"In Super Bowl XXXII, Terrell Davis, the physically powerful running
back of the Denver Broncos and the eventual MVP, missed the second
quarter of the game due to a migraine. Davis was suddenly incapacitated
in the middle of the biggest game of his life - he was forced to the sideline
because of severe headache pain and double vision. Fortunately for the
Broncos, Davis was knowledgeable about his disease and he was able to
return during the second half to help defeat the Green Bay Packers.
Terrell Davis, a "migraineur," had learned through experience how to treat
and manage his particular migraine disease. His detailed personal
knowledge of the disease and effective treatment allowed him to
overcome his migraine."
Migraine is pervasive throughout all human populations and it affects the
famous as well as our neighbors and family. Famous migraineurs include
Julius Caesar, Napoleon, Vincent van Gogh, Robert E. Lee and Ulysses
S. Grant, Lewis Carroll, Elvis Presley, Loretta Lynn, and Whoopi
Goldberg. Migraine has affected a great many people throughout history
and across society with chronic sufferers accounting for as much as 5% of
the American population. Approximately 75% of migraineurs are women
of which about 65% say they suffer their migraines before, during, or
immediately after their monthly period. Physicians report that on average
migraine patients suffer for 3.5 years before seeking treatment.
Migraine is a Disease
Migraine is not just a bad headache it is a disease that has a vast personal
and medical impact on society. Migraine is a neurological and often a
hereditary disease that affects between 18 to 26 million Americans overall
-- with 11 million migraineurs as chronic sufferers. According to the
National Headache Foundation, migraine workplace losses amount to
157 million workdays (1200 million work hours) lost annually at a cost to
the U.S. economy of $17.2 billion dollars. Each year about $4 billion is
spent on over-the-counter pain medications for migraine. Further
aggravating the plight of the migraineur is the personal cost due to being
perceived as weak, a malingerer, a hypochondriac, or simply someone
who is unproductive. Children may miss school, fall behind, be teased,
and eventually become ostracized at school. Insurance companies may
deny reimbursement for emergency room visits or hospitalizations.
Migraines, sometimes referred to as "vascular headaches," can be
dangerous also. Migraines are not only disabling because of the severe
head pain, Migraines can also be life-threatening. To understand the
magnitude of migraine to overall health in America and to gain a
perspective consider this: "more people died from migrainous stroke last
year (1998) than were murdered with handguns." Migrainous strokes
account for 27% of all strokes suffered by persons under the age of 45
and according to the Mayo Clinic, 25% of all incidents of cerebral
infarction are associated with migraines. Migraines are serious; physician
intervention is recommended (see also the Stroke protocol).
Migraine is the disease and a "headache' is the symptom. During a
migraine, blood vessels in the head go through a cycle of extreme
constriction followed by rapid dilation. Nerve pathway changes and
imbalances in brain chemistry may cause blood vessels to become
inflamed. The actual interaction between the brain chemistry and blood
vessel dilation is not clear, but scientists believe that migraines are caused
by alterations in the nerve pathways - specifically it is the trigeminal nerve
system that is a major pathway in the brain. The trigeminal nerve pathway
carries nerve signals from the head and face to the brain. When a migraine
is triggered, the trigeminal nerve releases neuropeptides causing
inflammation and dilation of the blood vessels. Subsequently, trigeminal
nerve endings stimulate the release of more neuropeptides and a vicious
cycle is begun.
Serotonin regulates pain messages via the trigeminal pathway. There is
evidence that changed levels of serotonin (a neurotransmitter) may cause
migraines. Other common causes of migraines include complicated
combinations of "triggers" such as foods, food additives, medications,
stress, flashing lights, loud sounds, changes in the weather, humidity,
altitude, and hormonal changes including HRT (hormone replacement
therapy). Three out of four migraineurs are women and migraine is
considered a hereditary disease. If both parents have migraines, there is
a 75% chance the children will be a migraineur and if only one parent
suffers from the disease the chance is a high 50% that the child will be
Migraines are generally of two types, known as classic and common.
Typically, migraines are biased to one side of the head and often the pain
is localized. Classic migraine is characterized by an "aura" (light spots) or
other sensations that are known by the migraineur to occur just prior to
the migraine itself. Common migraine is considered any migraine not
preceded by an aura or other symptomatic warning to the patient.
Migraines often start in the teen years but are more likely to occur for the
first time between 20 and 40 years of age. Frequency may be one a year
or as often as once a week. The severity of the migraine may be
aggravated by foods and food additives such as chocolates, meats
preserved in nitrates (hams, etc.), pizza, aged cheese, alcohol --
especially red wine and beer, caffeine (especially cutting back), nuts,
fermented, pickled or marinated foods, and foods prepared with
monosodium glutamate (MSG). Medications such as birth control pills,
certain blood pressure medications, certain antidepressants, and hormone
replacement therapy can cause migraine by their use, or by starting or
stopping their use. Changes in drug therapy that may cause migraine
should be brought to the attention of a qualified physician.
In the past these migraineurs were often misdiagnosed or underdiagnosed.
Migraineurs are commonly misdiagnosed with clinical depression and
therefore the drugs that are prescribed for the depression will leave the
migraine unaffected. Follow-up may lead the physician to believe that the
migraineur is still "depressed" and unable to cope, leading to continued
unnecessary drug treatment. Dr. Fred D Sheftell, M..D., Director and
Founder for the New England Center for Headache wrote in his letter
of endorsement that, "Migraine is absolutely a biologically-based disorder
with the same validity as other medical disorders1/4 there have been many
myths perpetrated in regard to this disorder. The most destructive of
which are "'It is all in your head,' 'You have to live with it,' and 'Stress is
the major cause.'" (From Migraine Awareness Group: A National
Understanding for Migraineurs (M.A.G.N.U.M.) @ www.migraines.org.)
Not everyone in medicine has grasped the fact that migraine is a
physiological (neurological) disease and not a psychological one.
However, migraine the disease, is about to be given the serious
professional attention migraineurs have deserved. Intractable migraine
may soon be included in the Code of Federal Regulations "Listing of
Impairments" Parts A & B. This healthcare reform law is being introduced
by M.A.G.N.U.M. and U.S. Senator Charles Robb of Virginia.
Recently, during the last decade, a 60% increase in the prevalence of
migraine has been noted due to better diagnoses and reporting, and
thankfully, success at identifying and managing the disease. Because
symptoms vary among each sufferer, making an accurate diagnosis is
complicated. For those who suspect that they may suffer from migraines
or who may have been frustrated by the physicians they have seen, there
is hope for a proper diagnosis, development of an effective treatment
regimen, and overall migraine management.
Migraine Treatment and Management Begins with a Plan
Migraineurs should begin by seeking out a specialist in migraines such as a neurologist or a physician with migraine experience able to detect the specific symptoms of migraine. Migraine symptoms are easily understood even by the patient, and physicians knowledgeable about migraines will be able to help with a customized regimen of treatment. Migraine sufferers are so unique that their individual treatments are complex and varied - there is no single treatment method. Treatments for migraine include diet changes, stress management, proper sleep, hormone replacement therapy, supplements, and prescription drugs.
The first step is acknowledging that migraine is a disease and not "in your head." The next step is to see a knowledgeable physician - inquire about the physician's experience with diagnosis and treatment of migraine. Results of surveys indicate that 68% of women and 57% percent of men have never consulted a doctor for headache. Most successful migraineurs begin by keeping a daily diary usually at the direction of their physician. The diary is a written record to determine the following: the kinds of foods eaten, the weather conditions prior to the migraine, medications being taken (when and how much), and any other trigger factors that may exist prior to or at the beginning of a migraine onset. It is important to record the complete details of the symptoms such as the description and location of the pain, and treatment used. It is very important that all medications be brought to the attention of the physician. The daily diary is designed to identify and quantify possible migraine "triggers" that precede the head pain. The complexity of each individual migraineur's "triggers" can be extensive, so accurate entries in a diary must precede any therapeutic regimen. In many cases individual triggers may not cause migraine, they may need to be in combination with other stimuli before a migraine will occur.
A comprehensive migraine therapy and management plan should consider the following:
Preventative therapy - prescription medications such as calcium channel blockers, methylsergide, some antidepressants, and cerebral vasoconstrictor abortive agents. A large selection of established and new nondrug alternatives to prevent migraines is gaining in popularity. These alternatives are discussed in the next section.
Trigger management to prevent migraine attacks. Once triggering factors are recognized by the migraineur, a significant number of migraines can be avoided altogether. Examples of triggers include bright sunlight, flourescent lights, chemical fumes, menstrual cycles, and certain foods or food additives such as processed meats (nitrites), red wines (nitrites), fermented cheeses, MSG, and aspartame.
Attack - aborting techniques to control migraine once it has begun. Generally attack-aborting medication should be taken as early as possible - for classic migraineurs this is more easily accomplished. Certain agents in the general class of drugs known as cerebral vasoconstrictors are specifically designed for migraine. Such examples are Imitrex, Migranal, and Zomig. Stadol NS (butorphanol tartrate), a nonvasoconstrictive abortive agent is available in a patient-administered injection and a nasal spray. There are also a class of drugs used for the relief of symptoms of nausea and vomiting associated with migraine such as metoclopramide (Reglan).
General pain management is used to control pain once the migraine has started. These are generally classed as narcotic, non-narcotic, and NSAIDs (non-steroidal anti-inflammatory drugs) such as naproxen, ketorolac, and ibuprofen. Simple analgesics are also used such as aspirin and acetaminophen.
Some people find migraine headaches can be relieved by taking 10 to 40 mg of the beta-blocking drug propranolol. However, those with very low blood pressure, congestive heart failure, and asthma should avoid this class of drugs.
Preventative Therapy with Supplements
Nondrug alternative therapies offer effective methods to prevent migraine. For most migraineurs, prevention therapy is successful and easily managed. Physicians skilled in migraine therapy are more generally aware of the synergistic effects of nondrug therapies. Migraineurs are currently using the following supplements:
Feverfew (Chrysanthemum/Tanacetum parthenium) extracts are used widely in the UK and Germany. In a double-blind, placebo-controlled, crossover study conducted in Israel, 57 patients were selected at random and divided into two groups. Both groups were treated with feverfew in the initial phase lasting 2 months. During the second and third phase a double-blind crossover study was conducted. The results showed that feverfew caused a significant reduction in pain intensity compared with placebo. Symptoms such as vomiting, nausea, sensitivity to noise and light were also dramatically reduced.
An earlier randomized double-blind placebo-controlled crossover study was conducted with 72 volunteers. At the completion of the trial 59 patients remained and from their daily diaries and medical testing its was found that "Treatment with feverfew was associated with a reduction in the mean number and severity of attacks (and a reduction in) 1/4 the degree of vomiting. 1/4 scores also indicated a significant improvement with feverfew. There were no serious side effects." (Lancet (England) July 23, 1988, 2 (8604) pp. 189-92)
Magnesium supplementation: The role of magnesium in the pathogenesis of migraine has been studied extensively. The mechanism of action was presented in a Medline excerpted abstract. "Magnesium concentration has an effect on serotonin receptors, 1/4 NMDA receptors, and a variety of other migraine related receptors and neurotransmitters. 1/4 evidence suggests that up to 50% of patients 1/4 have lowered levels of ionized magnesium. Infusion of magnesium results in rapid and sustained relief of 1/4 acute migraine in such patients." The study also found through two double-blind studies that oral magnesium supplementation may also reduce the frequency of migraine attacks. The report concluded; "Because of an excellent safety profile and low cost and despite the lack of definitive studies, we feel that 1/4 oral magnesium supplementation can be recommended to a majority of migraine sufferers." Clin. Neurosci., 1998; 5 (1):25-7
Magnesium deficiency is used widely in Canada as a preventative regimen. At the Henry Ford Hospital, research on the pathogenesis of migraine found that these mechanisms include "1/4 aura mechanisms, 1/4 transient cerebral ischemia, and spreading depression1/4 (and) headache involv(ing) trigeminovascular and brainstem mechanisms." The study concluded that " 1/4 magnesium deficiency and abnormal presynaptic calcium channels may be responsible for neuronal hyperexcitability between attacks." (Semin. Neurol. (United States) 1997, 17 (4) pp. 335-41)
Decreased serum and intracellular levels of magnesium have been reported in patients with migraine. It was found that platelet levels of ionized magnesium were significantly lower in patients with migraine headaches.
In juvenile migraine cases with low magnesium levels, it was found that a 20-day treatment with oral magnesium picolate seemed to normalize 90% of the patients. The data suggest that low brain magnesium may be related to migraine. (University of L'Aquilla, Italy)
Riboflavin (vitamin B2) is used as a prophylactic treatment for migraine. In a study conducted at the University Department of Neurology in Liege, Belgium it was postulated that since the brains of migraineurs were characterized by reduced mitochondrial phosphorylation, riboflavin could be used because of its potential to increase mitochondrial energy efficiency and that a prophylactic effect may be realized. A group of 49 patients were studied who suffered from migraine -- 45 with common migraine and 4 with classic or "aura" migraine history. Patients were given 400 mg of riboflavin as a single oral dose for at least 3 months. Mean global improvement between the groups was 68.2%. It was concluded that high-dose riboflavin could be an effective low-cost prophylactic treatment for migraine devoid of short term side effects.
Butterbur root (Petasites hybridus) is the most recent nondrug preventative treatment to become available. In a double-blind test it was shown to be 77% effective as a migraine prophylaxis. Butterbur root has been available in Germany and is now available in the US. The dose is one 50-mg capsule twice each day.
The hormone melatonin has been reported to reduce the incidence of migraine attacks and to treat active migraine. The suggested dose is 500 mcg to 10 mg a night for people over 40. Younger people may need only 500 mcg to 1 mg of melatonin every night. Those with acute migraine seeking to "sleep off" their pain may take melatonin to both facilitate sleep and provide relief of pain.
Migraine sufferers are finally receiving the attention they have deserved. This section was expanded because the number of people in the population affected by migraine is so large and until now migraineurs were not being well served. Migraineurs now have more options open to them for the control and management of their disease. Those who suffer from migraine should begin by seeking a physician with the proper experience with migraine.
Migraineurs should follow these guidelines to successful management of their disease.
Patients should write a detailed diary of all factors that pertain to migraines. Include the types of foods eaten, the amount of sleep, the weather conditions on each day, and for women it is essential to keep a detailed accounting of menstrual periods and/or any hormonal therapy - including birth control pills. The more detail that is recorded the more successful will be the treatment and management. Be aware of triggers and their role in migraine.
Consider a preventative protocol using supplements such as feverfew, magnesium, butterbur root,
melatonin (before sleep), and riboflavin therapies as a second step to reduce the threshold of migraine onset. This kind of protocol should be used in combination with diet adjustments, trigger control, and as necessary, drugs for severe attacks requiring attack-aborting techniques.
Because migraines are also called "vascular headaches" some attention should be paid to the section on "stroke". There may be useful supplements to overall vascular protection that may be appropriate to migraine preventative protocol and to prevent a migrainous stroke.
Warning: The class of prescription drugs used for migraine treatment
may have side effects. Consult your physician for an explanation of any
side effects or interaction.
- Mygracare (feverfew)
- Petadolex (butterbur root)
- Riboflavin (Vitamin 2)
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