Today I will be covering the topic of migraine headaches. This post was a special request, and a little while coming, because to be honest, I am not a headache specialist! I do treat some headaches, but more often I see tension headaches arising from neck/shoulder tightness or referred head/scalp pain from arthritis in the neck. So this was actually a learning opportunity for me too. Headache specialists are often neurologists that have undergone extra training specifically in headaches- similar to how I did extra training in pain management after anesthesiology training.
I’ll talk first about what migraines are, who they typically affect, and what we think causes them. Then I’ll move onto treatment. Treatment is divided into acute/abortive therapies, which is when we are trying to stop a migraine that is already happening, and chronic/preventative therapies, which try to prevent the migraine from happening in the first place.
Migraines are a specific type of headache that are severe, and can be throbbing/pulsing. They typically occur on one side of the head, and often are accompanied by a prodrome, which is a group of early symptoms that are followed by a migraine. Some patients will experience an aura, either right before or during the migraine. An aura is usually a visual or sound disturbance that the patient perceives, but can involve other neurological symptoms as well. Nausea/vomiting and light/sound sensitivity are typically associated with an attack. Migraines can last for hours to days, and can truly be debilitating. Afterwards, many people feel extremely fatigued and drained.
To be honest, we are still not sure exactly what causes migraines. It may be an interaction with the brainstem and the trigeminal nerve, a nerve that goes to the face and jaw. It may also involve chemical imbalances in the brain. Many people are able to identify triggers of their migraines by keeping a journal. Common triggers include lack of sleep, certain foods, alcohol, stress, and hormonal shifts. Migraines are more common in women, and can run in families. It affects about 15% of people from age 22-55. It is a huge cause of disability (lost time from work) as well as associated conditions like depression and anxiety. Patients tend to start getting migraines in childhood/adolescence, and the most common time for women to suffer from migraines is in their 30’s. If the migraines are hormonally triggered, sometimes they improve with menopause.
Acute treatments for migraines include over the counter painkillers like Tylenol and Advil. There are also special over the counter painkillers for migraines, which include caffeine. These can be helpful when used sparingly, but if patients are using them too often, side effects can occur including stomach/kidney issues and worsening of the headaches, known as rebound/medication overuse headache. Triptans are a class of abortive medication that are available with a prescription; they act by modifying chemicals in the brain that affect blood vessels.They aren’t safe in patients with certain other medical issues like heart problems. Ergots are another class of prescription migraine medications; they are less effective than triptans and can have unpleasant side effects of nausea/vomiting (not great if you already have this with the migraine!). We often will prescribe anti-nausea medication in the acute phase, and sometimes steroids are added to treatment.
Migraines are considered chronic if they affect a patient more than 15 days out of the month for 3 months. When patients have migraines more than 4 days a month, very severe attacks or attacks that last longer than half a day, this is a sign that a patient needs a preventative therapy. The first step to try to prevent migraines is to avoid triggers. This involves keeping a headache diary and trying to find patterns of what came before an attack. A common preventative therapy is the beta-blocker class of medication, a class of medication that is also used for high blood pressure. Propranolol is commonly used. Sometimes calcium channel blockers, another class of blood pressure medication, are used as well. Amitriptyline, which is an older type of antidepressant, is a different type of medication that is helpful in preventing migraines, probably because it impacts some of the brain chemicals involved in migraine formation. There are some newer antidepressants that may be helpful too. Some anti-seizure medications are used for migraine prevention, namely topiramate and valproate. A new medication recently came to market that is a monthly injection, Aimovig, which blocks receptors for chemicals involved in migraine formation. All these medications have pros and cons depending on the individual patient.
As far as other preventative options, Botox injections are an effective therapy to reduce the number of migraines a patient experiences. These injections are done into the muscles around the face and scalp. Transcutaneous supraorbital nerve stimulation (t-SNS) was recently approved as a preventive and abortive therapy for migraines. The device consists of a sticker that applies a generator to the forehead, which sends micro-pulses to a branch of the trigeminal nerve. Daily use showed a 54% reduction in migraine frequency and 75% reduction in medication usage. I’ve gotten involved in migraine therapy with occipital nerve blocks, a nerve block to the back of the scalp, and sphenopalatine ganglion blocks, which can be performed a number of different ways (but I most often do it with numbing medication on Q-tips inside the patient’s nose). For severe migraines, sometimes patients will undergo neurostimulator placement via surgery to some of these nerves.
Alternative therapies for migraine prevention and treatment include acupuncture and herbal supplements. Commonly used supplements include magnesium, feverfew, riboflavin, CoQ-10 and butterbur. Butterbur is not recommended due to safety concerns. Biofeedback, mindfulness based therapies and cognitive behavioral therapies all can have a role in migraine treatment as well.
If you think you might be suffering from migraines, the best thing to do is be evaluated by a physician in person. They will likely start with some laboratory and imaging testing to make sure nothing else is going on, before giving the diagnosis of migraines. Depending on how often attacks are occuring, a treatment plan can be created. I hope this was helpful in demystifying migraines a little! Don’t forget to sign up for my newsletter here so you never miss a post.