By JANICE BROWN, MD
Migraines are one of those ailments that has plagued humanity for as long as humans existed.
I want to preface this article by saying that it does not serve as advice on treatment of your symptoms, which may or may not be related to migraine. It is educational only, thus always seek advice from your doctor.
Despite the longevity of migraines, we still do not know what brings them on. However, we do know that there is a genetic predisposition to develop it and there is often involvement of the 5th cranial nerve (one of the newer treatments targets chemicals expressed in the ganglia nerves).
As per the American Headache Society, a group dedicated to improving the care and lives of people living with headache disorders, migraine is a chronic neurologic disease characterized by attacks of throbbing, often unilateral headaches that are exacerbated by physical activity and associated with photophobia (unable to tolerate light), phonophobia (unable to tolerate sound), nausea, vomiting and cutaneous allodynia (what would be considered a normal touch/feeling is now abnormally painful). It is so common to hear people say that they suffer from migraines. However, a diagnosis hinges on frequency of symptoms as well as ruling out other pathologies that could cause headaches with migraine features.
There are many types of migraines. For simplicity purpose, we will focus on the two most common types. Episodic migraine sufferers experience at least five attacks characterized by headaches that last 4 to 72 hours (assuming no treatment or failure of treatment) and have at least two of the following characteristics:
- headaches of pulsating quality
- more than a unilateral location
- moderate or severe pain intensity
- aggravated by or causing avoidance of routine physical activity
Headaches must also be accompanied by either nausea and/or vomiting or photophobia and phonophobia.
For chronic migraine sufferers, they have all the features listed prior, but attacks occur eight or more days a month for more than three months and can be accompanied by an aura (sensory changes that signal a migraine is about to come on).
I remember listening to a podcast that reviewed the historical treatment of women with pain whose etiology was unknown; opium was the drug of choice. I am sure a fair amount of these women probably were migraine sufferers. I am thankful that we have advanced our scientific knowledge of disease processes.
Today, the focus of treatment of migraine is first and foremost to prevent migraines for occurring. But for the acute migraine attack, immediate treatment options with proven efficacy include the triptans, ergotamine derivatives, non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen with or without caffeine derivatives. The use of opioids is not recommended.
Medications that have established efficacy in preventing migraines include antiepileptics (Valproate, Topiramate), beta blockers (Metoprolol, Propanolol, Timolol) and the triptans (Sumitriptan, Frovitriptan). Antidepressants have also been touted as being effective and include the tricyclic antidepressants (Amitriptyline) and the serotonin/norepinephrine reuptake inhibitors (Venlafaxine).
But what if someone develops intolerable adverse reactions to these drugs? Unfortunately, it is common hence the creation of injectable medications. The most popular is Onabotulinumtoxin A or Botox (it is injected into 31 sites at 7 muscle groups in the neck, face and scalp bilaterally); however, it is only approved for chronic migraine. I dedicate part of my practice to migraine management with Botox, and have special training to do so. The other injectables are 3 monoclonal antibodies approved for both episodic and chronic migraine: Fremanezumab, Galcanezumab and Erenumab. Unfortunately, insurance coverage for these three is limited.
It would behoove me as a rehabilitation specialist and a practitioner of integrative medicine to mention the non-pharmacologic modalities that can be used in the management of migraine. Not everyone can tolerate the medications, and there are people who prefer to take a more active role in the management of their health. I always advise people who prefer to go at it on their own to seek professional medical evaluation first. The research has now shown that stress, menstruation, visual stimuli, weather changes, nitrates, fasting and wine are probable migraine trigger factors, while sleep disturbances and aspartame are possible migraine triggers. Emotional stress topped the list. Thus, there is evidence-based benefit to incorporating massage therapy, yoga, tai chi, meditation, craniosacral therapy, acupuncture and/or regular exercise into your health care routine to manage your life stressors. I am a trained Physician Acupuncturist for treatment of acute and chronic pain conditions.
So, for the migraine sufferers out there, do not give up hope. There is something out there that can help; don’t be afraid to ask and control those life stressors.
References: The American Headache society.
“The American Headache Society Position Statement
On Integrating New Migraine Treatments Into Clinical Practice.”
December 10, 2018. Up To Date. Pathophysiology,
Clinical Manifestations and Diagnoses of Migraine in Adults.
About the Author
Janice Brown, MD, is a Physical Medicine and Rehabilitation Specialist who specializes in physical medicine, medical acupuncture, spasticity management and migraine management. She sees patients at the Bannasch Institute for Advanced Rehabilitation Medicine and the Grasslands Campus. To make an appointment, call 863.687.1250.