Management of migraines can be challenging

Management of migraines can be challenging

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Migraine triggers have a lot in common with a minefield — hard to avoid

Migraines are a debilitating disorder. Symptoms typically include nausea, photophobia and phonophobia — sensitivity to light and sound, respectively. The corresponding headache usually is unilateral and has a throbbing or pulsating feeling. Migraines typically last anywhere from four to 72 hours, which is hard to imagine. Then, there is a postdrome recovery period, when the symptoms of fatigue can dog a patient for 24 hours after the original symptoms subside. Migraines among the top reasons patients see a neurologist (uptodate.com September 2011).

According to the American Migraine Foundation, there are approximately 36 million migraineurs, the medical community’s term for migraine sufferers. This has increased from 23.6 million in 1989. Women are three times more likely to be affected than men (Headache. 2001;41(7):646), and the most common age range for migraine attacks is 30 to 50 (Medscape.com), although I have seen them in patients who are older.

What causes a migraine?

The theory was once simple: It was caused by vasodilation (enlargement) of the blood vessels. However, this may only be a symptom, and there are now other theories, such as inflammation of the meninges (membrane coverings of the brain and spinal cord). As one author commented, “Migraine continues to be an elephant in the room of medicine: massively common and a heavy burden on patients and their healthcare providers, yet the recipient of relatively little attention for research, education, and clinical resources (Annals of Neurology 2009;65(5):491).”

There are many potential triggers for migraines, and trying to avoid them all can be worse than navigating a minefield. Triggers include stress, hormones, alcohol, diet, exercise, weather, odor, etc. (Cephalalgia. 2007;27(5):394).

What is done to treat migraine sufferers?

For those who want to avoid traditional medicines, a feverfew-ginger combination pill — an oil-based herbal supplement — as a first-line treatment showed promising results for those suffering from mild migraine prior to the onset of moderate to severe migraine(Headache 2011;51:1078-1086). A sublingual preparation was the most beneficial. In this small, double-blind, placebo-controlled (well-designed) study, patients were aged 13 to 60 and suffered migraines from two to six times a month.

Sixty-four percent of patients in the treatment group rated the symptoms as mild to no pain, compared to 39 percent of those in the placebo group. The side-effect profile of the herbal remedy was similar to placebo. The challenge is, if it doesn’t work, you may have lost your window to take traditional medications. There is a caution: Women who are pregnant should not take feverfew.

Mild treatments for migraines include aspirin, Tylenol (acetaminophen) and NSAIDs, such as ibuprofen. In a randomized controlled trial, 1000 mg of acetaminophen reduced intensity of symptoms in episodic (occasional) and moderate migraine sufferers significantly more than placebo at the two-hour and six-hour marks (Headache. 2010;50(5):819-833). It also reduced the nausea, sensitivity to light and sound, and the functional disability. However, if you have more intense migraines this may not be effective.

In a Cochrane Database review (a meta-analysis of RCTs), ibuprofen 400 mg provided at least partial relief to migraine patients, though complete relief to relatively few (Cochrane Database Syst Rev. Oct. 6, 2010). There was statistical significance compared to placebo.
One of the most powerful and common treatments is the use of triptans which include Imitrex (sumatriptan), Zomig (zolmitriptan) and Relpax (eletriptan). These drugs are 5HT-1 receptor agonists. They stimulate a metabolite of serotonin to vasoconstrict (narrow) the blood vessels. These are more specific than NSAIDs and acetaminophen. Sumatriptan, which is generic, was more effective in a 6 mg subcutaneous (under the skin) injection than as a 100 mg oral formulation in an RCT (Cephalalgia. 1998;18(8):532).

In another study, sumatriptan in combination with naproxen sodium (an NSAID) was more effective than either drug alone in treating acute migraine attacks at the two-hour and 24-hour marks, according to two randomized clinical trials (JAMA. 2007;297(13):1443). These studies involved approximately 3,000 patients. While these results are inspiring, they are far from completely effective. In other words, the sumatriptan-naproxen sodium at its best showed a complete reduction in nausea in 71 percent of patients, but only 25 percent of patients were pain free overall with this combination.

Be cautious of drug overuse, which can cause rebound headaches, and thus increase the frequency of migraine (CNS Drugs. 2005; 19(6):483-497).

What happens to patients who don’t respond to therapy?

I recently encountered a patient who did not respond to therapy and it was difficult for both the patient and physician during the acute attack. Thus, the most effective treatment of migraine is prevention, but how do you prevent a migraine? Stay tuned to next week’s article on prevention of migraines.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.