Why do I have headaches?  

Headache is one of the most common problems bringing a patient to a doctor.  The most common type of headache is migraine. Migraine is a headache that comes and goes away on its own. It is not the only headache that comes and goes but is the most common of this type. It affects both men and women, much more so women than men. It may start in childhood, even in a few years old, when a young child may complain of “not feeling well”, a “tummy ache”. It may also start at a much later age, in 30s to 40s, or even later. In general, especially in women, headaches become more frequent and more intense with aging. They peak around menopause and, usually but not always, lessens after that part of life.

One way to understand migraine is that it is caused by an anomaly or a malfunction in a part of the brain. For sake of explanation, I call it a migraine switch. People who do not have the anomaly or the switch may not have migraine. The ones who inherit the switch always carry the risk of having one.  If the switch is on, they have a migraine, and turning it off makes it go away. Presently, there is no practical way to take away or permanently turn the switch off. Due to this problem, migraine at this time is not curable; it is only manageable.

 

Is migraine hereditary?

Migraine has hereditary tendency. But for most patients the genetic defects are not easy or possible to find. Usually it runs in families, but different family members may have different severity or variety of migraine. Genetic defect is better defined for a particular type of migraine called Hemiplegic Migraine, which can cause stroke like paralysis with headache. For most patients, a genetic analysis for migraine is neither available nor useful.

 

Is migraine a one-sided headache?

One-sided headache can occur in migraine but that is not the most common type. Most patients with migraine have headache all around the head. Pain of migraine can be on one side or both, in the face like sinus pain, in the back of the head involving the neck and shoulders, in forehead, in one or both eyes, and in all these places. Many people mistakenly believe that they have sinus disease while the real cause of pain is usually migraine.

 

How bad the pain of migraine could be?

Anyone who never experienced a migraine, and majority of people are in this category, may not understand the suffering associated with it. Migraine pain can be quite mild to the point that many patients hesitate to accept a diagnosis of migraine for their so-called “regular headaches.” Of course there is no regularity or normalcy about any headache. Sometimes there may not be any pain at all with migraine. On the other hand, it can be excruciatingly severe. There are very few pains worse and more disabling than a severe migraine.

 

Other than pain, what other symptoms and signs occur in migraine?

Though pain is the main feature of Migraine, for most patients, it is more than just pain. Migraine may also cause numbness, tingling, weakness, blurred vision, seeing bright expanding light, zigzag lines, kaleidoscopic vision, tunnel vision, double vision, loss of vision, difficulty speaking, difficulty walking, vertigo, scalp sensitivity, excessive yawning, nausea, vomiting, discomfort with light or noise, unsteadiness, weakness, nasal congestion, eyelid swelling, unequal pupils, droopy eyelid, ear fullness, flushing or sweating of face, forgetfulness, confusion, fatigue, lethargy, and diarrhea. These and some other symptoms may not affect every patient and may not happen with every attack. Many patients believe having a stroke while the cause of symptoms is migraine.

 

What is an aura of migraine?

Aura means a set of symptoms happening before the pain of migraine starts. Only a small percentage of patients have auras, most have migraine without aura. Symptoms of aura may last for a few minutes to about an hour or more. Most common aura is of visual type, which can cause flashes of light, or seeing a bright light getting bigger and bigger distorting or blurred vision. Patients describe their visual aura in many ways including zigzag or bright colorful lights, distorted vision, or kaleidoscopic vision. A different type of aura may cause numbness, tingling, or weakness of an arm, leg, body or face. And yet another type may cause excessive yawing, nausea, dizziness, vertigo, difficulty speaking, double vision, forgetfulness, or difficulty walking. Symptoms of aura can be quite anxiety provoking as they resemble symptoms of stroke. Proper diagnosis can reduce anxiety and, especially in women due to their fluctuating hormonal status, can help to take appropriate measures to avoid any complications.

 

What triggers Migraine?

In patients with migraine, exposure to certain situations, food or chemicals can lead to a migraine attack, though many patients are not able to figure out any trigger. Typical triggers are hormonal changes, hunger, stress, change in sleep pattern, certain foods like cheeses, chocolate, MSG, alcohol (particularly wine), certain perfumes and smells (e.g., artificial perfumes like in candles, or gasoline), heat, bright sun, severe cold, or change in barometric pressure (including going to an elevated location). In some patients, it can also be triggered by neck arthritis, allergies, some prescription medicines, infections, or head injury.

 

 What are the types of Migraine?

Types of migraine are based upon the nature and location of symptoms. Most common migraine is the migraine without aura. Some other types are as follows:

• Migraine with aura
• Migraine aura without pain, or migraine equivalent syndrome
• Menstrual migraine
• Ocular migraine
• Complicated migraine
• Hemiplegic migraine
• Brainstem migraine, used to be called Basilar migraine
• Status migrainosus, an intractable severe migraine not responding to treatment

 

What is Menstrual Migraine?

Many women have a predictable pattern of headaches around menstrual bleeding either before, during, or after, and sometimes all along. This headache may last many days, or a week or two, and usually is quite severe and disabling. It can have tremendous impact on patient’s physical, social, and mental wellbeing, with additional impact on people associated with the patient. It may be a difficult headache to treat, and usually require a combination of controlling or preventive pain medicines. Hormone treatment to regulate or control dramatic fluctuations in reproductive hormones can be helpful but does not work in all patients.

 

What is an Ocular or Eye Migraine?

In this migraine, symptoms are related only to an eye, or eyes, usually with no pain. Patient may have blurriness or distortion of vision usually lasting for a few minutes, and sometimes longer.

 

What is a Complicated Migraine?

This term implies a complicated set of symptoms lasting longer than a typical aura may last. In commonly seen cases of this condition, a patient may have weakness, numbness, unsteadiness, and difficulty speaking type of symptoms with a headache lasting for a day or days. These patients present with stroke like symptoms and signs, but have no evidence of stroke on brain imaging.

 

What is Hemiplegic Migraine?

In this rare type of migraine patients may have stroke like symptoms, like numbness or weakness of one side of the body. This migraine has a defined genetic basis, and the gene defect is known. In practice though, the gene test is rarely done, because of the ease of diagnosis from its history and presentation, and lack of any specific treatment.

 

What is Brainstem Migraine?

In this type of migraine, patient’s symptoms are from malfunction of the brainstem part of the brain. Its symptoms, other than severe headache, include dizziness, unsteadiness (walking like a drunk person), difficulty speaking (talking like a drunk person), yawning, nausea with or without vomiting, vertigo (false sense of motion), blurred vision or double vision, and may also be one-sided or bilateral weakness. Its previous name is Basilar Migraine.

 

What is Status Migrainosus?

It is a term for a severe continuous migraine lasting for hours to days, not responding to treatment. It may also be called intractable migraine. It is like the migraine switch is stubbornly on and despite trying multiple meds, not turning itself off. This may usually require hospitalization and treatment with stronger and injectable medicines.

 

What is Migraine Equivalent Syndrome?

Migraine is more than just a pain though headache being its main feature. Sometimes patients have many symptoms of migraine but no or minimal headache. It can be recognized by its particular history and pattern, with proper understanding of brain functions. There are number of different patterns, many so typical of migraine that if properly documented, require no further investigation. Treatment is reassurance and education of the patient, unless episodes are happening too frequently, in which case a migraine preventive medicine can be used. Pain medicine is not needed. Another name for this type of migraine is Acephalgic Migraine.

 

How is migraine diagnosed?

Unlike some diseases humans came across in recent history, like leukemia or prostate cancer, headaches and migraine have been known, treated, and documented for centuries. With centuries of collective medical knowledge, diagnosis of migraine is not that difficult to make. It is made based upon its particular set of symptoms. Other than in research settings, there is no test available to diagnose migraine. Its presentation is so typical that most of the time no test is needed to rule out anything else either. Even the type of migraine with stroke like features, if history is taken properly, is not difficult to diagnose.  Most patients of migraine in the world never have any test done, though this situation is different in USA. A lot many CT scans and MRIs of brain, many times repeatedly, are performed without solid medical reasoning.

Despite its common nature, ease of diagnosis, and standardization of treatment protocols, not every doctor, even not every neurologist, is comfortable with diagnosing and/or treating migraine.  May be, one way to tackle this issue and avoid unnecessary suffering and testing is to increase patient and public awareness about this condition.

 

Is there any migraine treatment other than medicines?

First, not every migraine needs a medicine. Many people have so mild migraine that it does not affect their quality of life, and many times they do not take any medicine. In many others, it is a rare occurrence, and they just prefer to sleep it over. For any headache that is more than a mild one intervention is needed. Following are some non-medicinal suggestions:

A: Resting in a quiet, dim or dark place

B: Sleeping

C: Avoiding bright light, especially flashes of light

D: Avoiding loud noise

E: Keeping quite

F: Avoiding certain foods and smells

G: Cold compresses

H: Head pressure-massage

I: Not skipping breakfast, and avoiding prolonged hunger

J: Appropriate hydration

K: Sleep hygiene

L: Avoiding alcohol

M: Stress management

N: Acupuncture

O: Avoiding heavy physical activity

P: Proper head cover, both in summer and winter

Q: Tying a tight bandana around the head

S: Sunglasses

 

What is Head Pressure-massage?

It is like the grandma way of treating a headache. Lay down in a quite comfortable and not well lighted place; put a pillow under your head; close your eyes; and ask someone to hold your head with both hands and put a little sustained pressure for a few seconds. Ask the person to change position of hands to cover different areas of your head including temples, but not eyes or face; and while this is happening, try to doze off. Mild to moderate migraine can be managed with a few minutes of this massage, or it could be a good additional component to other types of treatment.

 

How about natural remedies for migraine?

It is natural for people to ask for a natural way of treatment. With long collective experience with headaches and migraine, humans have tried any conceivable un-natural or natural mean of treatment. Usually quoted “natural” treatments are herbal or naturally occurring vitamins and minerals.

Probably the best known and most used, but usually overlooked, natural remedy for headache is caffeine, usually from tea or coffee. It is possible that the benefit of caffeine for headache is one of the main reasons for its initial human consumption. Caffeine has a complicated relationship with headaches. For someone who does not take it, a cup of tea or a light cup of coffee might be helpful. On the other hand, too much caffeine, and this amount varies for different people, may cause a headache. Someone taking a cup or two of tea or coffee daily and for some reason delaying or missing it can expect a headache. Caffeine can be a cause of headache, and its treatment, both in a cup and as a pill.

Caffeine is especially helpful in combination with other measures including some pain medications. Many caffeine containing combinations over the counter and prescription medications are available. It can be especially useful for someone with mild headaches. Other natural remedies sold for migraine treatment include magnesium, riboflavin, feverfew, and a variety of non-caffeinated teas. In my opinion, all these ingredients and combination of them are only marginally effective, or act as a placebo.

 

What about marijuana for migraine?

Due to complex legal reasons, formal experimental data is not available to provide an intelligent comment on effectiveness of marijuana for migraine. But there is no deficiency of claims from anecdotal experience. Looking at it in this manner, like other natural remedies, its effect on migraine is probably mild, may be like caffeine. One should be careful prescribing or taking any remedy for a life-long condition like migraine to avoid any unnecessary permanent injury to brain cells. Because of the federal restrictions attached due to its classified status in USA, medical research in marijuana is quite limited, and at this time not conclusive to make any formal judgment. This complex issue requires further exploration and formal scientific research.

 

What medicines are used for migraine pain?

The subject of migraine medicines is quite long, and I provide only an overview, useful for the patient. Following are the family of medicines used to treat migraine pain:

A: Non-steroidal anti-inflammatory agents or NSAIDs: They are the most used pain medicine and many of them are over the counter. For migraine pain, they are effective for mild to moderate pain, some little more effective than others. acetaminophen (Tylenol or Panadol) is mildly effective. Aspirin, ibuprofen (Advil or Motrin) and naproxen (Aleve) are little better, but also with more side effects (such as gastritis, high blood pressure and kidney problems). There are also some combination over-the-counter medicines sold for migraine. They usually have combination of acetaminophen, aspirin, and caffeine (like Excedrin Migraine). This combination is little more effective than other over-counter-medicines, but some patients do not tolerate caffeine well. There are also many prescriptions strength NSAIDs including higher doses of ibuprofen and naproxen, and medicines like diclofenac sodium. All these medicines have similar side effects and similar effect. Similarly, there are combination prescriptions strength medicines including Fioricet (butalbital + acetaminophen + caffeine), Fiorinal (butalbital + aspirin + caffeine), and Tylenol with codeine. They are about as effective as other NSAIDs but also potentially addictive.

 

B: Triptans (5-HT1B/D agonists)

These are the best medicine for migraine pain at this time in terms of efficacy and safety, if used as per recommendations. The most common one is sumatriptan (Imitrex). Oher examples are naratriptan (Amerge), rizatriptan (Maxalt), eletriptan (Relpax), zolmitriptan (Zomig), almotriptan (Axert), and frovatriptan (Frova). They have similar side effects and efficacy, though some are little better than others. They are not used in a patient with heart disease, or other vascular disease, or uncontrolled hypertension. Their common side effects are dizziness, lethargy, a constricted feeling around the neck and chest, and paresthesia. 

 

C: Ergotamines (5-HT1B/1D/1F agonist)

 In a way, they are the oldest migraine specific medicine, other than may be caffeine. The parent compound ergot is derived from a tree fungus, but modern medicines are made from its synthetic version, dihydroergotamine or DHE. It is taken as a nasal spray or an injection in hospital setting. It can have serious vascular and cardiac side effects. Other common side effects are nausea, dizziness, flushing, rhinitis, and altered taste sensation. Despite their significant side effects, this is a very useful class of medicine, especially for patients with severe intractable migraine not responsive to other medicines.

 

E: Ditans (selective 5HT1F agonists)

These medicines act on trigeminal system and do not cause vasoconstriction, making them relatively safe. Examples is Lasmiditan (Reyvow). It is about moderately effective, but because of lack of vascular side effects, it can be a useful choice for patients with heart or vascular disease, especially those who used to have good response to triptans. Common side effects are dizziness, sedation, paresthesia and fatigue. It also has mild abuse potential. Because of its sedative side effect, patients are advised to not drive for 8 hours after taking a dose.

 

F: Gepants (CGRP blockers)

This group include two types of drugs. Some are small chemicals like the Ubrogepant (Ubrelvy) and Rimegepant (Nurtec), given as tablets. They are moderately effective but relatively safe drugs, especially for patients with cardiac or vascular disease.

 

G: Opioids

For a life-long condition like migraine, habit forming medicines, especially opioids are best avoided. Sometimes they are used for acute treatment, especially in hospital settings. These medicines include codeine in its different preparations, tramadol, oxycodone, or butorphanol. In routine use, most of them are mild to moderately effective, but at the risk of addiction or intolerance.

 

Can electric stimulation help with migraine?

There is some evidence that mild electric stimulation with a TENS unit or a similar device applied to certain areas of head and neck can help to reduce pain of acute severe migraine. Its risk is negligible, but efficacy may be limited. It can be useful option during pregnancy and lactation, or for patients not able to take many other medicines, or not responsive to them.

 

How about transcranial magnetic stimulation?

Just like electric stimulation, it may have similar effects, but its availability is limited.

 

Does acupuncture work for migraine?

There is evidence that acupuncture can help with acute migraine and migraine control. Side effects are limited but the real issue can be its availability, logistics, and affordability.

 

Why does my doctor not prescribe more than a few headache pills for me?

It is well established that too much or too frequent use of pain medicines for migraine is not good and is counter- productive in controlling headaches. It can result in even more frequent or daily headaches that are called “rebound headaches,” or “analgesic rebound headaches”. Rebound headaches can easily become even more difficult to treat than the underlying migraine. Almost all medicines that we use to treat pain of migraine, over the counter and prescription can cause this problem. To avoid this issue, as a rule, pain medicines for migraine are limited to not more than 2-3 times a week. More frequent migraine headaches require additional treatment with controlling or preventive measures. 

 

What if I have more than 2-3 migraines a week?

Firstly, the solution is not to take more pain medicines. The solution is to bring the number of headaches down to a manageable amount, ideally zero but as little as possible. To reach this goal different set of medicines and measures are utilized. Medicines used for this purpose are called migraine preventive or controlling medicines. Following is a partial list of different classes of medicines used for this purpose:

Tricyclics: Amitriptyline, nortriptyline

Beta-blockers: Propranolol, atenolol, timolol, metoprolol

Calcium channel blockers: Verapamil

Anti-epileptics: Topiramate, valproic acid, gabapentin, pregabalin, levetiracetam

SNRIs: Venlafaxine, duloxetine

SSRIs: Sertraline, fluoxetine

ACE inhibitors: Lisinopril, candesartan

Antihistamines: Cyproheptadine

NSAIDs: Indomethacin

NMDA antagonist: Memantine

CGRP inhibitors: Ubrogepant (Ubrelvy), rimegepant (Nurtec ODT), Erenumab (Aimovig), Fremanezumab (Ajovy), galcanezumab (Emgality), eptinezumab (Vyepti)

It is important to note that many of them are not directly painkillers or analgesics. The choice of a medicine may depend upon what else a patient is suffering from, so to utilize one medicine for two or more problems.

 

Is Botox effective for migraine? 

In properly selected patients, treatment with Botox injections can help reduce the number and severity of headaches. This treatment is not for any migraine patient. In my practice, Botox injections are more useful in patients with frequent headaches associated with severe anxiety and stress. Botox treatment is usually offered to someone with too many headaches not responsive to standard above-described controlling medicines. It is only moderately effective and its common side effects include weakness of eye and face muscles, or temporary bruises.

 

Can migraine cause stroke?

Migraine alone is a relatively minor stroke risk factor. Its risk is little bit more with migraine with aura, but still small. If it is associated with smoking, and especially estrogen containing hormone treatment in women, it can be a significant risk factor. So the message to women with migraine with aura is, do not smoke and avoid hormone treatment with high estrogen level. Probably for this reason, there is an ultra-low level of hormone contraception, in a way, minimizing that risk. High blood pressure is the single largest modifiable risk factor for stroke, and its impact may be larger in patients with migraine. In such patients, use of a blood pressure medicine to control both hypertension and migraine may be a useful strategy.

 

Pregnancy and migraine treatment

In general, all medicines and chemicals should be avoided in pregnancy, especially in the first half of it. Due to lack of clinical studies, definitive data is not available to answer many specific questions. My recommendation is to utilize any or all of the natural treatments before considering taking a medicine. If needed, acetaminophen is usually the choice drug, though one cannot say that it is completely safe in pregnancy. Similarly, some other medicines like sumatriptan or butalbital/acetaminophen/caffeine combination can be utilized but with proper education of the patient and plentiful caution.

The situation during breastfeeding is somewhat less complicated but still not completely risk-free. Ample education and caution, and reliance on non-medicinal management are advised.

 

Can migraine cause nosebleed, or nosebleed a migraine?

Not really. Both problems can co-exist and get worse in certain drier times of the year. In some patients, nosebleed can be a sign of very high blood pressure that sometimes can also cause a headache. More commonly it happens due to a local problem in the nose, which may get aggravated in drier environment.

 

I get severe eye pain with migraine, is that normal?

It is not normal, but eye pain is a common symptom of migraine, in both or one eye. In such cases, especially with one-sided eye pain, blurred vision, watering and redness, one should have an eye examination to check eye pressure to rule out glaucoma. If eye pressure is normal, it is generally not a concern. In most cases of migraine, there is no particular risk to an eye. In rare situations, with a severe migraine, there could be some injury to the blood vessels supplying the eye or the nerves around the eye.

 

Can migraine cause seizures?

No, but they can co-exist. A seizure on the other hand can result in severe headache or migraine.

 

Can migraine cause unconsciousness?

In rare situations, with severe intractable migraine headaches, especially if patient is also dehydrated, fainting may occur.

 

I have frequent headaches; do I need a brain scan?

Typical cases of migraine do not require any testing to make or confirm the diagnosis of migraine. In some situation testing is recommended. Following are some of those situations:

A: Sudden worst headache of life, or sudden very severe headache

B: Sudden severe headache in certain situations when the brain pressure is usually high, e.g., at orgasm, straining to pass bowels.

C: Sudden change in headache pattern

D: Seizure or stroke like symptoms

E: Neurological findings on examination suggestive of brain dysfunction

F: Some cases of head injury

G: Finding of disc swelling on eye examination

 

What is the goal of migraine treatment?

As we do not have a way to permanently shut off the “migraine switch”, the goal of treatment is to minimize headaches, and minimize suffering and disability. Ultimately, any treatment plan is designed to improve quality of life.

 

Do people grow out of migraine?

In general, intensity and frequency of migraine increases with age, more so in women than men. It peaks around mid-forties or around menopause. After that age, migraine seems to regress but it never completely disappears. Also, with aging the nature and symptoms of migraine can change, and new symptoms may appear.

 

What should I do if I have migraines?

Discuss it with your primary care doctor. Share what type of treatment you already have tried and keep a log of the types of treatment tried. You do not have to make detailed notes; just names of the treatments and medicines usually suffice. Majority of patients who have migraine, do not even seek medical advice, but some need expert care. Most of the time, migraine can be managed at a primary care’s office.

 

What should I be careful about my treatment options?

Because of the common nature of migraine, and our tendency to keep on looking for a cure or a better or “natural” treatment, there is a lot of information available on the net or otherwise. Many of us get attracted to these infomercials. With due diligence, read, research, and discuss with your doctor before spending any resources or taking a risk on a treatment that may not have rightful claims of effectiveness or safety.

 

Where can I get more information about migraine or headaches?

A: American Academy of Neurology, AAN

B: American Headache Society, AHS

C: American Heart Association, AHA

D: National Stroke Association, NSA

E: Centers for Disease Prevention and Control, CDC