Common Questions About Migraines... and the Answers

No. Most people will suffer from headache at some time during their lives and these can usually be resolved with a couple of simple painkillers, a short rest or something to eat. A migraine can be much more debilitating. Symptoms can include visual disturbances such as flashing lights, zig-zag patterns or blind spots in the vision, an intense throbbing headache, often on one side of the head only, nausea and vomiting and increased sensitivity to light, noise and strong smells. Some people can also experience difficulty in co-ordination, slurring of speech and tingling, pins and needles or numbness of the limbs on the affected side of the body. A migraine attack can last for anything from 3 to 72 hours.

There is no definitive test for migraine such as an X-ray or blood test, diagnosis depends on careful history taking, so there is no absolute proof that an individual is a migraine sufferer. During an attack some people will appear deathly pale or take on an almost grey appearance with dark circles under their eyes. Their concentration may deteriorate, they may have difficulty in focusing, be unable to articulate as clearly and concisely as usual or move more slowly and deliberately in order to overcome co-ordination problems. However unless you know a person well or observe them closely these changes may not be immediately noticeable. Obviously some people are more severely affected others and many migraineurs are accomplished in managing their condition and disguising it from their employers and colleagues. Migraine has been described as "the hidden disease" as there are often no external signs of the sometimes extreme pain of the sufferer; a broken limb will attract a good deal of attention and sympathy but may not be as painful as a single migraine attack .

It is a common misconception that if you don't see "flashing lights" you can't be suffering from migraine. In fact only 10-15% of migraineurs experience visual disturbances. This type of migraine is called migraine with aura formerly known as classic migraine. I met a colleague out shopping this morning and she seemed absolutely fine but when I got to work for the evening shift the supervisor told me that she wasn't coming in because of a migraine. I think she just felt like an evening at home.It is a feature of migraine that sufferers are quite well between attacks. Migraine attacks can strike at any time, often without any warning. Attacks can develop very quickly in some people. Non sufferers find it difficult to understand how someone can be perfectly well one minute but almost totally debilitated a couple of hours later.Some migraine sufferers experience a feeling of exceptional well being shortly before an attack strikes and during this period they may be especially bright and chatty making it even more difficult to believe that they can be so ill a short time later.

Migraine triggers are numerous and varied and occur in combinations almost peculiar to each individual. They include stress, overtiredness, insufficient food or long gaps between food, changing sleep patterns (e.g. shift work), environmental factors such as poor lighting, a hot, stuffy or smoky atmosphere, loud noises or strong smells and emotional traumas. Food may not be implicated at all. It can be helpful to keep a migraine diary to try to identify trigger factors. For most people an attack is not triggered by one thing but by a combination or accumulation of factors which individually can be tolerated but when they all occur together a threshold is passed, triggering an attack. It can work like a kind of points system: if for example your migraine threshold is 10, eating chocolate may be 2 points, a stressful day 4 points, missing lunch 3 points and you will still feel fine but if you then have a glass of wine (possibly 2 points) or a late night (3 more points perhaps?) an attack may be triggered. It is easy to cite the wine as the trigger factor when in fact this could quite probably have been drunk without any ill effects if the other trigger factors were not also present.

It is believed that everyone has the potential to experience a migraine attack. We all have a personal threshold beyond which an attack will occur. For the 10% of the population who regularly suffer migraine this threshold is lower, possibly because of a genetic predisposition.The threshold can also be lowered at certain times of your life such as times of additional pressure (e.g. coming up to an important deadline), during emotional traumas (e.g. bereavement, divorce etc.) or when the immune system is lowered by other illnesses. Migraine can affect people from all age groups, all social classes and ethnic origins and research has shown that there is no such thing as a "migraine personality". However migraine is most prevalent in the 20-50 age group.

Although over three times as many women as men suffer from migraine, possibly because of the involvement of hormonal factors, around 8% of the male population experience migraine. Their attacks can be exacerbated by pressures of being the principle breadwinner for the family (especially if loss of earnings is a result of taking time off) and a tendency to hide their condition for fear of being branded a wimp, particularly by male colleagues.

We now know that children and even babies can suffer from migraine.

Sometimes in young children the predominant symptoms are abdominal pain often accompanied by nausea and vomiting and it is only the regular intermittent pattern of the attacks, sometimes coupled with a family history of migraine that suggest the diagnosis.

When the more typical migraine symptom of headache occurs in children they will often report it in the forehead or the middle of the head rather than on one side.

Children may also experience symptoms including pallor, sometimes with dark rings around the eyes, dizziness, confusion, lack of co- ordination or occasionally non specific aches and pains in the limbs. Children with migraine often have a tendency to travel sickness.

Attacks in children are usually shorter than in adults.

During a migraine a child will usually want to sit or lie quietly and may refuse food. A child who complains of headache and then runs off to play does not have migraine.

It is useful to keep a migraine diary to try to establish any pattern to the attacks. Dramatic improvement can be achieved by the avoidance of trigger factors. One of the most common trigger factors in children is lack of food or long gaps between food and attacks can often be eliminated completely by eating small regular meals containing slow release carbohydrate; migraine precipitated by a long overnight fast can often be overcome with a snack at bedtime (e.g. a bowl of cereal) and a substantial breakfast.

While migraines may be excruciatingly painful, the vast majority of them pose no serious health risks. However, not all painful headaches are migraines, and some can be indicative of more serious medical problems. You should always get a proper diagnosis from your doctor.

According to traditional classification schemes, the two most common types of migraine are classic, and common. In classic migraine, the headache is preceded by an "aura", which usually consists of visual disturbances (but can involve the other senses such as the sense of smell). Common migraine has no aura.

While the incidence is very, very small, migraine sufferers are slightly more likely to suffer strokes at a young age (under 50) than the rest of the population. Migrainous stroke (stroke occurring during a migraine) usually shows aura-like symptoms and most commonly affects the visual system.

There are other, potentially life threatening, medical situations that can mimic migraine (brain tumors, lesions, etc.). Therefore, it is advisable to see your doctor if you have not previously been diagnosed, especially if you have suddenly begun having severe headaches and were not previously prone to them.

Most obviously, headache, beginning as a dull ache of head and/or neck, and building to extreme, throbbing pain. Pain is usually, but not always, confined to one side of the head, and persists for at least several hours (or longer). After the pain subsides, the migraine sufferer is commonly left feeling tired or drained, and occasionally elated.

Other characteristic symptoms (may occur before and/or concurrently with headache):

• constipation or diarrhea
• irritability
• nausea and/or vomiting
• sensitivity to light
• sensitivity to noise
• sensitivity to odors
• tender scalp
• visible enlargement of blood vessels
• neck and/or shoulder pain and stiffness
• extremity pain
• numbness
  

Aura (usually preceding pain in classic migraines):

• visual disturbance
• blind spots
• flashing lights
• tunnel vision.
• visual and auditory hallucinations
• zig-zag patterns
• numbness of parts of body
• ringing in ears
• speech disturbance
• other sensory disturbances
• blurred vision
• visual hallucinations
• olfactory hallucinations
  

Other common symptoms:

• abdominal distention
• chilliness
• cold extremities
• compulsion to yawn
• dry Mouth
• edema
• excessive sweating
• heavy or light nasal drainage
• increased urine activity intellectual disturbance (e.g. confusion, difficulty concentrating, or increased ability to think clearly prior to headache onset) mood changes
• sensitivity to touch
• tremors
• vertigo
• increased heart rate

While the exact physiological cause of migraine is poorly understood, researchers have made some progress in understanding what happens during an attack. Of course, there are various theories as to what causes them.

Vasocative Amine

The vasoactive (acting on blood vessels) amine (class of substances that can cause inflammation) theory seems to be the leading hypothesis about the cause of migraine. The release of these substances into the cranial blood vessels leads to an inflammatory reaction (i.e. painful, distended blood vessels). What causes this release is unclear, but it could be the result of pain information being transmitted by nerve fibers that run along the cranial arteries. When they are depolarized (sending signals) they release peptides into the vascular walls which can lead to this reaction.

Researchers do seem to agree that migraine is definitely a disorder of cerebral blood flow, and is under the control of many (poorly understood) factors.

That said, while most agree that cerebral blood flow changes are an important feature of migraine, and the distention of the blood vessels surrounding the skull is the cause of the pain, most researchers no longer support the idea that the blood flow changes are the actual cause of migraine.

Other substances and syndromes you may have heard about in relation to migraine:

Serotonin

Blood seratonin levels fluctuate during migraine (they increase during the pre-headache phase, and drop during the headache). This is likely to be caused by an alteration in blood platelets. Platelets, which store serotonin, exhibit chronic aggregation in migraine patients and increase their adhesiveness prior to an attack. They also affect the amount of vasoactive amines in the blood.

Magnesium and Spreading Depression

Spreading depression, characterized by a gradual wave of decreased cortical activity that starts at the back of the brain and gradually moves toward the front, occurs in people suffering from classic migraine. It coincides with the symptoms of the aura. This effect can be induced in animals, and is more easily induced when the magnesium (Mg) concentration is low. Not surprisingly, Mg tends to be low in classic migraine sufferers, especially during an attack.

Reduced Cerebral Blood Flow

Following the spreading depression, classic migraine sufferers also experience a wave of reduced cerebral blood flow that follows the same pattern. It could be a response to the decreased activity from the spreading depression, but this is just a theory. Reduced cerebral blood flow also occurs during the aura phase. Blood flow is increased during the pain phase of the migraine.

While reduced blood flow has not been consistently demonstrated in common migraine, there is evidence that common migraine sufferers do experience an increase in cerebral blood flow during the headache phase.

Circadian pattern of migraine

There is some evidence that migraines are more likely to occur at certain times of the day. The most frequent period of onset seems to be the mid to late morning. This pattern, which follows that of myocardial infarction and platelet aggregability, among other things, suggests that alteration of vasomotor tone may be involved in migraine initiation. Another study suggests a possible link of migraine occurrence to the environmental factors that entrain the routines of peoples' lives.

Regardless of the physiological underpinnings, many migraine sufferers have identified things that seem to trigger an attack. While triggers are different for everyone, some of the most common ones are listed below:

Environmental Factors:

• Altitude changes
• Air pollution (including ozone and smog)
• Bright sunshine or lights
• Fluorescent lights, or any flickering light, such as rooms with ceiling fans, sun-light streaming through venetian blinds, strobe lights, computer monitors, etc.
• Headbands or tight ponytails
• Loud or repetitive noise, such as crying babies, cooling fans, power supplies, echoing hallways, etc.
• Perfumes--some common triggers are musk and oris root
• Other strong odors or chemicals, such as cloth sizing, paint, garbage, automobile exhaust, etc...
• Weather changes (barometric pressure change, change in humidity change in temperature, thunderstorms and strong winds)
• Stale air
• Seasonal changes (spring and fall are usually the worst)
• Winds (recent studies have shown a correlation between Chinooks and migraine)
  

Food/Drink:

• Alcohol (especially red wine)
• Aspartame
• Caffeine (relieves migraines for some)
• Coconut and coconut oil (including suntan lotions)
• Citrus
• Pineapple
• MSG (monosodium glutamate--often labeled as "autolyzed yeast extract," "hydrolyzed vegetable protein," or "natural flavoring") MSG can be found
• Chinese food
• Broth or stock
• Canned or instant soup
• Whey protein
• Textured soy protein and soy extract
• Spices and seasonings
• Meat tenderizer
• TV dinners
• Malt and barley extract
• Chicken, pork and beef flavoring (including smoke flavor)
• Processed meat
• Caseinate
• Dry-roasted nuts
• Some potato chips
• Buttermilk
• Nitrites (found in cured meats such as bologna, hot dogs, brats, ham, etc.)
• Olive oil
• Salt
• Pickled or marinated foods
• Sour cream or yogurt
• Sauerkraut
• Onion
• Fried food
• Seafood
• Pork and chicken liver
• Food dyes (esp. red)
• Wheat products
• Sodium phosphates
• Sulfites

Tyramines, found in many foods, including:

• Avocados
• Bananas
• Beans (except green)
• Strong or aged cheeses
• Chocolate
• Corn
• Cultured dairy products, e.g. buttermilk, sour cream
• Eggplant
• Dried fruit
• Kiwis
• Chicken livers
• Mangos
• Aged, canned, or processed meats
• Mincemeat
• Nuts and seeds, including peanuts
• Papayas
• Pickled vegetables
• Red plums
• Sauerkraut
• Snow peas
• Strawberries
• Spinach
• Canned and powdered soups and bouillon
• Soy sauce
• Tomatoes
• Yeast extracts
• Home made yeast breads or products (when fresh--cooled and reheated is OK)
  

Other:

• Skipping meals
• Oversleeping or lack of sleep
• Cleaning agents or scented dryer sheets and detergents
• Airplane trips
• Birth control pills (can increase frequency of migraines, as well as incidence of stroke in migraine sufferers by as much as 12 times the normal rate.
• Progesterone only pills may work for some.)
• Cigarettes/cigars/pipes (tobacco in general)
• Dehydration
• Exercise (though it relieves headaches for some)
• Hormonal changes in women (migraines may increase before, during, or after menses, and often disappear after the third month of pregnancy.)
• Hypoglycemia (low blood sugar--can be caused by fasting, eating a lot of carbohydrates at once, or excessive sleep)
• Physical trauma
• Pressure on the head (but can also relieve headaches for some)
• Change in sleep patterns
• Sex (can relieve migraines in some people)
• Steroids
• Stress, especially the reduction of stress (e.g. the "weekend headache" syndrome)
• Power of suggestion (e.g. reading this group, really)

Yes. Women are more likely to be classic or common migraine sufferers. Estimates vary, but they hover at around 70%.

Migraines can begin at any age, but most develop them around adolescence or in the 20's.

Usually. Most migraine sufferers have a close family member who also gets them. According to Neil Raskin in his book Headache: 50-60% of parents of migraineurs have a history of migraine vs. 10-20% of parents of headache-free subjects.

Frequency is highly variable, and to some extent depends on what your individual triggers are. In general, common migraines are said to occur more frequently than classic ones, and no matter what type you suffer from, the frequency usually decreases with age. Migraines can occur from once a day or as rarely as once a year.

Yes, migraine sufferers also commonly get tension headaches. Tension headaches are characterized in part by an inability to relax the scalp and neck muscles. Low serotonin has been implicated in tension headache pain. They worsen with vasoconstrictive drugs, and get better with vasodilators.

Many migraine sufferers suffered from motion sickness as children, and continue to suffer from it as adults. Migraine sufferers may also be more prone to motion sickness.

There may be a connection between allergies and migraines, although the results are somewhat inconclusive. Some believe that food allergies can cause migraines, and that histamine levels in the blood can trigger a headache. Others are finding a connection between migraines and other types of allergy (such as asthma, hives and rhinitis). There is some indication that this association is stronger in children.

No. Previously, migraines were thought to occur mostly in people who fit a specific psychological profile. Migraine sufferers were said to be neurotic, obsessive, compulsive, rigid, and to suffer from repressed hostility. Research done in the last 15 years has shown that migraine sufferers, in fact, have psychological profiles no different from anyone else. Many physicians, however, still cling to the old stereotype. Hopefully, this is changing with the new research being done on the causes of migraine.

Non-Migraine Headaches and Rare Forms Of Migraine

Abdominal Migraine

Symptoms may include stomach pain (which can be severe), bloating, nausea, vomiting (sometimes vomiting a bile-like substance) or diarrhea. This type of migraine is seen more often in children. The above symptoms may or may not be accompanied by a headache.

"Ice Pick" headaches

These headaches have been defined as short lived (only seconds in duration) pain that feels as if an ice-pick has been stabbed through part of the head. They can recur over and over throughout the day. Migraine sufferers are more likely to experience them than non- migraine sufferers, but they tend to occur between migraine headaches, rather than as a migraine accompaniment.

Chronic daily headache (aka. transitional, transformational, or combination headaches)

Combination headaches have symptoms of both chronic tension and migraine headaches. They are characterized by dull, continuous, bilateral pain that worsens as the day goes on and is usually associated with migrainous symptoms such as photophobia, phonophobia and nausea. This pain can be interspersed with severe or acute migraines. To be classified as having chronic headache, a person must suffer from them at least 15 days a month for at least 6 months. One study has found that most people with chronic daily headache started out as migraine sufferers whose headaches gradually evolved into the chronic daily type over a number of years. Standard migraine therapy is, in fact, often the most effective way to treat these headaches.

People who suffer from combination headaches frequently end up chronically overusing analgesics or ergotamines, which, paradoxically, can trigger rebound headaches. People suffering from chronic daily headache typically have a family history of headache, and it has been suggested that many also suffer from depression, anxiety, and sleep disturbances.

Combination headaches are typically difficult to diagnose and treat. You may need to try several types or combinations of prophylactic and abortive medications before you find something that works. You may also have painful withdrawal from accustomed use of analgesics or other medications. Above all, see your doctor. The first line of defense is a continuous relationship with a trusted physician. (Text originally submitted by Peggy Parker, who thanks Dr. Kent England for working with her so compassionately to control her headaches)

Occipital Neuralgia

Symptoms: Headache that is localized or following a "ram's horn" pattern on the side of the head, often starting in the upper neck or base of the skull; scalp that is tender to the touch, often hypersensitive; pain at the base of the skull; reduced ability to rotate or flex the neck; shoulder pain; pain or pressure behind the eyes; eyes are very sensitive to light, especially when the headache is present.

The headaches almost never stop. Various medications help a little for a while, but it seems the best way to reduce the pain is to have someone rub the back of your head and neck. Occipital neuralgia is used to describe a cycle of pain-spasm-pain originating from the suboccipital area (base) of the skull that often radiates to the back, front, and side of the head, as well as behind the eyes. Occipital neuralgia occurs more often in women than men. Commonly the nerves are inflamed and sensitive because they are trapped within the muscles through which they pass. Muscle spasm and pain are often associated with nerve entrapment, which causes localized pain, spasm and muscle cramping.

Hemiplegic Migraine

Sufferers experience a motor deficit on one side of their body that outlasts the headache phase. Sensory deficits also frequently accompany the motor problems.

Basilar Artery Migraine

This is more common in women than men, and more common in teenagers than other age groups. This type of migraine includes at least some of the following symptoms, as well as the headache, which may precede or accompany the pain: ringing of the ears, hearing loss (sometimes fluctuating), vertigo, disturbance of gait, bilateral numbness or tingling in the limbs, loss of consciousness. The headache is almost always bilateral, and is usually located at the back of the head.

Dysphrenic Migraine

Many migraine sufferers experience some disturbance of mental functioning during an attack. People who suffer from dysphrenic migraine experience severe disturbance of it. Symptoms include: loss of memory (amnesia), severe disorientation, confusion, agitation, with or without accompanying headache.

Exertional Headaches

This type of headache is a migraine, usually of relatively short duration, which is brought on by physical activity, such as running, weight-lifting, or even sex. It can also sometimes be triggered by coughing or sneezing. This type of headache occurs more commonly in people that suffer from other types of migraine as well.

Hemicrania Continua

Rare one-sided headaches which last from 5-60 minutes and include dull, throbbing or severe pain, which is pulsating with several minutes of intense "ice pick" type pain. They occur up to five times in a 24-hour period. Alcohol and exercise often increase the pain, and sufferers may have other symptoms of migraine, such as light sensitivity and nausea.

Chronic Paroxysmal Hemicrania

This condition is characterized by frequent headaches in any one day, as many as 10 to 30. These headaches are brief and very severe, and seem to only respond to indomethicin (Indocin).