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Major Headache

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“Not tonight. I’ve got a headache,” might sound like a silly cliche these days—that is, unless you’re one of the 36 million Americans who suffer from migraines. The pain can be so intense that sufferers are incapable of functioning, costing employers about $13 billion a year in lost productivity, with another $1 billion spent on medical care. Ironically, the very medications designed to cure migraines can cause them to recur if used too often.

Thankfully, local migraine expert Dr. Elliot Schulman knows how to break the cycle. “First, we address the pain,” says Schulman, a neurologist who specializes in headache management at Lankenau Hospital. “I look at the intensity, frequency and associated disability.”

Before prescribing the appropriate pain medication, Schulman often has to wean patients off their existing dependence on over-the-counter analgesics or prescription drugs. “If you take Tylenol, Excedrin Migraine or a narcotic more than two days a week, you are at risk for rebounding. The more analgesics you take, the more headaches you’ll get,” he says. “It can take two months to get people off daily meds before we can start them on the road to prevention.”

Also remember that Excedrin Migraine has caffeine. “If you’re taking four a day, that’s like four Tylenol, four aspirin and four cups of coffee,” Schulman says.

For treatment, Schulman considers each patient’s medical history and symptoms, which may include nausea or sensitivity to light, sound and smells. “There are eight different migraine-
specific medications called triptans, including Imitrex, Maxalt and Zomig,” he explains. “The goal is to pick the right drug that has the least side effects.”

Migraines are often misdiagnosed as sinus or tension headaches, probably because they cause nasal congestion, pressure or pain in the forehead or below the eyes. In one study, 90 out of 100 people with self-diagnosed sinus headaches were found to have migraines. On average, they had seen more than four physicians before getting the correct diagnosis and relief.

Long believed to be the result of constriction and expansion of blood vessels in the head, migraines actually stem from neural changes in the brain and the release of neuroinflammatory peptides that sensitize nerve fibers, causing pain. Before the onset of a migraine attack, some people experience flashing lights, numbness in their hands, dizziness or the inability to speak. According to findings published in the Journal of the American Medical Association, people who experience these symptoms have a doubled risk of cardiovascular disease. Other precursors include feelings of elation or intense energy, cravings for sweets, thirst, drowsiness, irritability or depression.

Migraines typically begin in childhood, adolescence or early adulthood. Children’s migraines tend to last for a shorter time, but the pain may be disabling and can be accompanied by nausea, vomiting, lightheadedness and increased sensitivity to light. Some children suffer from “abdominal migraines,” in which they experience all of the above symptoms without head pain, making diagnosis especially difficult.

If you have typical migraines or a family history of migraines, your physician can reach a diagnosis with a physical exam and oral history. But if your headaches are severe, sudden or without history, tests may be needed to rule out other possible causes. Tests may include computerized tomography (CT), MRI or spinal tap.

Women are three times more likely than men to have migraines. In Schulman’s headache practice, 80 percent of his patients are female, and 60 percent have headaches associated with their periods. “Migraine is primarily a disease of healthy, young women,” says Schulman. “Its onset often coincides with the onset of menstruation.”

Changes in estrogen levels are believed to be the culprit. As a result, migraines may occur more frequently during pregnancy or menopause, while taking birth control pills, and when undergoing hormone replacement therapy. Because estrogen levels decrease during menopause, some women stop getting migraines. For others, headaches become worse. In these cases, Schulman prescribes triptans.

“If there are other risk factors such as coronary artery disease or uncontrolled hypertension, and triptans are not an option, the aging patient might want to consider an anti-inflammatory such as Aleve or an antidepressant,” says Schulman, who designs a personal treatment plan for each patient, emphasizing the mind-body connection.

Other factors that contribute to migraines include snoring, sleep apnea, head and neck injuries, and overuse of caffeine and medications. Another is weight. “People who are obese get more headaches,” says Schulman.

If you have none of the above risk factors and you still get migraines, chances are your problem is inherited. It’s not uncommon for several members of a family to experience migraines, including children. And other than a change in hormone levels, the main trigger is stress. “When a person has a biological predisposition for migraines, all it takes is getting too much or too little sleep, losing a job, going through divorce, or any other stressful life event to ignite a debilitating headache,” says Schulman. “For some people, it can be something as ordinary as a change in the weather or seasons. For others, it can be a result of exercise or exertion.”

Most people who suffer from migraines may have “a hyperactive or overly sensitive brain,” says Schulman. “They often suffer from depression, anxiety or a mood disorder due to a biological deficiency of serotonin.”

For these patients, he prescribes antidepressants, which increase serotonin to prevent headaches. Women who suffer from migraines should keep track of their headaches to determine if they’re triggered by medications containing estrogen, such as birth control bills or hormone replacement therapy. If that’s the case, they should talk to their doctors about the best alternatives or dosages.

Regular aerobic exercise can help prevent migraines while keeping weight under control and reducing the risk of cardiovascular disease. Warm up slowly—sudden intense exercise could lead to headaches.

Above all, find a method to control stress, whether it’s meditation, breathing exercises or medication. Spend at least a half-hour each day doing something you find relaxing.

“Unfortunately, only half of the 36 million who have migraines are diagnosed,” says Schulman. “People think it’s just a headache. You need to be your own advocate.”


Migraine Triggers

Hormonal changes: Fluctuations in estrogen levels during menopause, pregnancy, and when taking contraceptives or HRT, seem to trigger headaches in women.
Foods: Beer, red wine, aged cheeses, chocolate, fermented or pickled foods, MSG, and caffeine can all trigger headaches.
Stress: Loss of a job, divorce, the death of a loved one, serious health issues, work stress, road rage and career pressures can precipitate a migraine.
Sensory stimuli: Bright lights, fireworks, sun glare, perfumes, second-hand smoke, strong smells and unpleasant odors may trigger a headache.
Sleep patterns: Getting too much or too little sleep.
Physical factors: Intense physical exertion from exercise or sex.
Environmental factors: A change of weather, season, barometric pressure or time zone.
Over-the-counter medications: Excedrin Migraine, Tylenol, Advil, Aleve and Motrin can cause headaches if used too often.


Migraine Glossary

Antidepressants  Prevent all types of headaches, including migraines, by elevating serotonin levels in the brain.
Anti-nausea medications  Drugs like metoclopramide or prochlorperazine are frequently used in combination with other drugs.
Anti-seizure drugs  These include divalproex sodium (Depakote), topiramate (TOPAMAX) and gabapentin (Neurontin).
BOTOX  Used to relax facial muscles for cosmetic purposes; also seems to lower the incidence of headaches for some migraine sufferers.
Butalbital  A combination of a sedative and aspirin or acetaminophen; may also contain caffeine or codeine. Carries a high risk of rebound headaches.
Cyproheptadine  An antihistamine that affects serotonin activity; may be given to children to prevent migraines.
Ergotamine (Ergomar)  A drug that was common before triptans were introduced; less expensive but less effective than triptans. Dihydroergotamine, an ergot derivative, is more effective, with fewer side effects.
NSAID  Nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin, Aleve, etc.).
Opiates  Used as a last resort, since they are habit-forming.
Triptans  The drug type of choice for severe migraine attacks; effective in relieving pain, nausea and sensitivity to light and sound.

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