Headaches are so common that almost everyone has had at least one headache, and 90% of Americans have at least occasional headaches.  I want to focus on migraine headaches today.  Why migraines?  Migraine headaches affect an estimated 20% of the women in this country, plus there are new medical insights and theories into migraine headache prevention and treatment.

Migraines are severe headaches, usually on one side of the head, lasting from a few hours up to a whole day.  They are often accompanied by nausea, vomiting, photophobia (sensitivity to light) and phonophobia (sensitivity to sound).  These symptoms usually leave migraine sufferers scrambling for a dark quiet corner to lie down.  Migraines are divided into two major types “classical migraine” those with an aura and “common migraine” those without.  Auras are preceding sensations before the migraine.  The word aura originally meant “cold breeze” in Greek.  Auras can consist of numerous sensations (visual, hearing, touch, taste, and smell).  They occur in about 15%of migraine sufferers.  The most common auras are moving lights, visual field cuts (scotomas), and sensory distortions.  Most last about twenty minutes and mesmerize patients.  The majority of migraine sufferers do not experience auras.

Migraines can be precipitated by certain physical factors.  The most common ones are skipping meals, too little sleep, menstrual periods, and alcoholic drinks. Red wine and brandy are the most common to precipitate migraines while vodka and white wine are the least likely.  Contrary to old, elitist views, migraines are not more prevalent among people in upper-income brackets.

The role of psychological stress in precipitating migraines is interesting.  On the one hand stress is thought to cause migraines, but the relief of stress “letdown” also produces migraines.  People with difficult jobs, for example, often awaken on weekend and holiday mornings with a migraine.  Likewise, at the start of a vacation, especially after examinations, students develop migraines.

Certain foods can trigger migraines as well.  The clearest example is the Chinese restaurant syndrome, where the offending agent is monosodium glutamate (MSG) and the hot dog headache, where the offending agent is the nitrites in processed meat.  Most people have also experienced an ice cream headache from eating something cold too fast.  In some this produces a migraine.  Tyramine-containing foods such as ripened cheese and phenylethylamine-containing foods like chocolate can also cause migraines.  People hooked on caffeine can suffer caffeine-withdrawal headaches when deprived of their morning coffee.  Foods are only thought to trigger migraines in about 20% of people.

The most common question I hear from patients is: what causes migraines?  The long-standing outdated theory is that the aura of migraines is caused by blood vessels in the brain constricting followed by blood vessel dilatation, which stretches the arteries and causes a pulsating pain.  Modern theories focus on the trigeminal nerve and faulty transmission of the neurotransmitter serotonin as the culprit.  We know there is undoubtedly a genetic component involved as well.  There is a family history of migraines in 90% of patients.

Concerning women, there is evidence that estrogen plays a role in migraines.  We know migraines affect women at a ratio to men of 3:2.  We also know migraines tend to start at menarche (first menstrual period), improve at menopause (end of menstrual periods) and worsen right before menstruation.  Birth control pills have been thought to worsen migraines and most women who suffer migraines are advised to stay off oral contraception.  Rather than the actual level of estrogen it is surmised to be a rapid fall in estrogen levels that precipitate migraines.  This helps explain the reason migraine headaches tend to be worse the week of menstruation.  If this is the case then taking birth control pills could actually help lessen migraine headaches in reproductive age women.  Some physicians have in fact started doing this.  One new strategy is taking oral birth control, but rather than taking inactive pills for seven days, as most birth control pills are dosed for the week of menses, taking the inert pills for only three days.  This still allows enough time for the period to start, but decreases the incidence of estrogen-withdrawal migraines.  If this sounds like a familiar pattern in your migraines then see you physician.

Several newer treatments for migraine headaches are now on the market.  Simple analgesics often abort mild to moderate migraines.  More potent migraine abortive medicines work on serotonin receptors in the brain.  These can be administered by pill, suppository, or inhaler such as Cafergot and Wigraine.  More recent medicines such as Imitrex come in both pill form and as an injection.  Prophylactic therapy is recommended if migraines occur more than three times a month.  Beta blockers such as Inderal are used for this as well as anticonvulsants and tricyclic antidepressants.  All of these meds can effect mood and personality.  Biofeedback and relaxation therapy have been shown to also help prevent migraines.  Psychotherapy has shown only very modest results.  With the advance of science and technology hopefully the sheer throbbing pain and disability that accompany migraines will soon be a thing of the past.