What to Expect
As we have emphasized at multiple points thus far in this book, migraine is a disorder that can be con- trolled—but not cured—and its clinical course is highly variable. While many exceptions occur, migraine tends to subside as we age. Female migraineurs frequently experi- ence worsening of their headache syndrome prior to and during early menopause but then enjoy lessening or even termination of migraine as more years pass. Even so, this course is far from inevitable; even if your sisters, your mother, and your mother’s mother all miraculously ceased having migraine following menopause, this does not en- sure you will duplicate their experience. Migraine is by no means a justifiable indication for performing a hys- terectomy/bilateral oophorectomy (removal of uterus and ovaries).
Courses of effective prophylactic therapy should help improve the natural history of your migraine by smoothing out those rough spots wherein you otherwise would suffer frequent or chronic headache. Effective abortive therapy should enable you to minimize the time you spend disabled due to a migraine attack or the side effects of any medica- tion taken.
It is our hope that for you, the individual reader and headache sufferer, the knowledge you gain from this book will lead you to a better understanding of your disorder and its appropriate treatment. Thus empowered and working in tandem with your physician, you may become your own best ally in managing your headaches.
Migraine: What You Can Do Introduction
While migraine cannot be cured, most patients with mi- graine can expect with education and treatment to achieve better control of their headaches. It is likely that many aspects of your life have been affected by your headaches, and, conversely, that there are circumstances in your life which influence your headaches. Effective treatment of your headaches will require more than a doctor’s prescription; optimal treatment implies a two way street—you and your physician working together.
What Is Migraine?
Everyone has a headache threshold, and given a suffi- cient stimulus, anyone can suffer a headache attack symptomatically identical to migraine. Individuals who
are said to have migraine appear to have a relatively low biologic threshold for headache; their headaches occur spontaneously or in response to internal and external stimuli (e.g., menstruation, weather changes, ingestion of alcohol) at a greater frequency than would be expected for the general population. This lowering of the headache threshold may be inherited, may be acquired (e.g., fol- lowing head trauma), or may occur spontaneously in the absence of any family history of migraine. While we re- main uncertain as to what precise physiologic and ana- tomic factors work together to cause migraine, it is clear that the brains of migraineurs may be especially sensi- tive and that transient changes in brain blood vessels oc- cur in many patients during an attack.
Acute (abortive) treatment for migraine involves an attempt to halt and reverse acutely the biologic process that is causing the headache. Preventative (prophylactic) treatment for migraine involves an attempt to raise the individual’s headache threshold and thus render him or her less susceptible to attacks.
What You Can Do
Start by recognizing triggers, or patterns which are head- ache producing. For example, can you count on getting a headache if you are sleep deprived or oversleep? if you drink wine? if you smoke a cigarette? if you are emo- tionally upset? On your first day off after a hard week at work? When you menstruate? These and other factors commonly aggravate migraine and keeping a headache diary may help you identify which of them regularly con- tribute to your particular headaches. For some people,
merely avoiding such triggers may reduce or eliminate the majority of the problem.
For everyone who suffers from migraine, an impor- tant point to emphasize regarding treatment is consis- tency of lifestyle. Many inpatient units designed for the control of headache utilize a very regimented schedule, and to some extent, it may be worth trying this on your own. For example, eat at regular intervals; attempt to go to sleep and awaken at the same time each day; avoid foods that seem to have provoked headaches in the past;
begin a regular aerobic exercise program; and take any medications prescribed at consistent and appropriate intervals.
The effect of diet on migraine is controversial and varies widely from individual to individual. A complete diet list has been prepared by the National Headache Foundation and may be obtained by contacting that or- ganization. Dietary suggestions for headache prevention include:
1. Be wary of alcohol: Aromatic alcoholic beverages (red wine, champagne, liqueurs, brandy, scotch) are par- ticularly prone to cause headaches; vodka appears to be somewhat less likely to provoke an attack.
2. Be wary of aged or “strong” cheese.
3. Use monosodium glutamate (MSG) sparingly.
4. Be wary of cured meats (such as hot dogs or salami).
5. Use caffeine sparingly. Chronic, extensive ingestion of caffeine (in coffee, tea, soft drinks, and certain med- ications) may worsen migraine overall, and even short periods of caffeine withdrawal may provoke a severe migraine attack.
6. Avoid skipping meals, prolonged fasting, or excessive ingestion of sweets.
There are many great reasons not to smoke. For one, smoking may aggravate migraine.
A relationship exists between migraine and emo- tional stress. An acute migraine headache is certainly stress producing, and stress usually worsens the inten- sity or frequency of migraine attacks. While migraine is not “just nerves” or strictly psychosomatic, many pa- tients will have a headache during or immediately after a stressful period. Stress is often impossible to avoid, but you can learn ways to recognize and deal with stress more effectively as it arises. This may include such sim- ple measures as getting up from your desk from time to time to stretch your neck and legs, employing a babysit- ter one afternoon a week or exercising on a regular ba- sis to relieve frustration, relax musculature, and improve cardiovascular tone. Exercise can be anything from a ten- minute daily walk to much more strenuous activity.
What is important is that it suits your lifestyle and pro- motes your sense of physical and emotional well-being.
In some people, feelings of anxiety, anger, or impa- tience seem to be linked to their migraine. You must de- cide how true this is for you. Your headaches may be telling you that you need to alter certain circumstances or interactions with people in your life. Easy enough to say! This is clearly a lifelong process.
If your problems with headache are frustrating to you, it is probably safe to assume that those close to you also are frustrated. It may be helpful for you to discuss with them what you have learned about your head-
aches—preferably not when you are having one. They also may gain reassurance (and a measure of compas- sion) from speaking with your physician and being in- formed of the treatment plan.
There are a variety of resources available to help you understand and cope more effectively with your head- aches. If you have heard about and would like to try ex- ercise regimens, stress management courses, biofeedback training, acupuncture, dietary changes, or psychological counseling for help with your headache control, please ask your physician for assistance. For certain patients these can be quite useful and may have a place in your treatment program. One cautionary note in selecting such programs: beware of those that promise a cure for headaches.
Another obvious treatment for migraine involves use of medications, either prescription or over the counter.
Avoid both over treatment and under treatment of your headaches. Many medications prescribed for migraine can actually cause headache if taken too frequently or if taken at inappropriate times. On the other hand, if you are given a medication to abort attacks, do not wait to take it until your headache has become so severe that nothing is likely to help. A sufficient dose of aspirin taken early may go a lot further towards providing relief than narcotics given too late.
During a migraine attack, take whatever medication your doctor has prescribed. If possible, lie down in a quiet dark room with your head slightly raised. If you can take fluids, try caffeinated coffee, tea, or soft drinks. Some people find relief by pressing on the affected part of the head or by applying ice packs. After the acute attack has
subsided, try to remain in bed or at least relax for a while longer. Keep a record of your acute headache attacks.
This information should be communicated to your doc- tor, as it may assist in designing an optimal treatment program.
Migraine: What Your Doctor Can Do
Based on your history and the results of your medical evaluation, a treatment plan is constructed. This is some- thing you and your doctor must do together, and you should expect your doctor to share his/her thoughts on the treatment plan and goals. Treatment plans always in- volve an ongoing process of educated trial and error in an effort to discover what works best for you.
If your doctor suggests a medication (either pre- scription or over the counter), it is crucial that you un- derstand its action, how you should take it for optimum benefit, and what side effects may be associated with its use. There is a vast array of medications available for the treatment of migraine; none, unfortunately, is universally effective for all patients, and most have potential side ef- fects. Again, treatment should be a cooperative process, involving active participation by both doctor and patient.