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Stop the Pain: HEADACHESSidelined by headache pain? Identify your type of headache, triggers, treatments and preventive measures.

INSIDE

5 headache red flags

10 common migraine triggers

4 stages of migraines

6 lifestyle changes to help prevent headaches

Quiz: What’s behind the throbbing

Plus: Migraine 101 and migraine news

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Most people have headaches at some point in their lives. Doc-tors have identified 200 differ-

ent types of headaches, and the proper treatment depends on which type you have. Most headaches are relatively harm-less, but some can be debilitating or may point to serious or even life-threatening underlying conditions. Fortunately, there are several measures you can take to treat the most common headaches, and certain “red flags” can help you recognize when you need immediate medical attention.

THE MOST COMMON TYPES OF HEADACHES� TENSION HEADACHES. Tension headaches, also known as myogenic or muscle contrac-tion headaches, are the result of tensing of the facial and neck muscles. Their underly-ing causes include stress, anxiety, depres-sion, sleep problems and jaw clenching. Typically, the pain is constant and can be located anywhere throughout the head or neck. Sometimes people describe the pain as feeling like a “hatband” or a “vise,” and it can vary widely in frequency, intensity and duration. Tension headaches may occur in reaction to stress or a migraine attack. The most common treatments for tension headaches are rest, stress reduction and over-the-counter pain relievers such as aspirin, acetaminophen (brand name Tylenol), ibuprofen (Advil or Motrin) or naproxen sodium (Aleve).

�MIGRAINE HEADACHES. The causes of migraines aren’t completely understood. The traditional view has been that they are

caused by the dilation of arteries in the head. However, an emerging alternative hypothesis suggests the problem lies in the nervous system with cranial nerves called the trigeminal nerves, a nervous pain pathway or imbalances in nerve chemicals (neurotransmitters) such as serotonin, which is responsible for regulating pain. Migraine headaches occur more com-monly in women than in men and usually begin during childhood, adolescence or early adulthood. They may be triggered by hormonal changes (in women), lack of sleep, lack of food, certain foods or food additives, alcohol, caffeine, stress and sensory stimuli such as bright lights or loud noises.

Migraines typically cause intense puls-ing or throbbing pain in one area of the head. They can be accompanied by sensi-tivity to light or sound, nausea, vomiting and blurred vision. There also may be a prodome, a set of symptoms that occur one or two days before the migraine, including constipation, depression, food cravings, irritability and neck stiffness. In an estimated one-third of migraine sufferers, a set of neurological symptoms called an aura may occur before or during the migraine attack. The aura symptoms may include visual disturbances such as flashes of light, zig-zag patterns or tem-porary vision loss; a “pins and needles” feeling in the arms or legs; and difficulties with speech or language.

Two broad categories of medicines are used to treat migraines—acute medica-tions to treat migraines already in prog-

ress and preventive medications taken regularly to decrease the frequency and severity of migraines. Acute treatments consist of several different types of med-ication, including painkillers such as acetaminophen, aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen sodium. Trip-tans, which help constrict blood vessels and block the pathways responsible for pain in the brain, include sumatriptan (Imitrex, Imigran), rizatriptan (Maxalt), almotriptan (Axert, Almogran), naratrip-tan (Amerge, Naramig), zolmitriptan (Zomig), frovatriptan (Frova, Migard), eletriptan (Relpax) and a combination of sumatriptan and naproxen sodium (Treximet). Most of these medications are in tablet form, but some also are available as nasal sprays or injections.

Ergotamine medications also may be used. They appear to alleviate migraines by constricting blood vessels in the brain, but according to some experts, they are not as effective as Triptans. Ergotamine is combined with caffeine in the products Migerot and Catergot. Ergotamine may worsen the nausea and vomiting associated with migraines. The ergotamine derivative dihydroergotamine (D.H.E. 45, Migranal) may be more effective than ergotamine, with fewer side effects.

Sometimes anti-nausea drugs such as chlorpromazine (Promaper, Thorazine), metoclopramide (Reglan) or prochlorper-azine (Compro) are used for migraine-as-sociated nausea. Opioid medications such as codeine sometimes are used to treat

ALL HEADACHES

By Robert DinsmoorHow to determine if yours is harmless or indicative of a more serious condition

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headache pain in people who can’t take trip-tans or ergotamines. Glucocorticoids such as prednisone (Cortan, Deltasone, Orasone, Sterapred) or dexamethasone (Bycadron, DexPak, Zema) sometimes are used in com-bination with other medications to better relieve pain.

People who have frequent, prolonged or intense migraine attacks or aren’t helped by pain relievers may need preventive med-ications on a regular basis. Beta blockers, calcium-channel blockers and angioten-sin-converting enzyme (ACE) inhibitors—classes of drugs commonly used to treat high blood pressure and cardiovascular disease—may be used to reduce the frequency and severity of migraines as well. Beta blockers include propranolol (Inderal, Innopran), metoprolol tartrate (Lopressor) and timo-lol (Betimol). The calcium-channel drug verapamil (Calan, Verelan, Covera, Isoptin) sometimes is used for migraine prevention. The ACE inhibitor lisinopril (Zestril, Prinivil, Tensopril) also may be used to decrease the duration and intensity of migraine headaches.

Antidepressants sometimes are used to prevent migraine headaches. Tricyclic antidepressants such as amitriptyline (Elavil, Endep, Vanatrap) appear to prevent migraines through their effects on serotonin and other neurotransmitters. A serotonin and norepinephrine uptake inhibitor called ven-lafaxine (Effexor) also appears to be helpful in preventing migraines.

� CLUSTER HEADACHES. Cluster headaches are severe, debilitating headaches that occur in “clusters”—that is, they occur repeatedly for a period of weeks to months, alternat-ing with periods of being headache-free. The exact cause of cluster headaches is not known, but it involves overactivation of the trigeminal nerves, the largest pair of cranial nerves. They are more common in men than in women. They may be triggered by alcohol, smoking, certain medications and sleep disturbances. Cluster headaches tend to begin quickly, without warning, and peak within minutes. The pain tends to be excruciating and continuous and typically begins around the eye or temple on one side of the face. There may be eye redness and teardrop production on the side of the head with the pain. Like migraines, cluster headaches typically are treated with Trip-tans, and they may benefit from prednisone, ergotamine or lithium.

Rheumatic Conditions that May Cause HeadachesTEMPORAL ARTERITISTemporal arteritis is an inflammation of the temporal arteries, which supply blood to the head and brain. The exact cause of temporal arteritis is unknown, but it may be associated with the body’s autoimmune response. In addition to headache, temporal arteritis may have a number of symptoms, including visual disturbances, vision loss, hearing loss, muscle aches, fatigue and weight loss. If left untreated, temporal arteritis can have such serious complications as stroke, aortic aneurysm and blindness. If temporal arteritis is suspected, it usually is treated with oral corticosteroids such as prednisone or aspirin.

LYME DISEASELyme disease, caused by a bacterium called Borrella burgdoferi and transmitted to humans through tick bites, can cause such symptoms as headache, fever, fatigue and skin rashes. If not properly treated, it can cause complications in the joints, heart and nervous system. Fortunately, if properly diagnosed, Lyme disease usually can be treated successfully with a few weeks of antibiotics.

TRIGEMINAL NEURALGIATrigeminal neuralgia (TN), also known as tic douloureux, is chronic pain due to injury or inflammation of the trigeminal nerve, also known as the fifth cranial nerve. The classic form of the condition (known as TN1) can cause extreme, sudden and sporadic burning or shock-like facial pain in episodes that can last anywhere from a few seconds to two minutes. These episodes can occur in rapid succession for as long as two hours and can be triggered even by such mild stimulation as brushing one’s teeth or applying makeup. A less traditional form of the condition known as TN2 is characterized by constant aching, burning or stabbing pain that is generally less intense than is experienced with TN1. Both forms of TN can occur in the same person, sometimes at the same time. TN1 can be treated with anticonvulsant medications such as carbamazepine (Tegretol), oxycarbazepine (Trileptal), topiramate (Qudexy, Topamax, Trokendi), gabapentin (Neurontin, Fanatrex, Gaberone, Gralise), pregabalin (Lyrica), clonazepam (Klonopin), phenytoin (Dilantin, Phenytek), lamotrigine (Lamictal) and valproic acid (Depakene, Depakote, Stavzor), but they are less effective at treating TN2. Tricyclic antidepressants sometimes are used to treat the pain. If medication fails to adequately relieve pain or produces intolerable side effects, surgical treatment sometimes is indicated.

ARTHRITIS-RELATED CERVICAL HEADACHECervical headaches are caused by problems in the neck such as arthritis. The pain tends to occur in the back of the head and may be accompanied by weakness or tingling in the arms. Osteoarthritis and rheumatoid arthritis are the most common causes of cervical headache. Cervical headaches first are treated with NSAIDs and acetaminophen. In some cases, the underlying arthritis is treated with medications such as methotrexate (Rheumatrex, Trexall). If the neck is damaged and presses on nerves or the spinal cord, surgery may be necessary.



�TRACTION AND INFLAMMATORY HEADACHES.Traction headaches are caused by the pulling, stretching or displacement of pain-sensitive parts of the head. One cause of traction headaches may be tens-ing of the eye muscles to compensate for eye strain, but they may have more serious underlying causes such as brain tumors, strokes and head trauma. Symptoms may vary according to the cause (see Red Flags, below) Traction headaches are treated by addressing the underlying cause.

Inflammatory headaches result from diseases of the sinuses, spine, neck, ears and teeth. They can be caused by a number of diseases, including sinus infections, tooth infections and meningitis. As with traction headaches, the symptoms and treatments depend on the underlying causes. (See Red Flags, below)

One common cause of inflammatory headaches is sinus inflammation (sinus-itis), which can cause pain and a sensation of pressure in the face. A sinus headache often is accompanied by other symptoms such as nasal congestion, runny nose and cough. Sinus inflammation can be caused by allergies, the common cold or bacterial infection, all which can cause the sinuses to swell. Acute sinusitis can be treated with over-the-counter decongestants and nasal drops, and antibiotics may be used if it is believed to be the result of an infection. Chronic sinusitis may be treated with steam from a vaporizer or a pan of boiling water, warm compresses and saline nasal drops. If sinusitis is the result of allergies, over-the-counter oral antihistamines such as loratidine (Claritin or Alavert), fexofenadine (Allegra), diphenhydramine (Benadryl), clemastine (Tavist), chlorphe-niramine (Chlor-Trimeton) or certirizine

(Zyrtec), and antihistamine sprays such as fluticasone (Flonase) and triamcinolone (Nasocort) may help. In rare instances when the sinus openings are narrowed and mucus movement is blocked, surgery may be needed.

RED FLAGSAlthough headaches are common and usu-ally nothing to worry about, they also can be a symptom of a serious underlying con-dition such as a stroke or meningitis. Call 911 or go to the emergency room imme-diately if you experience a sudden, severe headache, the worst headache you’ve ever had or a headache accompanied by any of these symptoms.

• Neurological symptoms such as con-fusion; trouble understanding speech; trouble seeing, speaking or walking; numbness, weakness or paralysis on one side of your body

• Fainting• High fever• Stiff neck• Unexplained nausea or vomiting

These symptoms may indicate such serious conditions as stroke, aneurysm or spinal meningitis.

GENERAL GUIDELINES FOR TREATING HEADACHESMost headaches can be treated with rest or over-the-counter pain medications. It is best to get ahead of the pain by taking these medications while the symptoms still are mild. Avoid taking more than the recommended dosage to avoid rebound headaches. If these medications fail to work, talk with your family doctor about other medications he or she can prescribe (many mentioned above).

You also can take lifestyle measures to help prevent headaches. They are bene-ficial to overall health as well.

• Don’t skip breakfast, because fasting is a common cause of headaches.

• Get enough sleep. Lack of sleep can interfere with your ability to manage stress.

• Exercise regularly. The American Col-lege of Sports Medicine recommends getting 30-60 minutes of moderate-in-tensity exercise five times a week.

• Consider yoga, meditation and relax-ation therapy to relieve stress.

• Take a break, from a brief walk to a vacation, to get away from stressful situations.

• Find pleasurable activities, such as playing a sport, listening to music, reading a book or playing with pets.

When headaches do occur, there are nonmedical measures you can take to alleviate the pain.

• Take a hot shower.• Place a heat pack or an ice pack on

your head or neck.• Massage your temples and the mus-

cles in your neck and shoulders. This can be useful especially for treating tension headaches.

Not all headaches are created equal. They can have a variety of underlying causes and can be accompanied by a vari-ety of symptoms. The more you and your doctor know about your specific type of headache, the better treatment can be tailored to your needs. ■

Robert S. Dinsmoor is a medical writer and editor based in Massachusetts.

Most headaches can be treated with rest or over-the-counter medications. It is best to get ahead of the pain by taking medication while the symptoms still are mild.



If you suffer from migraine head-aches, you’re not alone. According to the Migraine Research Foun-dation, nearly one in four U.S.

households includes someone who develops migraines.

Migraines affect more than 12 percent of the population, including children — more than diabetes, epilepsy, and asthma combined. And nearly half of all people who have migraines are never diagnosed.

A migraine is not a symptom, it is a syn-drome — a collection of symptoms that arise from a common cause. A migraine headache can feel like intense throbbing or pulsing in one area of the head and commonly is accompanied by light or sound sensitivity, nausea, and vomiting.

The Migraine Research Foundation states that although most sufferers expe-rience attacks once or twice a month, 14 million people in the U.S. have chronic daily headaches and attacks at least 15 days per month. Migraine attacks can cause a person to feel extreme pain that lasts from hours to days. Although med-ications can reduce the severity and fre-quency, it’s important to find the right medicines and make proper home care and lifestyle choices.

MIGRAINE CAUSESUnfortunately, the causes of migraines are not well understood. A migraine is a complicated condition involving the brain and the blood vessels around the brain and head. The brain may become hyperactive in response to certain envi-ronmental triggers, such as light or odor.

This initiates chemical changes that irritate the pain-sensing nerves around your head and cause blood vessels to expand and leak chemicals. It can become a vicious cycle.

Genetic makeup also may be a contrib-uting factor. For example, the trigeminal nerve is one of the body’s major pain path-ways. The way in which it communicates with the brain when certain changes occur may lead to migraines.

Another possible cause may be imbal-ances in brain chemistry. Researchers believe this can include imbalances to the chemical neurotransmitter sero-tonin, which helps regulate pain in the nervous system. Serotonin levels have been shown to decrease during migraine attacks. This change in the brain may cause the trigeminal system to release

neuropeptides, which travel to the brain’s outer covering (the meninges), causing migraine pain.

MIGRAINE TRIGGERS“I can feel my migraines coming the day before,” said Felicia, 24. ”I have lots of triggers, like bright lights, perfumes, and strong scents like cleaning agents. The weather and barometric pressure also are triggers for me. I need to wear sunglasses on foggy days.”

Many things can trigger migraines. To narrow yours down, keep a journal or record of any possible triggers you may have experienced prior to your migraines. Then it’s possible to look for patterns later in your notes.

Here are common migraine triggers:

MIGRAINE 101Overview and Facts



• Beverages: Alcohol, particularly wine, and drinks high in caffeine.

• Environmental changes: Changes to the weather or barometric pressure.

• Foods: Aged cheeses and foods high in salt content, or skipping meals or fasting.

• Food additives: Artificial sweeteners and monosodium glutamate (MSG), a common preservative in foods.

• Hormonal changes (in women): The most common trigger. Two-thirds of women who have migraines get them only around the time of menstruation. Migraines in women usually are worse around puberty and often disappear around menopause. Changes in estro-gen levels seem to trigger headaches in many women. Other women develop migraines during pregnancy.

• Hormonal medications: Oral contra-ceptives and hormone replacement therapy (HRP) have been found to worsen migraines, but some women find their migraines occur less often when they take these medications.

• Physical factors: Intense physical activ-ities, including sexual activity.

• Sensory stimuli: Being in the sun, bright lights, loud sounds and unusual smells, such as perfume, paint fumes, secondhand smoke, and chemicals odors.

• Sleep: Any changes in your wake-sleep pattern, such as changing time

zones and jet lag, missing sleep or getting too much sleep.

• Stress: Stressful situations and life events.

RISK FACTORSFactors that put you at a greater risk of developing migraines include:

• Age: Migraines can start at any age; however, for most people migraines start during adolescence.

• Family history: Up to 90 percent of people who get migraines have a fam-ily history of them. According to the Migraine Research Foundation, if one parent has migraines, there is a 40 percent chance a child will get them. If both parents have them, the chance rises to 90 percent.

• Gender: Women are three times more likely to have migraines than men. According to the Migraine Research Foundation, about 18 percent of women and 6 percent of men in the U.S. have migraines. A woman with migraines may find headaches begin just before or shortly after the onset of menstruation. Generally they tend to improve after menopause.

SYMPTOMS AND TYPESThere are two types of migraines — those with aura and those without aura. People who experience migraine without aura

experience the symptoms of migraine attack, including intense pain on one or both sides of the head, light or sound sensitivity, nausea, and vomiting.

“Before my migraines start, I see flash-ing lights, my vision gets blurry, and I get dizzy,” said Elana, 38, who has had migraines on a regular basis for more than 20 years. “During a migraine attack, I experience nausea and dizziness, and it’s hard for me to concentrate. After a migraine attack, I feel exhausted, and I always need a nap to recover my strength.”

THE FOUR STAGES OF MIGRAINESMigraine headaches often begin in child-hood, adolescence or early adulthood. Although you may not experience all of them, migraines often progress through four stages: prodrome, aura (in 15% to 20% of migraines), headache, and postdrome.

STAGE 1: PRODROMEAbout one or two days before you expe-rience a migraine, you may experience small changes that alert you to its onset, including constipation, depression, food cravings, hyperactivity, irritability, neck stiffness, and uncontrollable yawning.

STAGE 2: AURAAuras are physiological warning signs that occur visually or through other senses. The symptoms, which originate in the nervous system, usually are visual disturbances, such as flashes of light. Auras also can be experienced as touch (sensory), movement (motor), or speech (verbal) disturbances.

An aura may occur before or during migraine headaches, although it’s more common beforehand. The aura experience typically warns a person that a migraine is about to occur. According to Cleve-land Clinic, 15-20 percent of those with migraines experience an aura.

The symptom of auras usually start grad-ually, build up over several minutes, and often last for 20 minutes to an hour. Here are some examples of auras:

• Problems with your speech or language (aphasia).

• Ringing in your ears.• Sensations of pins and needles in your

arm or leg.• Visual phenomena, such as seeing

different kinds of shapes, bright spots, or flashes of light that look like stars or dots. You might see zig-zagging lines or experience distorted vision.

• Visual loss or a blind spot.



• Limb weakness, also referred to as hemiplegic migraine, is far less com-mon than other symptoms of aura.

STAGE 3: MIGRAINE ATTACKAccording to the American Headache Society, when a migraine without aura is left untreated, it usually will last from four to 72 hours. The length of migraines is very individual. During a migraine attack, you may experience blurred vision, lighthead-edness sometimes followed by fainting, nausea, and vomiting, pain on one or both sides of your head, pain that pulsates or throbs, and sensitivity to light, sounds, and sometimes smells.

STAGE 4: POSTDROMEThe final migraine stage occurs after a migraine attack. Most people feel exhausted at this point.

When should you see your doctor?See your doctor if you experience the symptoms of migraine attacks regularly. Record the dates, symptoms, and what helped. Also, see your doctor if your symp-toms change or if your headaches suddenly feel different.

See your doctor immediately or go to a local hospital emergency room if you experience these symptoms, which may be signs of different, seri-ous medical problems:

• Abrupt, severe headache.• Chronic headache that becomes worse

after coughing, exertion, straining, or sudden movement.

• Headache with fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness, or trou-ble speaking.

• Headache after a head injury.• Headache pain that is new, if you are

age 50 or older.

COMPLICATIONSSee your doctor if you experience these complications from migraines:

• Chronic migraine: If a migraine lasts 15 or more days a month for more than three months.

• Status migrainosus: You have had migraine attacks for more than three consecutive days.

• Persistent aura without infarction: An aura typically goes away after a migraine attack. In some people, an aura can last more than one week after an attack. A prolonged aura can create symptoms similar to stroke.

• Migrainous infarction: Some people have aura symptoms that last more than one hour. This can be a sign of stroke. Neuroimaging tests can deter-mine if there is bleeding in the brain.

The following complications can occur from various medications:

• Abdominal problems: Nonsteroidal anti-inflammatory drugs (NSAIDs), which are pain relievers including ibuprofen (Advil, Motrin IB, etc.), can cause abdominal pain, bleeding, ulcers, and other complications, par-ticularly when taken in large doses or for long periods of time.

• Medication-overuse headaches: Tak-ing over-the-counter or prescription headache medications for more than 10 days a month for three months, or in high doses, can result in the medi-cation causing headaches.

• Serotonin syndrome: Serotonin syn-drome is a rare condition that can occur when the body has too much of the neurotransmitter serotonin, and it can be life-threatening. Medications for migrains, such as certain triptans (sumatriptan [Imitrex] or zolmitrip-tan [Zomig]), certain antidepressants called selective serotonin reuptake inhibitors (SSRIs), or serotonin and norepinephrine reuptake inhibitors (SNRIs), can increase risk of this syndrome. Common SNRIs include duloxetine (Cymbalta) and venlafaxine (Effexor XR). They are designed to raise serotonin levels and, when combined, can increase the risk of producing too much serotonin.

DIAGNOSIS AND TESTSAfter a physical examination, your doctor will refer you to a neurologist, who likely will diagnose your migraine syndrome. This will include an investigation of your medical history, your symptoms, and a physical and neurological examination. In addition, your neurologist also may recommend a variety of tests to rule out

possible causes for your pain.Potential tests include:

• Blood tests: Your doctor may order blood tests to look for blood vessel problems, infections in your spinal cord or brain, and toxins.

• Computerized tomography (CT) scan: This test takes simultaneous X-rays from several different angles to recon-struct a realistic cross-sectional image of the brain. This helps doctors diag-nose infections, tumors, bleeding in the brain, and other possible underlying medical problems.

• Magnetic resonance imaging (MRI): An MRI uses a magnetic field and radio waves to produce detailed images of the brain and blood vessels. MRI scans help doctors diagnose bleeding in the brain, infections, stroke, tumors, and other neurological conditions. The machine moves along the body using magnetic waves to take images, which generate a two- or three-dimensional image that can be viewed as a series of cross-sections. It does not involve radiation exposure.

• Spinal tap (lumbar puncture): Your doctor may recommend a spinal tap (lumbar puncture) if an underlying condition is suspected. A needle is inserted between two vertebrae in the lower back to extract a sample of cere-brospinal fluid for analysis.

TREATMENT AND MANAGEMENTThe majority of people who have migraines do not seek medical care for their pain. But a variety of medications are available to treat migraines. Medications used to treat migraines either are preventive or pain-relieving. Different medications can cause various side effects. Many are not recommended for people at risk of stroke and heart attack.

“Medication helps me, but I also need a spiritual outlet. I find meditation, rest, and relaxation to be very helpful in helping me manage the pain of migraines, both before and during attacks,” said Nancy, 48, who has long-term, chronic migraine syndrome. “Yoga, deep breathing, and meditation help me to restore a level of equilibrium and calm in my body. These practices give me some sense of control



over my emotions and an inner strength and belief that I will be okay.”

Here are some examples of available medications.

PAIN-RELIEVING MEDICATIONS• Anti-nausea: Medication for nausea

is prescribed as needed and usually is combined with other medications. Examples include chlorpromazine, metoclopramide (Reglan), or prochlor-perazine (Compro).

Ergots: Ergotamine and caffeine combi-nation drugs (Migergot, Cafergot) are less effective than triptans. Ergots seem most effective for migraine pain that lasts for more than 48 hours. Dihydroergotamine (D.H.E. 45, Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine, and it is less likely to cause medication-overuse headaches.

• Glucocorticoids (prednisone, dexa-methasone): This medication may be used with others to aid in pain relief. There is a risk of steroid toxicity, so they shouldn’t be used frequently.

• Opioid medications: Opioid medi-cations containing narcotics, such as codeine, sometimes are used by people who can’t take triptans or ergot medi-cations. These are habit-forming and typically are used when other medica-tions fail to help with pain relief.

• Pain-relieving medications: These also are known as acute or abor-tive treatments. The medications are taken during migraine attacks. They need to be taken as soon as you experience the first signs or symp-toms. Examples include:

- Pain relievers: Aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, etc.) and acetaminophen (Tylenol, etc.). The combination of acetamino-phen, aspirin, and caffeine (Excedrin Migraine) also may ease moderate migraine pain but aren’t effective on their own for severe migraines. If taken too often, these medications can lead to ulcers, gastrointestinal bleeding, and medication-overuse headaches.

- Triptans: Triptans are commonly pre-scribed medications and help con-

strict the blood vessels and block pain pathways in the brain. Medications include almotriptan (Axert), eletrip-tan (Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig). A single-tab-let combination of sumatriptan and naproxen sodium (Treximet) has proved to be more effective in reliev-ing symptoms than either medication taken individually.

PREVENTIVE MEDICATIONSThese drugs are taken regularly, often daily, to reduce severity or frequency. Cer-tain medications are not safe for women who are pregnant or breastfeeding, and only a few medications are safe for chil-dren. Your doctor may recommend you take preventive medication daily or when a trigger is approaching.

If you have four or more debilitating attacks per month, if your attacks last more than 12 hours, if pain-relieving medica-tions aren’t helping, or if your migraine signs and symptoms include a prolonged aura or numbness and weakness, these medications may be recommended. They can reduce the frequency and severity of your migraines, but they won’t necessarily eliminate your headaches completely. Here are some examples:

• Cardiovascular drugs: These medica-tions are used commonly to treat high blood pressure and coronary artery disease. It is not exactly clear why these cardiovascular medications prevent migraine attacks. The beta blockers metoprolol tartrate (Lopressor), pro-pranolol (Inderal La, Innopran XL, etc.), timolol (Betimol), and others are effec-tive for preventing migraines. If you are 60 or older, have certain heart or blood vessel conditions, or smoke, these med-ications may not be safe for you.

Calcium channel blockers are another class of cardiovascular medications used to treat high blood pressure and keep blood vessels from becoming narrow or wide. They also may be helpful in prevent-ing migraines and relieving symptoms. Examples include Verapamil (Calan, Verelan, etc.).

• Antidepressants: Certain antidepres-sants can help to prevent migraines, even if you do not have depression. Tricyclic antidepressants can be effec-tive and may reduce the frequency of migraine headaches by boosting levels of serotonin and other chemi-cals. Amitriptyline is the only tricyclic antidepressant that has been proven to prevent migraine headaches. Research suggests one serotonin and norepinephrine reuptake inhibitor (SSRI) — venlafaxine (Effexor XR) — may help prevent migraines.

• Anti-seizure drugs: Some anti-sei-zure drugs, such as valproate sodium (Depacon) and topiramate (Topamax), seem to reduce the frequency of migraines. Valproate products should not be used by pregnant women.

• OnabotulinumtoxinA (Botox): This medication has been shown to help treat chronic migraine headaches in adults. Injections are made in the muscles of the forehead and neck. If effective, this treatment usually is recommended every three months.

• Pain relievers: Nonsteroidal anti-in-flammatory drugs such as naproxen (Naprosyn) may help reduce symp-toms or even prevent migraines.

ALTERNATIVE TREATMENTSAlternative treatments including chiro-practic, physical therapy, and massage can be effective in helping to treat migraine syndrome and control pain intensity.

According to the Association of Migraine Disorders (AMD), “Studies have shown that they might be comparable to the effectiveness of some preventive medications, but often the studies are not of the most rigorous quality.”

The AMD also views certain vitamins, minerals, and supplements as ingredients that can contribute to treating migraines. But it cautions that like all drugs, the ingre-dients can have side effects, and their effectiveness depends on the purity of the particular batch of the herb or supplement. The AMD specifically recommends the use of magnesium, vitamin B-2, Coenzyme Q10, melatonin, and feverfew in helping treat migraine syndrome. ■



FDA APPROVED NEW TREATMENT FOR MIGRAINESMigraine syndrome affects over 12% of the population, including children. The U.S. Food and Drug Administra-tion (FDA) earlier this year approved the medication ONZETRA Xsail, formerly “AVP-825” (sumatriptan nasal powder) with the use of the Xsail breath powered delivery device for the acute treatment of migraine with or without aura in adults. It is not indi-cated for the prevention of migraine attacks and its safety and effectiveness has not been determined for treating cluster headaches.

Sumatriptan is in a class of med-ications called “selective serotonin receptor agonists.” It narrows the blood vessels in the head, stops pain signals from being sent to the brain and blocks the release of certain natu-ral substances that cause pain, nausea and other symptoms of migraine. The medication is a low-dose powder, administered through the nose with a unique Xsail breath powered delivery device, providing another option for migraine sufferers.

The Xsail breath powered delivery device works by using the patient’s breath to help deliver the medication into deep areas of the nasal cavity. After exhaling into the device, the pa-tient’s exhaled breath takes the medi-cation into the nose (nostril) through a nose piece. The medication is then car-ried beyond the nasal valve to specific sites. Air flows to the opposite side of the nasal cavity and goes out through the other nostril.

ONZETRA Xsail was approved by the FDA for the acute treatment of migraine based on research involv-ing 230 migraine patients. They were randomly assigned to self-administer the sumatriptan powder or a place-bo using the Xsail breath powered delivery device when experiencing moderate to severe migraine pain. The results showed a significant-

ly greater number of patients who received the treatment reported headache relief after 30 minutes and at every time point studied, up to two hours post-treatment, in comparison with patients who used the place-bo. Adverse reactions associated with the use of the medication were abnormal taste, nasal discomfort, rhinitis (inflammation of the nose or its mucous membrane) and rhinor-rhea (excessive discharge of mucus from the nose).

“The design of the Xsail Breath Powered Delivery Device harnesses

the patient’s own breath to seal off the nose from the throat and deliver a low dose of a trusted medication to the richly vascular passages deep in the nose. It’s an alternate approach to treating migraines that is both unique and effective,” said Stephen Silberstein, M.D., neurologist at the Headache Center, Thomas Jefferson University Hospital in Philadelphia, Pa. Silberstein also is past president of the American Headache Society and a Principal Investigator in the OptiNose clinical development program for ONZETRA Xsail.

➫NEWS MIGRAINE


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NEW DRUG HOLDS PROMISEDrug maker Alder BioPharmaceuticals said earlier this year that tests of a new drug to prevent migraines have been promising. Multiple doses of the injectable drug, ALD403, were tested against a placebo in patients suffering from chronic migraines — those who experienced 15 or more headache days per month, of which at least eight were assessed as migraine days.

The two highest doses of the drug, 300 mg and 100 mg, brought about a 75% reduction in migraine days in 33% and 31% of patients, respectively. The

drug currently is in a late-stage trial for use in frequent episodic migraine. A late-stage study for chronic migraine sufferers also is scheduled. Alder BioPharmaceuticals is recommending that, if approved, the drug would be administered four times per year. FDA approval could occur by 2019.

NEW CONCERNS OVER MIGRAINE TREATMENTS DURING PREGNANCYDoctors at Wake Forest Baptist Medical Center have reported that medications and treatments long considered safe to treat pregnant

women with migraines may not be. In a review published in Current Neurology and Neuroscience Reports, Rebecca Erwin Wells, M.D., raised questions about using magnesium, ondansetron, acetaminophen and butalbital for treating pregnant women with migraines.

She encourages women to consult their doctors, adding, “There are many available treatment options for migraine during pregnancy and lactation, so patients can be assured that they will not suffer during this important time in their lives.” ■

MIGRAINE ➫NEWS

Stop the Pain: Headaches ❙ Pain-Free Living



WHAT’S BEHIND THE THROBBING?

1. Which of these can trigger a migraine? (Circle all that apply):A. Menstrual cycle/

hormonal factorsB. StressC. WeatherD. Changes in sleepE. Skipping a mealF. All of the above 2. Migraine apps such as iHeadache and Curelator Headache can be useful in helping those with migraines discover their triggers. TRUE FALSE

3. Exercise and stress reduction programs such as meditation are helpful in mitigating migraines or preventing them. TRUE FALSE

Q:4. Which research-backed dietary changes will help most people decrease the number of migraines they have? A. Avoiding or

limiting caffeineB. Reducing salt C. Not skipping mealsD. A & C E. Drinking

carbonated beverages

5. Migraine treatments generally fall into two areas: acute and preventive.TRUE FALSE

6. Using certain medications too frequently actually can lead to more headaches. TRUE FALSE

(Answers on next two pages.)

Lightspring/Shutterstock

ANYBODY WHO has had migraines knows how unbearable they can be—the stop-you-in-your-tracks throbbing, the flashes of light.

“Migraine is more than just a headache,” said Noah Rosen, M.D., a headache specialist who, as director of The Headache Center at Hofstra North Shore-LIJ School of Medicine, cares for patients with some of the worst migraines.

Migraines—which usually last from four to 72 hours—can cause severe pain, queasiness and dizziness.

The worst part for migraine sufferers is that something as simple as the weather can trigger a migraine, leaving a person unable to perform the tasks of daily living, said Rosen. Even more unnerving: The person in pain has no clue when it will abate.

These beastly headaches share at least two of these common features: They are one-sided, they are moderate-to-severe in inten-sity, they include throbbing and they worsen when a person moves. They also may cause nausea and sensitivity to light and/or sound.

Thirty-six million Americans—11% of the population—get migraines, according to the American Migraine Foundation. About 18% of women in the U.S. get migraines, compared to 6% of men. One percent of the population has chronic migraines, defined by having headaches at least 15 days a month for at least three months (with eight of those 15 being migraines), according to the International Headache Society.

And the pain does not stop with the headache. Those who get migraines have an increased risk of developing ulcerative disease (which may be a result of a medication taken for migraines), said Rosen. Women with migraines have a higher risk of heart attack and stroke, according to recent research. Fibromyalgia and irritable bowel disease also may be more common in those with migraines.

According to David Buchholz, M.D., everyone can get migraines because there is a mechanism for them

deeply wired into our brains activated when a person’s “trigger level” builds up beyond the individual’s tolerance threshold. If you have frequent migraines, do not despair. “In general, the prognosis is good,” said Rosen.

“The first step is to get to diagnosis.” The next step, he said, is to keep

track of your migraines and figure out if anything specifically triggers them. Finally, work to find an effec-

tive strategy to stop your headaches. To learn more about migraines, take

the following quiz.

How much do you know about migraines?

TEST YOUR KNOWLEDGE QUIZ



1. F. All of the above. Each of these factors has the poten-tial to set off a migraine in some people. Stress is the number one trigger, Rosen said. For most people, stress is unavoidable, said Buch-holz, because it is related to family health issues, finances, work and relationships. And sometimes just the “let down” from stress can trigger a migraine, added Rosen. (Think of weekend or post-holiday headaches.)

Hormonal changes also are common migraine triggers in women. Typically, the migraine occurs from two days prior to the start of the menstrual cycle to one day into it, although some women can have peaks in frequency toward the end of their cycles or during ovulation, Rosen explained. Birth control pills—used either for contraceptive pur-poses or to control heavy, painful periods—tend to be “like rocket fuel” for migraines, Buchholz added.

The weather is another potential migraine trigger. Studies have shown entering

hotter weather may be a trig-ger, as is an absolute change in temperature, said Rosen. Rapid barometric pressure shifts [such as thunderstorms] are another big migraine trigger, added Buchholz.

Calorie restriction also is a trigger. There is something known as “the fasting head-ache,” which people may get when fasting on certain religious holidays such as Yom Kippur or Ramadan, Rosen said.

Certain medications might trigger migraines, Buchholz added, as do certain foods. Changes in sleep, snoring and sleep apnea are all known risks for migraines as well.

People who get migraines are at risk for more frequent headaches if they have trau-matic brain injury, obesity, depression and anxiety, or if they have undergone a significant stressful life event such as physical or sexual abuse, Rosen said. Also, having frequent migraines puts you at risk of developing more migraines.

2. True. Food diaries have been around for a long time, Rosen said, but now there is a new generation of technology—apps—that allow people to answer a series of questions about their headaches and lifestyle habits and then track their migraines. Rosen is a paid

consultant for Curelator Headache. Others include iHeadache and Migraine Buddy. (Some of these apps are available for free; others cost up to $4.99.) The technology is useful to both patients and physicians, he said.

After about 20 head-aches, the apps make correlations with known triggers, Rosen said.

Some of these apps also can synch to other bio-metrics devices such as a Fitbit and show people with migraines that, for example, on days on which they exer-cised, they were less likely to have a migraine.

3. True. Research has shown that exercise, as well as stress reduction techniques such as mindful meditation, helps reduce the frequency of migraines, Rosen said.

4. D. Research has shown that avoiding or limiting caffeine and not skipping meals help reduce the frequency of migraines, according to Rosen.

“Caffeine in the short run, if anything, seems to help take the edge off a head-ache. But in the longer term, it is probably the most pow-erful and common dietary trigger of all,” Buchholz emphasized. He warned that while weaning yourself off

A:WHAT’S BEHIND THE THROBBING?

Lightspring/Shutterstock

TEST YOUR KNOWLEDGE QUIZ



caffeine might lead to more headaches initially, that is just a temporary withdrawal. If you can cut out caffeine entirely, he said, you likely will get fewer migraines.

Others dietary hab-its—such as staying well hydrated, avoiding alcohol, managing your weight to avoid obesity and avoiding monosodium glutamate (MSG), a common flavor enhancer often disguised by other names such as hydro-lyzed vegetable protein—are evidence-backed techniques to reduce the frequency of migraines, said Buchholz. He suggests numerous other foods and drinks have the potential to trigger migraines in certain people, including chocolate; nitrites found in processed meats and other foods, cheese and other dairy products; citrus fruits; and vinegar.

Odors such as paint fumes or perfumes also can trigger migraines, he added.

5. True. People can take medications both to help treat active migraines and to prevent them from occurring or reduce their frequency in the future.

In the midst of a migraine,

people may take an anti-in-flammatory drug such as ibuprofen (Motrin), acet-aminophen (Tylenol) or Excedrin to ease pain and other symptoms. They also may take prescription drug sumatriptan (brand name Imitrex) or one of seven other “triptan” medications: Amerge, Frova, Maxalt, Relpax, Axert, Zomig and Treximet, said Rosen.

In tougher cases, if a person has many headaches or is not responding to medications, he or she may need preventive medication, he said. Some prescription medicines can help prevent migraines, including certain blood pressure, anti-seizure and anti-depressant medica-tions, Rosen noted.

These medicines decrease abnormal firing of neurons in brain cells, he explained. Other treatments that might help chronic migraines include: Botox injections, nerve blocks and trig-ger-point injections (these contain a local anesthetic or saline and may have a corticosteroid.)

Certain vitamins also have been shown to reduce the frequency of migraines, including magnesium,

riboflavin and coenzyme Q10, said Rosen.

“It’s a very treatable con-dition,” Rosen said, “and the more you know about your condition, the more likely you are to do well with it.”

6. True. If you use certain medications too often to stop a migraine, “you can actually start getting more frequent headaches,” Rosen said.

Rebound headaches are a huge problem among chronic headache sufferers who rely too heavily on both over-the-counter and prescription drugs, Buchholz said. Certain drugs, such as those that contain caffeine (including Excedrin, Tylenol Sinus, Benadryl-D or Clari-tin-D) may help temporarily, but ultimately, “they mag-nify a person’s underlying migraine tendency and create a vicious cycle of escalating headaches and increasing dependence on the rebound-producing, quick-fix drugs,” he said. The same is true for caffeinated beverages.

But not all doctors agree on the frequency with which other medications can cause rebound head-aches. For example, Rosen

said Triptans (such as Imitrex and Zomig) are known to lead to rebound headaches if taken more than 10 to 12 days a month, but Buchholz said taking these drugs even less often can lead to rebound headaches.

And while Buchholz said plain anti-inflammatory drugs (ibuprofen, naproxen, etc.), plain acetaminophen (Tylenol) and aspirin do not lead to rebound headaches, Rosen said anti-inflamma-tories can cause rebound headaches and should not be taken more than 15 times a month.

Buchholz said he feels strongly that a person should not take more than two rebound-causing drugs (combined from any drug class) per month for migraines, although he acknowledges there is dis-agreement about that also.

It is very important to not be in a rebound state when you are working to prevent migraines, he said. “If people are in a rebound state, the preventive measures will not be effective.” ■

Joanna Broder is a freelance health and science journalist based in Maryland.

“Caffeine in the short run, if anything, seems to help take the edge off a headache. But in the longer term, it is probably

the most powerful and common dietary trigger of all.”

– David Buchholz, M.D., author of Heal Your Headache: The 1-2-3 Program for Taking Charge of Your Pain


http://www.webmd.com/pain-management/guide/pain-relievers

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