Managing migraine: A women’s health issue

What else do we know about migraine? 

Migraine headaches have a significant adverse impact on quality of life. Between half and three-quarters of headache sufferers say they are less productive at work, in school, and at home, and that the headaches force them to miss family and social events.1

Sadly, fewer than half of all migraine sufferers consult a physician.2 The overwhelming majority of those who do seek help turn to their primary care physician.3

Key points 

•Half of all persons suffering from migraine develop headaches before age 20. Prevalence peaks in the mid-30s, then starts to decline.

•Recurrent headaches that are moderate to severe in intensity are considered migraines until proved otherwise.

•A rapidly decreasing estrogen level is substantially more likely to result in a migraine than a gradually decreasing level.

•Fewer than half of all migraine sufferers consult a physician.

•Migraines are easily triggered by variations in cycles of sleeping, eating, exposure to caffeine, and stress levels. A migraineur is most able to limit headache frequency by maintaining a “nearly boring” regular routine.

•A goal of 50% reduction in headache frequency and severity can be reasonably attained by preventive treatment.

Recognizing a migraine for what it is 

The International Headache Society criteria for migraine and other headaches, published in 1988 and updated in 2004,4 remain the standard (Table 1). Not all migraine sufferers meet the IHS criteria, however. Several other important diagnostic considerations help make migraine easier to identify (Table 2). Overall, headache specialists widely believe that recurrent headaches that are moderate to severe in intensity are migraines until proved otherwise.

TABLE 1. International Headache Society criteria for migraine

	•Five or more attacks lasting between 4 and 72 hours •Two or more of the following features: —Unilateral —Pulsating —Moderate or severe intensity —Aggravated by routine physical activity •One or more of the following: —Nausea and/or vomiting —Photophobia and phonophobia •Not attributable to another disorder

TABLE 2. Migraine: Key diagnostic points

	•41% of migraine patients report bilateral pain •50% of migraine headaches are nonpulsatile •Nausea is extremely common, but vomiting occurs in less than one-third of patients

Migraine with aura (previously known as classical migraine) is migraine with an accompanying neurologic disturbance. The disturbance may occur either before or during the migraine. The most common disturbance is visual—for example, the image of sparkling lights or a loss of a portion of the vision, known as scotoma. Table 3 summarizes features typically associated with migraine, including its predictable perimenstrual flare-ups.5

TABLE 3. Features commonly associated with migraine

	•Predictable perimenstrual occurrence of headache •Characteristic triggers (see Table 6) •Improvement with sleep •Positive family history of migraine •Childhood precursors (motion sickness, episodic vomiting, or episodic vertigo) or osmophobia (or aversion to strong odors) during the migraine •Stereotypical symptoms occurring shortly before the migraine, such as yawning, stiff neck, craving for sweets

Migraine: the great masquerader? 

Migraine is frequently mistaken for other types of disorders.

The role of imaging studies 

The diagnosis of migraine is based on clinical criteria. After a systematic review of the efficacy of diagnostic testing, the American Academy of Neurology has recommended that neither CT scan nor MRI of the brain is likely to increase the diagnostic yield or to uncover pathologic entities in patients whose symptoms are consistent with migraine (Table 4).7 Thus, the routine use of imaging studies in patients whose headaches fit the broad definition of recurrent migraine is not warranted.

TABLE 4. Diagnostic testing using CT and MRI of the brain

	•In patients with typical recurrent migraine, neither CT nor MRI is warranted •CT or MRI is warranted in patients with: —Recent significant change in headache pattern —Focal neurologic symptoms or signs —History of seizures •When imaging is warranted in non-migraine headache, consensus expert opinion is that MRI is more sensitive than CT

Imaging studies are called for when headaches do not meet clinical diagnostic criteria for migraine, that is, in patients in whom the headache pattern has suddenly changed, and in patients who have focal neurologic symptoms or signs or seizures. The use of EEG testing is not warranted unless the patient’s symptoms suggest seizures.8

The origins of migraine 

Our understanding of migraine pathophysiology has burgeoned in recent years. Migraines are now known to be a genetically based disorder. The gene loci of migraines have been identified in an extremely rare form of the disease known as hemiplegic migraine. These loci have been found to be the result of an ion channelopathy.9

The genetic tendency toward migraines also makes individuals more sensitive to a variety of environmental triggers. A migraineur is most able to limit headache frequency by maintaining a “nearly boring” regular routine. Specifically, migraines are easily triggered by variations in cycles of sleeping, eating, exposure to caffeine, stress levels, and the like.

Migraine is felt to be neurovascular in origin. While the pathogenesis of migraine pain is not fully understood, a number of components seem to be involved. First, the ion channels within the brainstem nuclei become activated. This results in cerebral blood vessel dilation with pain, with further activation of the trigeminal nerve. Brain stem pathways that normally modulate sensory input are affected. The trigeminal nerve communicates with the spinal tract of the trigeminal nerve, leading to neck pain. The trigeminal nerve also communicates with other portions of the brain via interneuronal synapses, leading to the experience of migraine.10

Managing migraines: setting goals 

The management of migraine starts with a therapeutic partnership between the patient and physician. It can be tremendously helpful to teach the patient that migraines are genetically based and the result of neurovascular disturbances in the brain (Table 5). Offering the patient strategies for identifying and avoiding certain headache triggers is important (Table 6). Reinforcing behavioral management strategies—including regular sleep, meals, exercise, moderate caffeine use, and stress management—plays an important role in headache control. Flag that key word: The patient should be educated to expect control of this chronic condition, rather than a cure.

TABLE 5. Basic principles of migraine management

	•Establish a therapeutic partnership with the patient •Provide patient education —Explain the nature of the disorder (genetic, neurovascular) —Review common triggers and how to avoid them (see Table 6) —Emphasize important behavioral management strategies: “Boringly regular” lifestyle (regular sleep, meals, exercise) •Stress management •Caffeine use only in moderation and only early in the day

TABLE 6. Common migraine triggers

	•Sleep deprivation or excess •Missed or delayed meals •Hormonal changes, most notably rapid drops in estrogen levels •Stress and anxiety •Physical exertion •Environmental factors

Headache pharmacotherapy includes both acute and preventive measures. The goal of acute treatment is to stop pain and prevent progression of the headache and its associated features. The goal of preventive treatment is to decrease migraine frequency and severity. The goal of a 50% reduction in headache frequency and severity can be reasonably attained by preventive treatment. That objective can be substantially exceeded with a combination of trigger and lifestyle management and effective medication for acute migraine episodes.

Identifying migraine triggers 

Most patients who episodically have migraines can identify certain triggers (Table 6). Common triggers include changes in daily sleep or meal schedules. Environmental factors such as noise, bright lights, and fumes often trigger migraines in susceptible individuals. Decreasing estrogen levels are also associated with migraines; a rapidly decreasing estrogen level is substantially more likely to result in a migraine than a gradually decreasing level. Changes in progesterone, on the other hand, have not been shown to be associated with migraine.11, 12, 13

Some people are susceptible to certain foods that predictably trigger migraines. Eliminating the suspected food from the diet for 2– 3 weeks is the most effective way to test this potential trigger. Diets purporting to reduce migraines are not generally helpful.

Treatment: acute and prophylactic 

Acute migraine treatment may consist of nonspecific pain relievers, including nonsteroidal anti-inflammatory drugs, opioids, or analgesics. Medications that specifically address the neurovascular changes occurring in migraine include the triptans and ergotamine products, and dihydroergotamine. The triptans and ergotamines are serotonin agonists, though ergotamine-containing compounds are not as selective in their effects.

A recent U.S.-funded meta-analysis of acute migraine therapies permits the categorization of treatments.14 Drugs considered to have substantial empirical and clinical benefit include those listed together in the meta-analysis as well as others that have been introduced recently. All of the currently available triptans—sumatriptan (Imitrex), naratriptan (Amerge), zolmitriptan (Zomig), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova), and eletriptan (Relpax)—are in this group, as are naproxen, ibuprofen, prochlorperazine, and butorphanol nasal spray (Stadol NS).

Prophylactic migraine treatments are used in persons whose headaches are especially frequent (2–3 days a week or more), especially disabling, and in whom acute treatments are either contraindicated or ineffective. Preventive treatments are drawn from several medication categories, including betablockers, tricyclic antidepressants, and antiepileptic drugs, among others. Many patients with headaches of this frequency could benefit from a neurologic consultation to help in management.

In summary, migraine headaches are common and disabling. They are the result of a neurovascular process, a genetically based phenomenon. Highly effective treatments are available to reduce the disability of this condition, making its treatment gratifying to both the patient and physician. □