Managing Migraine Headaches

Almost 10% of the population and three times more women than men suffer from migraine headaches. Although any head pain can be miserable, a migraine headache is often disabling. It is believed that even 50% of migraines are not diagnosed or mislabeled as tension or sinus-headache (which is rare according to experts).  In some cases, migraines are preceded or accompanied by a sensory warning sign (aura), such as flashes of light, blind spots or tingling in your arm or leg. A migraine headache is also often accompanied by other signs and symptoms, such as nausea, vomiting, and extreme sensitivity to light and sound. Migraine pain can be excruciating and may incapacitate you for hours or even days.  When left untreated, a migraine headache typically lasts from four to 72 hours, but the frequency with which they occur can vary from person to person. You may have migraines several times a month or just once a year.

Fortunately, management of migraine headache pain has improved dramatically in the last decade. If you’ve seen a doctor in the past and had no success, it’s time to make another appointment. Although there’s still no cure, specific life style adjustments and medications can help reduce the frequency of migraine headaches and stop the pain once it has started.  Most important: You are the manager of your life and need to communicate with your doctor how to keep the migraine under control.  If you ask your doctor about help with migraine and his answer is handing over a prescription, please look for another doctor. Initially medications may help, but without the right knowledge in using them they could quickly become counter effective.

Migraine headache symptoms in children

Migraines typically begin in childhood, adolescence or early adulthood and may become less frequent and intense as you grow older. Children as young as age 1 can have these headaches. In addition to physical suffering, severe headaches often mean missed school days and trips to the emergency room, as well as lost work time for anxious parents.
Children’s migraines tend to last for a shorter time. But the pain can be disabling and can be accompanied by nausea, vomiting, lightheadedness and increased sensitivity to light. A migraine headache tends to occur on both sides of the head in children, and visual auras are rare. However, children often have premonition signs and symptoms, such as:
·    Yawning
·    Sleepiness or listlessness
·    A craving for foods such as chocolate, hot dogs, sugary snacks, yogurt and bananas

Migraine headache triggers.
Migraine is a genetic neurological disease affecting the bloodvessels in the brain. Whatever the exact mechanism of migraines is, a number of things may trigger them. Common migraine headache triggers include:
·    Hormonal changes. Fluctuations in estrogen and progesterone seem to trigger headaches in many women with migraine headaches. Women with a history of migraines often have reported headaches immediately before or during their periods.  Hormonal medications, such as contraceptives and hormone replacement therapy, also may worsen migraines but sometimes also give relief.
·    Foods. Certain foods appear to trigger headaches in some people. Common offenders include alcohol, especially beer and red wine; aged cheeses; chocolate; fermented, pickled or marinated foods; aspartame; caffeine; monosodium glutamate — a key ingredient in some Asian foods. Skipping meals or fasting also can trigger migraines.
·    Stress. A period of hard work followed by relaxation may lead to a weekend migraine headache. Stress at work or home also can instigate migraines.
·    Sensory stimulus. Bright lights and sun glare can produce head pain. So can unusual smells — including pleasant scents, such as perfume and flowers, and unpleasant odors, such as paint thinner, secondhand smoke and my co-workers armpit.
·    Physical factors. Intense physical exertion, including sexual activity, may provoke migraines. Changes in sleep patterns — including too much or too little sleep — often  initiate a migraine headache.  It is important for migraineurs to keep a steady daily rhythm
Triggers may not inevitably lead to migraine, often more triggers are needed to offset the brain i.e. lack of sleep, dehydration and alcohol. Although sensitive people might get migraine every time they drink a glass of red wine .Migraine Food Triggers on Philipsburg Pharmacy

Management and Medical  Advice

Migraines are a chronic disorder, but they’re often undiagnosed and untreated, often waived as incidental headaches.  If you experience signs and symptoms of migraine, track and record your attacks and how you treated them including (or especially) the over the counter medication you took. Then make an appointment with your doctor to discuss your migraines and decide on a treatment plan.

·    If you don’t have a treatment plan when a migraine headache strikes, try over-the-counter (OTC) medications such as ibuprofen (Advil, Motrin, others), naproxen sodium (Aleve) or  paracetamol, or other self-care measures for a day or two. Keep in mind that soluble formulations in a high starting dose often work the best and can be combined with i.e. domperidon or metoclopramide to promote absorption if the migraine is accompanied with  nausea . If you don’t get relief, see your doctor.

Complications

Sometimes your efforts to control your pain cause problems. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen (Advil, Motrin, others) and aspirin, may cause side effects such as abdominal pain, bleeding and ulcers, especially if taken in large doses or for a long period of time.
In addition, if you take over-the-counter (OTC) or prescription headache medications more than two or three times a week or in excessive amounts, you may be setting yourself up for a serious complication known as rebound headaches. Although these drugs can give you temporary relief, they not only stop relieving pain, but actually begin to cause headaches. You then use more pain medication, which traps you in a vicious cycle. If you’re caught in the rebound headache trap, talk to your doctor.

Treatment

At one time, aspirin was almost the only available treatment for headaches. Now there are drugs specifically designed to treat migraines. Several drugs commonly used to treat other conditions also may help relieve migraines in some people. All of these medications fall into two classes:

·    Pain-relieving medications. These stop pain once it has started.
·    Preventive medications. These reduce or prevent a migraine headache.

Pain-relieving medications
For best results, take pain-relieving drugs as soon as you experience signs or symptoms of a migraine headache. It may help if you rest or sleep in a dark room after taking them:

·    Nonsteroidal anti-inflammatory drugs (NSAIDs).  (Ibuprofen, Naproxen, Diclofenac, others) may help relieve mild migraines. Drugs marketed specifically for migraine, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraines, but aren’t effective alone for severe migraines.  Combination drugs are suspected to have a higher incidence of initiating medication induced (rebound) headache.

·    Triptans. Sumatriptan (Imigran) was the first drug specifically developed to treat migraines. It mimics the action of serotonin by binding to serotonin receptors and causing blood vessels to constrict. Sumatriptan is available in oral, nasal and injection form. Injected sumatriptan works faster than any other migraine-specific medication — in as little as 15 minutes — and is effective in most cases. A number of similar drugs have become available, including rizatriptan (Maxalt),  zolmitriptan (Zomig) and eletriptan (Relpax). Experience has shown that sometimes people have to try 3-5 different triptans before they find the one that suits them best. A look at the different durations of effect and relative strengths might be helpfull. Dispersable tablets (wafers) do not have a quicker onset of effect or additional advantage with nausea. In fact the highest concentration in the blood is reached even at a later time then with conventional tablets. Taking triptans during the aura has no effect and might reduce the effect due to earlier elimination. Taking them when the pain becomes unbearable has no use either, they will not work anymore.

·    Ergots. Drugs such as ergotamine (cafergot) and dihydroergotamine help relieve pain. Due to the fact they have more side effects than triptans, they are less prescribed and reserved when the patient is resistant to other drug therapies. Most used is DHE as injectable.

·    Medications for nausea. Metoclopramide (Primperan) or domperidon are useful for relieving the nausea and vomiting associated with migraines, not the migraine pain itself. It also improves gastric emptying, which leads to better absorption and more rapid action of many oral drugs. It’s most effective when taken early in the course of your migraine or even during the aura before your headache begins.
Morfine like medications like vicodin, oxycodone etc. are very effective painkillers as long as they last. Due to their highly addictive properties, drug dependency  and weaning of effect they should be avoided for treatment of headaches.

Preventive medications

Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of pain-relieving medicines used during migraine attacks. In most cases, preventive medications don’t eliminate headaches completely, and some can have serious side effects. They are considered an option with more than 2 attacks per month.

·    Cardiovascular drugs. Beta blockers — which are commonly used to treat high blood pressure and coronary artery disease — can reduce the frequency and severity of migraines. These drugs are considered among first-line treatment agents. Calcium channel blockers and certain RAAS drugs (atacand) are also used. Consider these medication as choice if you suffer from high bloodpressure as well.

·    Antidepressants. Certain antidepressants are good at helping prevent several  types of headaches, including migraines. Most effective are tricyclic antidepressants, such as amitriptyline, taken in low dosage at night) Newer antidepressants (SRNI’s), however, generally aren’t as effective for migraine prevention. Effect has been measured with ie venlafaxine. In some people these drugs may cause headaches.

·    Anti-seizure drugs. Some anti-seizure drugs, such as valproic acid (Depakin) and topiramate (Topamax), which are used to treat epilepsy and bipolar disease, seem to prevent migraines. Gabapentin (Neurontin), another anti-seizure medication, is considered a second-line treatment agent. They might stabilize the nerve cells that trigger migraines.

·    Cyproheptadine. This antihistamine specifically affects serotonin activity. Doctors sometimes give it to children as a preventive measure.
Preventive medications are normally tried when suffering more then 2 x monthly from migraines. It may take 3 month of slowly increasing dosage before the effect can be evaluated.

Prevention

Whether or not you take preventive medications, you may benefit from lifestyle changes that can help reduce the number and severity of migraines. One or more of these suggestions may be helpful for you:

·    Avoid triggers. If certain foods seem to have triggered your headaches in the past, eat something else. If certain scents are a problem, try to avoid them. In general, try to establish a daily routine with regular sleep patterns and regular meals. 
To detect triggers it is important to keep a daily diary in which you keep note of daily life events and medications taken and effect on possible migraine as well. Most smartphones have apps for migraine diaries.

·    Exercise regularly. Regular aerobic exercise reduces tension and can help prevent migraines. If your doctor agrees, choose any aerobic exercise you enjoy, including walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches.

·    Reduce the effects of estrogen. If you’re a woman with migraines and estrogen seems to trigger or make your headaches worse, or if you have a family history of stroke or high blood pressure, you may want to avoid or reduce the amount of medications you take that contain estrogen. These medications include birth control pills and hormone replacement therapy. Women that experience migraines during the stopweek might consider continuous  treatment. Talk with your doctor about the best alternatives or dosages for you.

·    Quit smoking. If you smoke, talk to your doctor about quitting. Smoking can trigger headaches or make headaches worse.

·    Supplements to consider.  Additional Vitamin B2 (riboflavin) Magnesium and CoQ10 , have shown effect in several studies

·    Relaxation techniques, massage, physical therapy, yoga etc. can all have a beneficial effect.

Summarizing.

A Diary is important to evaluate if you use your medication the right way.  The right time, dosage form, rate of effectiveness and if you are not using to much or maybe to less. It is also important to identify possible triggers for the migraine. A 2 month period of recording would give your doctor (and yourself) a good assessment tool.

Lifestyle is important, taking the right medications is also important. Worrying on dietary triggers is less important. 
It will probably take several months to get the combinations right of type and dosage. This may count for preventive and relieve medication.

Keep in mind to limit the amount of painkillers and triptans to 2-3 days per week. If not you might see a tendency of increase in the frequency of headaches and related an increase in medicine consumption and before you know it you are in a vicious circle of medication dependent headaches. You can always improve !  Do not hesitate to ask for help.