Virtually everybody knows that a migraine headache is a very severe headache. As a result many patients with recent onset of some other kind of severe headache will complain of “migraine”. We physicians quietly translate “migraine as “very severe headache” lest the patient misinterprets skepticism of the diagnosis as failure to understand the severity.
Typically migraine starts with an aura, a stereotyped non-painful precursor and warning that a headache is coming in about 30 to 60 minutes. Most commonly the aura is visual such as seeing snow flakes in front of the right or left half of the visual field. Many patients have discovered early on that this is the most effective time to take any remedy. After the pain starts there is usually nausea, intolerance of bright light, of loud noise, or of movement. Without treatment these symptoms and the pain may last from hours to a couple of days. Commonly the pain affects only one side of the head. Headaches without these features, but that come in episodes at irregular intervals, may be diagnosed as “atypical migraine”--especially if they respond to treatment specific for migraine such as triptans.
The most modern and generally most effective remedies for migraine attacks are the “triptans” (example: Imitrex). Triptans are specific for migraine in that they do not relieve other pain and may totally prevent an attack if taken during the aura. All of them are prescription only medications because women over 40, men over 50, and all with cardiac risk factors require caution in the use of triptans. When migraine attacks come inconveniently close together and the maximum tolerable dose of triptans is approached, there are several types of medications that may very nearly or even completely prevent migraine, but they must be taken continuously as prevention—compare with drugs for epileptics. All are totally ineffective when taken only at the time of an attack in progress.
These preventives include certain antidepressants in doses usually smaller than those needed for depression. The best way to limit side effects is to increase the dose very gradually over a period of weeks or a month or so. One dose daily in the evening limits the main side effect of drowsiness. Dry mouth and constipation are usually minor. Beta blockers such as propanolol may be used alone or with antidepressants. They may slow the pulse rate and cannot be used in people with asthma because they cancel the effects of adrenaline. Topirimate (Topamax) is an anticonvulsant remarkably effective in preventing migraine. Very slow increases in dose are especially important with topirimate (and similar anticonvulsants). Side effects include weight loss, tingling sensations, mental dullness. No generic equivalent is currently available making topiramate relatively expensive.
The good news about using medications to prevent migraine is that there are many combinations to try with good assurance of some success. Furthermore, the first attempt frequently is successful. The bad news is that a successful combination may not be found for some months. If doses are increased rapidly, a toxic side effect from a dose much larger than the small dose which could have been effective over time may be reached before relief occurs. This may result in what I call the “poisoned coyote effect”---an abiding prejudice against a medication which otherwise could have been close to ideally effective. In addition to going slowly another trick is to reduce the dose that caused unacceptable side effects and add another new one to it. When success occurs, further experimentation is advised to see if some of the medications being taken are necessary at all--the new one might have been effective by itself.
For all types of headache sufferers, life style changes may avoid behaviors that tend to precipitate attacks. Of course migraine may occur in some of us without significant bad habits such as 1) erratic nutrition, 2) lack of sleep or irregular hours for sleep (especially rotating shifts), 3) the let down after a stressful event. Some of the latter can be “engineered” out of one’s life---for example, visiting problem relatives on their turf plus learning the correct duration of visits---not a bad program even if you don’t suffer from migraine.
Another topic that applies to all headache sufferers is medication rebound headache. This diagnosis is made in retrospect after stopping the suspect medications results in improvement. Consider this situation when simple, single OTC (over-the-counter) medications are used more than 5 days per week, triptans, or combinations with sedatives or caffeine more than 3 days per week, or ergot alkaloids more than 2 days per week. Ergot alkaloids are older prescription preparations such as Cafergot, largely replaced by triptans. When withdrawing medications suspected of causing rebound headaches, acetaminophen (Tylenol), triptans, aspirin, and ibuprofen can be stopped abruptly. Opiates and sedatives, especially short acting ones, should be tapered. Withdrawal headaches from triptans will clear in about 4 days, others in 9 days. Long acting NSAIDs (non-steroidal anti- inflammatory drugs) such as naproxen (Aleve) do not cause withdrawal headache and may be used during the transition (never take any NSAID without food). A long term preventive medication can be started right away, but its benefits will only come a little sooner after the withdrawal period.
It is noteworthy that caffeine withdrawal consistently causes a severe headache even in people not otherwise susceptible to headaches. House guests, vulnerable to an inadvertent switch to decaffeinated coffee, might be well advised to carry No Doz (caffeine) tablets, illustrating our final point that migraine and other headaches (especially tension headaches) do get muddied up together.
John A. Frantz, MD
Green County Health Committee
November 26, 2005
Our daughter was riding with us to St. Louis to our grandson’s (her nephew’s) wedding. The above question occurred to me as I observed her watching a man on his riding lawn mower mowing the 5-acre (approximately) lawn of his trophy house.
When we get washing machines, most of us don’t get the full advantage of the labor saving device because we wash more stuff more often using up much of the time and effort we might have saved. Riding lawn mowers permit the same “wheel spinning” compulsion.
And when we get good roads and automobiles, many of us spend two hours per day commuting—ample time to put in quite a large garden resulting in great health improvement for the entire family.
John A. Frantz, M.D.
June 19, 2003