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Stop migraines before they start

AUG 2012

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Take advantage of proven therapies.

If you are a migraine sufferer, then you undoubtedly long for something, anything, to keep these painful episodes from recurring. Migraines affect about 15% of the adult population, but only a relatively small percentage of those people take advantage of preventive medications.

Migraine prevention guidelines released earlier this year by the American Academy of Neurology and the American Headache Society note that about 38% of people who have migraines could benefit from preventive medications, but less than a third of those people actually utilize these treatments. Dr. Lee Schwamm, vice chairman of the Department of Neurology at Massachusetts General Hospital, suggests that one explanation may be that these drugs must be taken every day to be effective, even though migraines might only be "an intermittent problem."

"The evidence shows that the more often you have to take a medicine, the less likely you are to take it faithfully," says Dr. Schwamm. "If you don't have the symptom right away when you skip a dose, then you are even more likely to skip doses." He adds that the expense of some pills also may diminish compliance.

The mystery of migraines

The mystery of migraines

These are three current theories about what causes migraine pain.

What causes migraines?

The cause of migraine headaches is still not completely understood. Nerve fibers that have endings on blood vessels in the brain become extra sensitive to pain. Every heartbeat creates extra pressure on the blood vessel walls. The supersensitive nerve endings turn this into a throbbing headache. Why the nerve endings are sensitized is not known. Migraines also are influenced, in part, by genetics. Diet, exercise, hormones, sleep, and other illnesses or medications can all play a role in when and how a migraine hits.

Preventive medications

Drugs listed in the new guidelines include the antiseizure drugs divalproex (Depakote), valproate (Depacon), and topiramate (Topamax), along with the beta blockers metoprolol, propranolol, and timolol. The herbal remedy butterbur was also listed as an effective prevention option for some migraineurs, people who experience migraine headaches.

Dr. Schwamm notes that all of these medicines have side effects, which may also play a part in their underuse. "Because topiramate has a side effect of weight loss, some patients are more compliant with this drug," he says. The antiseizure medicines listed above used to prevent migraines can reduce concentration and may cause some drowsiness. Beta blockers can slow heart rate, cause low blood pressure, and in some cases cause depression or sexual dysfunction. Check with your doctor about side effects.

"These drugs can reduce the frequency and severity of migraine attacks, and may require different doses over time to achieve these benefits," says Dr. Schwamm. "They must be taken daily. They are different from pain-relieving medicines—drugs that halt a migraine once it has started."

The pain-relieving medicines used most often are over-the-counter medications such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) and prescription drugs such as Fiorinal or Fioricet, or a class of medicines called triptans. These medicines can be quite effective at stopping a migraine, but they are not helpful for preventing migraines, according to Dr. Schwamm.

Personalized migraine prevention

Migraine prevention, however, does not always require medications. "Good sleep hygiene, attention to diet and exercise, and reducing stress are all very effective strategies, but are not always sufficient to prevent disabling attacks," says Dr. Schwamm.

Knowing your migraine triggers can also help you cut down on the frequency of attacks. Items such as chocolate, caffeine, and alcohol are known triggers for some. The causes of migraines are all very individual.

If you suspect that chocolate, for example, is a trigger for you, Dr. Schwamm suggests experimenting to see if it's true and whether a small amount of chocolate is safe to eat. "Try a nibble of chocolate and then see if a headache predictably follows," he advises. "Increase the dose daily until you discover that you either get migraines reproducibly, or you get to eat yummy chocolate whenever you want. Repeat this process for other potential provocative foods."

Caffeine has a causal relationship with headaches. Abrupt cessation of caffeine triggers migraines in many people, as does the abrupt withdrawal of commonly prescribed pain-relieving medicines such as NSAIDs or prescription medications such as Fiorinal or Fioricet, which contain caffeine.

In addition, Dr. Schwamm says it is very helpful to record when your migraines occur and what was going on that day. Include details such as what you were doing when the headache started, what your day had been like (stressful, sedentary, active, etc.), if you were hungry, when you ate last, if you had a fever or other symptoms, and, for women, at what point in in your menstrual cycle the headache occurred. He also suggests rating your symptoms as mild, moderate, or severe, and noting how long the migraine lasted.