2006-08-22
Dawn/The New York Times News Service

Everything you thought you knew about migraine headaches — except that they are among the worst nonfatal afflictions of humankind — may be wrong. At least that’s what headache researchers now maintain. From long-maligned dietary triggers to the underlying cause of the headaches themselves, longstanding beliefs have been brought into question by recent studies.

As if that were not enough dogma to overturn, there is growing evidence that almost all so-called sinus headaches are really migraines. No wonder then that the plethora of sinus remedies on the market and the endless prescriptions for antibiotics have yielded so little relief for the millions of supposed sinus sufferers.

While these findings may not be an obvious cause for joy among the afflicted, the good news is that there are available many drugs that can either prevent migraine attacks in the frequently afflicted or abort the headaches once they start.

Knowing where to turn

Migraine therapy has come a long way in two decades, and those who know or suspect that they have migraines would be wise to see a neurologist or a headache specialist to obtain a proper diagnosis and the best treatment now available. Surveys have indicated that only about half of “classic” migraine sufferers are reaping the benefits of what modern medicine offers.

If those presumed to have sinus headaches are included, the number of underserved migraine sufferers could easily be doubled. The World Health Organisation ranks migraines among the most disabling ills. About 28 million Americans suffer from severe migraines that leave them temporarily unable to function at work, at home or at play.

Many more millions have them in milder forms. All told they cost employers about billion a year in lost productivity, with another billion spent on medical care.

A migraine is more than a headache. The throbbing pain of a migraine, which typically occurs on one side of the head, is often accompanied by nausea, vomiting and extreme sensitivity to light and sound. A person feels sick all over.

Symptoms may include nasal stuffiness, blurry vision, diarrhoea, abdominal cramps, abnormal sensations of heat or cold, anxiety, depression, irritability and inability to concentrate. Without effective treatment, those most severely affected are unable to cope with even the simplest tasks and must take to their beds until the attack ends.

Afterwards, people often feel tired, irritable, listless or depressed, though some feel unusually refreshed and energised. About 4 per cent of prepubescent children have migraines. After puberty, the incidence rises to 6 per cent among men and 18 per cent among women and gradually declines after age 40.

The higher rate among women is linked to fluctuations in blood levels of estrogen; the drop in estrogen just before menstruation sets off menstrual migraines, which tend to be more severe and longer lasting than other forms. I suffered from estrogen withdrawal migraines three times a month from age 11 until menopause.

Each attack lasted three days. Pregnancy, when estrogen levels remain high, was my only respite until menopause ended the estrogen fluctuations.

Though long believed to be primary vascular headaches, the result of constriction then expansion of blood vessels in the head, migraines are now recognised to stem from neural changes in the brain and the release of neuro-inflammatory peptides that in turn constrict blood vessels.

The headache often begins before these vessels dilate. The inflammatory peptides sensitise nerve fibres that then respond to innocuous stimuli, like blood vessel pulses, causing the pain of migraine.

In some people, the headache is preceded by an aura of visual, sensory or motor symptoms that last for less than an hour. They include seeing flashing lights or specks, numbness in the hand, dizziness and an inability to speak. People who experience these have a doubled risk of cardiovascular diseases, according to findings published last month in The Journal of the American Medical Association.

Migraines sometimes run in families, and these familial migraines have been traced thus far to mutations in either of two genes. Although hard to mistake in their classic form, migraines can be — and apparently often are — misclassified as sinus or tension headaches, probably because they can cause nasal congestion, pressure or pain in the forehead or below the eyes, and discomfort on both sides of the face.

The right diagnosis

In one study by Dr Eric Eross of Scottsdale, Arizona, 90 of 100 people with self-diagnosed sinus headaches were found to have migraines. On an average, they had seen more than four physicians for their headaches before getting the correct diagnosis and significant relief.

Neither the American Academy of Allergy, Asthma and Immunology nor the American Academy of Otolaryngology recognises “sinus headache”; headaches only sometimes occur with sinus infections. Migraine sufferers have long been cautioned to avoid certain foods believed to bring on attacks, especially chocolate, alcohol (red wine in particular) and aged cheese.

But the evidence supporting this notion is meagre. More common causes include stress (positive or negative), weather changes, estrogen withdrawal, fatigue and sleep disturbances (hence, perhaps, the association with alcohol, which can disrupt sleep), as well as overuse of over-the-counter pain medications.

To determine what may set off your headaches, keep a calendar to record occurrences, noting foods you ate or the circumstances preceding each one. If you are a woman of childbearing age, record the stages of your menstrual cycles. If necessary, to uncover foods that may cause your headaches, try an elimination diet, cutting sharply on various foods, then reintroducing them one at a time. This way, a friend discovered that her migraines were set off by corn and corn products.

Preventives and treatments are numerous. If one doesn’t work, try another. If your migraines are rare, using a drug in triptans class at the very onset of a headache can usually abort it or reduce its severity and duration. Frequent migraines are best treated preventively, with rescue medication — like a triptan or an opiate, perhaps combined with aspirin, amphetamine and caffeine to relieve a breakthrough headache.

Among the medications most effective as preventives are tricyclic anti-depressants, beta blockers like propranolol and anti-epileptic drugs like gabapentin. Some people are helped by relaxation therapy, biofeedback or stress management. Several good studies have shown benefits from supplements of the B vitamin riboflavin (400 milligrams a day) or the herb butterbur (50 to 75 milligrams twice daily).

Perhaps most important in finding relief is seeing a doctor highly experienced in diagnosing and treating migraines. Too many people try to muddle through, sometimes causing more frequent migraines by overusing self-prescribed medications. Others may see a physician who fails to help and then conclude that their headaches are beyond help.

Even if an expert was unable to help you years ago, there are now so many new therapies — and a far better understanding of the nature of migraines — that you’d be wise to try again. —