feelings like a numb face or tongue, or pins and needles that spread across body.
-ICHD3 breaks these down even further into four types: typical aura, brainstem aura, retinal aura, and hemiplegic aura.- ICHD-3 Subtype 1: Typical Aura
-Typical aura brings visual symptoms, inc temporary blind spots, geometric patterns, zigzag lines, stars or shimmering spots, and flashes of light. – ICHD-3 Subtype 2: Brainstem Aura
-Brainstem aura involves symptoms that seem to originate in the brainstem, like difficulty speaking, double vision, ringing ears, or vertigo.- ICHD-3 Subtype 3: Retinal Aura
-Retinal migraine (a.k.a. ocular migraine and optical migraine) differs from a typical migraine with aura in that you typically only have visual disturbances in one eye. Because they cause visual issues, they’re sometimes called “ocular migraines” or “optical migraines.”- ICHD-3 Subtype 4: Hemiplegic Aura
-Hemiplegic migraine involves symptoms like motor weakness or a loss in the strength of your muscles, usually on one side of your body; you may also struggle with language and feel confused or tired.
-Like with typical aura migraines, these symptoms usually last only minutes, and usually for no more than an hour, though may be longer for some; but memory loss and problems with your attention span can linger for weeks or even months. -Sometimes, hemiplegic migraines can cause more serious issues, like seizures, coma, and long-term problems with brain function and body movement.
-These facts might be frightening to read, but these types of migraines are rare and the extreme side effects are uncommon.
3. Menstrual Migraine
-Also called “hormonal migraines.”
-Pretty much as they sound: migraines in women triggered by hormonal changes.
-Duration: 4 to 72 hours
-ICHD-3 notes that menstrual migraines can happen with aura or without, and usually strike just before or at the beginning of your period.
-If you experience migraines during this time in two out of three periods, they are likely to be menstrual migraines.
-According to the US Office on Women’s Health, menstrual migraines might be triggered by the quick drop in the hormones estrogen and progesterone that happens before your period starts. -Affect about 7% to 19% of women
-Most women who usually get menstrual migraines also have other migraine types at other times.
-Frustrating but good-to-know: menstrual migraines tend to last longer than your average non-menstrual migraines, and might be more painful.
4. Vestibular Migraine
-Main symptoms: vertigo, dizziness, and trouble with balance
-Duration: ranges from a few seconds to a few days
-Surprisingly common, affecting 30%-50% of migraine sufferers.
-Vestibular migraines can give you sudden bouts of vertigo, where you see the world spinning or feel like you’re moving when you’re not.
-These bouts of vertigo might not always occur like aura symptoms, ie right before a headache sets in…
-These vertigo bouts may happen for just a few random seconds or may even happen intermittently for a few days.
-Sometimes this occurs when you move your head too quickly or when you see something particularly stimulating.
5. Migraine without Headache
-Main symptom: no actual headache pain, thank you Captain Obvious.
-Duration: each aura symptom can last 1 hour or less
-If you get aura symptoms but never get the telltale splitting pain in your head, you might have a migraine without a headache, sometimes known as a “silent migraine,” “painless migraine,” or “acephalgic migraine.”
-ICHD-3 simply calls them a “typical migraine with aura without a headache”
-An acelphagic migraine, or a migraine with no pain, can have all the same symptoms of migraines with aura, except the headache just never shows up!
-Interestingly, migraines without headaches become more likely as you get older. Something to look forward to!
6. Abdominal Migraine
-Main symptom: stomach pain instead of a headache
-Duration: 1 to 72 hours
-Migraine can cause extreme pain in your abdomen rather than your head; this is an abdominal migraine.
-Causes pain near the belly button, can make you feel nauseous, give you no appetite, cause vomiting, and make you look pale.
-This is more common in children than adults, but 2/3 of the children with a history of abdominal migraine actually end up developing migraine headaches as adolescents.
-Just like common migraines, abdominal migraines can be triggered by things like stress, bright lights, and food additives like monosodium glutamate (MSG). -Typically treated using the same medications as standard migraines with headaches.
7. Status Migrainosus
Main symptoms: a migraine that that lasts more than 72 hours
Duration: 72+ hours
-Basically a migraine (with or without aura) that lasts longer than the standard max of 72 hours.
-ICHD-3 recognizes status migrainosus, and points out that overusing migraine medications could be a likely cause
-Other triggers can bring on Status Migrainosus, like: changes in food and sleep habits, changes in medication, changes in weather, head and neck traumas, hormones, illnesses like the flu or a sinus infection, sinus, tooth, or jaw surgeries, and stress.
-Status migrainosus can be extremely frustrating; called a “trick candle on a birthday cake,” because the headache might briefly respond to medication, just to flood back randomly after a break.
Next week I’ll get into more specifics on these seven migraine types, along with the various medications used to treat the specific types and why they’re used. Also lots of intel on non-pharma methods of managing migraine, including devices.
That’s all for today folks. Please make sure to share my blogs and YouTube vids with friends and fam, and like, subscribe, and comment people! As always you can find my book Tales from the Couch on Amazon.com.
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Thanks and be well!