Migraines can come on like a train thundering into the station, or they can blow a warning whistle, announcing their arrival in time to give you a chance to react.

Suzanne suffered her first migraine as a freshman in college, and she soon learned to recognize the warning signs. She would first see flashing lights and experience numbness in one hand. Although not aware of it at the time, if she was taking notes her handwriting would trail off into meaningless scribble. Within 15 or 20 minutes these early symptoms would develop into a severe headache, so excruciating she would have to ask a friend to drive her home. Often it took a day or two before the pain and disorientation subsided.

At first Suzanne took over-the- counter medication to treat her migraine, but the pills weren’t able to control the headaches, and she found she was living in fear of the next attack. Finally, at her mother’s urging, she made an appointment with her physician.

Migraine affects some 28 million Americans, two thirds of them women. The most recognizable symptom is the recurring disabling headache, often severe enough to keep a person in bed for a day or two. Other possible symptoms include gastrointestinal upset that can take the form of nausea, queasiness, vomiting or diarrhea and neurological symptoms that might show up as sensitivity to light, sound or touch, numbness on one side, dizziness and disorientation.

Many people with migraine never consult a doctor and treat the symptoms with over-the-counter medications such as aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs) and drugs containing caffeine. When migraines are relatively mild, these medications may provide adequate relief. But over-the- counter drugs are not effective for migraines that cause more serious impairment, such as missed work days.

One survey found that 32 percent of women and 43 percent of men with migraine had never visited a doctor for their headaches, despite the fact that many admitted having poorly controlled migraine that interfered with work and overall quality of life. For these individuals an important first step is making an appointment with a doctor to properly diagnose the migraine and discuss possible treatment options including medications and lifestyle changes.

Physicians usually diagnose migraine based on a physical exam and the patient’sdescription of symptoms. It’s helpful for patients to keep a diary of headaches and to bring this to an appointment.

Factors to describe include frequency, duration and intensity of headaches; triggering events such as menstruation, stress, specific food or drinks; other symptoms such as nausea, vomiting, sensitivity to light or sound; and drugs that have already been used to treat symptoms. In the initial exam, a physician needs to rule out other types of headache as well as other possible but less common causes of symptoms.

There a number of types of drugs as well as treatment approaches commonly used to treat migraine. Lifestyle changes can also help some patients avoid triggering events.

Migraine triggers include chocolate, red wine, aged cheeses, a change either up or down in caffeine consumption, too much or too little sleep, stress, loud noise, bright lights, and for many women, the onset of menstruation.

Treatment might focus on drugs that can stop a migraine soon after it begins. This approach tends to work better for patients with less frequent migraines and when headaches are in the mild to moderate range. Another treatment approach is preventive therapy in which patients take drugs on a regular schedule. Because the drugs used for preventive therapy have a number of undesirable side effects they are generally reserved for patients with more severe migraine that results in disability for three days or more per month or those who have tried and failed acute therapy.
Stopping Migraine In Its Tracks

Recognizing a migraine early and taking medication to stop symptoms (known as abortive therapy) is a key strategy. There are a number of drugs commonly used to stop acute attacks.

Nonsteroidal anti-inflammatory drugs (NSAIDs). Physicians often start patients off on NSAIDs such as naproxen sodium (Anaprox) or ibuprofen (Motrin) at specific doses. Ketorolac (Toradol) is a new drug in this class that acts rapidly and is effective for about six hours. It is generally used to abort severe migraines.

Ergotamine is an old drug considered effective for aborting migraines, but it is used less often now because overuse often leads to rebound headaches. Dihydroergotamine (Migranal) and preparations combining ergotamine and caffeine (Cafergot) are effective for some patients.

Triptans are a relatively new class of drug developed specifically to treat migraine. There are a number of triptans on the market including sumatriptan (Imitrex), zolmitriptan (Zomig) and rizatriptan (Maxalt). As a class these drugs have been shown to stop migraine and provide significant relief to 60 to 70 percent of patients. For 20 to 25 percent of patients they provide complete relief.

There are more than half a dozen triptans on the market. Some patients respond well to one triptan but not to another, so it’s important to work with your doctor and try others if the first one doesn’t work out.

Triptans work by constricting arteries in the brain. They also constrict coronary arteries by about 20 percent, so they’re not prescribed for patients with heart problems. Possible side effects of triptans include fatigue, dizziness, and chest pain from esophageal spasms. Overuse can cause rebound headaches.

Zomig is available as a nasal spray which allows faster absorption of the drug through the nasal passages, providing relief within 15 minutes, compared with 30 minutes for an oral drug.

Almost half of those with migraine report that they are often or always awakened by migraine. Experts suggest that when the pain is already intense and patients may already be affected by nausea and vomiting, an injectable triptan may be the best approach.

Preventive therapy is used when migraines seriously impact a patient’s quality of life. The beta blocker propranolol is sometimes prescribed, but patients must weigh the risk of side effects including weight gain and sedation. Tricyclic antidepressants such as amitryptilene may be used, but again side effects are an issue. A number of other drugs are used for long-term therapy. Patients need to weigh benefits against side effects

When Suzanne consulted her doctor, her headache diary showed that chocolate was a trigger and that her migraines often coincided with her menstrual period. Her doctor suggested she eliminate chocolate from her diet and prescribed a triptan drug that she took at the first sign of a developing migraine. Although not totally free of migraines, she feels she’s back in control of her life.

REFERENCES:

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“Clinical Data: Zomig-ZMT Delivers Early and Sustained Headache Response,” Pain and Central Nervous System Week, January 6, 2003.

James Couch, “Management of Migraine,” Primary Care Reports, Part 1, July 22, 2002, Part 2, August 5, 2002.

Seymour Diamond, “When are OTC Analgesics Appropriate for Acute Migraine?” Consultant, February 2003.

Giles Elrington, “Migraine: Diagnosis and Management,” Journal of Neurology, Neurosurgery ands Psychiatry, June 2002.

Bruce Jancin, “Many Migraineurs Are Awakened by Their Headaches,” Clinical Psychiatry News, February 2003.

Bruce Jancin, “Zolmitriptan Nasal Spray Acts Fast in Migraine,” Family Practice News, September 1, 2002.

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