Migraine headaches

Dear Low Tolerance,

Headaches are one of the most common reasons people seek medical care, so your wife is in good company. While the treatment and prevention of migraines is complex, many health care providers and people suffering from head pain suggest that the best way to manage these conditions is to identify the underlying cause. Identifying the type of headache she's experiencing (i.e., being sure it's a migraine) can help to ensure the right combination of medication and lifestyle adjustments may be made.

There are multiple types of primary headaches (headaches not caused by another medical condition), such as:

• Tension-type headaches: These are the most common form of primary headache with 75 percent of people experiencing one in their lifetime. These headaches typically last anywhere from 30 minutes to seven days, occur on both sides of the head, and rarely disrupt normal daily activities despite people describing feelings of having a “band around their head.” Treatment usually consists of over-the-counter analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) such as Motrin (generic name: ibuprofen) or aspirin. Some people find better relief with combination treatments of analgesics and caffeine. A possible combination might contain acetaminophen, aspirin, and caffeine. Overall, tension-type headaches are usually treatable at home.
• Cluster headaches: These occur in cyclical patterns or cluster periods characterized by multiple, short attacks (clusters) of periorbital (around the eye) pain that may last from weeks to months, followed by a period of remission. People typically describe pain in the periorbital region and on one side of the head. Other symptoms may include excessive tearing and eye redness on the affected side. These cluster attacks might occur seasonally or follow a similar pattern, unique to each person. Remission, a period of no headaches, may last anywhere from months to years. These are the types of headaches that may wake people at night with intense pain, which may last from 15 minutes to three hours. Treatment of these headaches focuses on preventing the attacks, which may involve reducing exposure to underlying triggers such as alcohol, stress, and sleep disturbances.
• Migraines: These are a type of neurovascular headache. During migraines, abnormalities in the constriction and dilation of blood vessels and subsequent interactions with nerves causes a throbbing pain, often on one side of the head. While experiences vary, the four phases of a migraine might include: prodome (early symptoms), auras (changes in vision or other neurological symptoms), attack (pain sometimes accompanied by vomiting), and postdrome (fatigue). People may either experience migraines “with aura” or “without aura.” Although the cause of migraines is still not well understood, there seems to be a genetic component. It's believed that neurotransmitters (such as serotonin) and nerve pathway disrupters play a role in causing migraines in some people.

Because your wife may be suffering from migraines, it might be helpful to discuss specific treatment and prevention strategies. Medications that are used in the treatment of migraines are considered abortive therapies and are taken during migraines attacks to stop symptoms. Over-the-counter medications (such as ibuprofen and aspirin) may not be sufficient to treat ongoing migraine pain. Therefore, a class of drugs called triptans have become the most popular and widely used migraine medication. Triptans work by normalizing the dilated intracranial arteries (blood vessels in the brain) and inhibiting excessive nerve stimulation and transmission. Example of these drugs include sumatriptan and zolmitriptan, which come in pill form. A word of caution: overuse of these medications may cause medication overuse headaches (MOH) or rebound headaches. If migraines are frequent, a preventive medication may be prescribed.

Non-medical treatments for migraines may include:

• Stopping current activity and moving to a location where you may turn out or dim the lights.
• Using a cold or hot compress on the head or neck.
• Drinking a caffeinated beverage (this is best in the early stages of migraine pain).

List adapted from Mayo Clinic. 

However, if your wife is someone that gets frequent migraine headaches, it may be beneficial to look into preventative strategies. For instance, the American Migraine Foundation suggests that it may be time to start a preventative strategy if a person is using abortive medications more than two days per week. Ideally, the migraines would stop completely; however, a successful regimen of preventative medication may only cut the frequency, severity, or intensity of the migraines in half. But that's still a win most of the time!

There are multiple categories of preventative medications for migraines that might be considered:

• Blood pressure medications: These medications help address elevations in blood pressure and reduce anxiety, which many people who suffer from migraines may experience, go figure! 
• Anti-seizure medications: Certain anti-seizure medications such as valproate sodium and topiramate are Food and Drug Administration (FDA)-approved for migraine prevention and may be just as effective as blood pressure medications.
• Antidepressant medications: These medications often work by helping with sleep, mood, and anxiety, which are all factors that play a painful role in migraine onset.
• Nutritional supplements, vitamins, and minerals: Examples include: melatonin, riboflavin, magnesium citrate, coenzyme Q10, and feverfew.
• OnabotulinumtoxinA (Onabot): This is one of the few FDA-approved medications for preventing chronic migraines (defined as migraines for at least 15 days per month for at least four hours per day). Onabot is administered through many small injections in the head and neck.
• Injections: The newest options on the market are injections that target the calcitonin gene-related peptide (CGRP). These are some of the first preventive medications that were specifically designed for migraines. They block a pathway in the brain that may contribute to migraines.

Non-medical preventative therapies for migraines may include:

• Behavioral treatments, such as cognitive-behavioral therapy, biofeedback, or relaxation strategies.
• Lifestyle changes, such as keeping a regular schedule of sleep, physical activity, and meals, along with refraining from taking medications that contain the hormone estrogen.
• Stress reduction, as stress can be a common trigger for migraines. 
• Keeping a diary to help determine what triggers the migraines. In this journal it may be helpful to note what was happening at the time of onset, how long the migraine lasted, and what provided relief (if anything).

Despite how it may feel, your wife’s migraine isn't all in her head. Encouraging your wife to work with a health care provider may be helpful, as they can make recommendations for the appropriate treatment based on her experiences. Hopefully you and your wife find these migraines to be less of a pain!