Calming the Hell in Your Head
Migraines are three times more common in women than men. Here’s the latest on treatment and prevention
Like 23 million other women, I am what doctors call a migraineur. A couple of times each month, I’m felled by debilitating headaches that send me to bed for a day or more, unable to think, read, write or even watch television.
Until recently, my best remedies were ice packs, hot showers and a variety of prescription and over-the-counter pain pills. Sometimes the remedies worked; most often they didn’t. And frequently I couldn’t even keep the pain pills down, thanks to the nausea that usually accompanies a migraine.
Now, as soon as I feel the stirrings of a migraine, I have another option. I pop a newly approved pill, Imitrex, which works directly on the brain chemical that triggers migraines. The pain is gone within the hour.
Once considered a unique species of headache, migraines are now seen as one end of a spectrum of headache pain. Chronic headaches seem to involve a glitch—probably inherited—in the way the brain handles serotonin, a neurotransmitter that influences mood and sleep and regulates constriction and dilation of blood vessels. One theory suggests that an electrical change in the brain produces a surge in serotonin, which narrows the blood vessels; serotonin then leaks into surrounding tissues, dilating the same blood vessels and irritating nerve endings. Result: throbbing head pain.
Still, a genetic propensity does not a headache make. Over- or undersleeping, missing a meal, getting too much sun, a change in barometric pressure, eating foods containing nitrites (like bacon) or amines (aged cheese or red wine) and the letdown after a stressful event are all common triggers for the serotonin disturbance that ends in head pain, nausea, light sensitivity, numbness of extremities, or any combination of these symptoms.
The biggest trigger in women, however—and an explanation for why migraines are three times more common in women than men—is the dramatic drop in estrogen that occurs just before menstruation. Fluctuating estrogen levels are probably why a third of migraineurs have their first migraine attack around puberty, and 70 percent get predictable and often difficult to treat headaches between ovulation and the end of their cycles. It’s also why women in their forties, who are subject to several years of declining estrogen levels, often suffer from more frequent and intense migraines prior to menopause.
About a third of migraine sufferers also say their headaches get worse when they take the Pill—presumably because they’re still susceptible to the drop in estrogen that occurs before their periods. Another third of Pill-takers get better, and the remaining third report no change.
Three quarters of women find temporary relief from migraines during the last six months of pregnancy, when estrogen levels rise and stay steady. And 70 percent of migraineurs become migraine-free after menopause, when estrogen levels fall and stay low.
New Drug Treatments
Women don’t need to wait until menopause to find relief from migraines, but effective treatment requires experimentation and patience. “Migraine isn’t a one-drug-cures-all disorder,” explains Richard Lipton, M.D., codirector of the headache unit at New York City’s Montefiore Medical Center. “There are different types and degrees of migraine, and not everyone responds in the same way to every drug.”
A new generation of medications that act directly on the serotonin system makes treatment easier than ever before. Here, an update on the options:
Imitrex Available as an injection since 1993, this drug was recently approved in pill form and may soon become available in a quick-acting nasal spray. By mimicking the action of serotonin in the brain, Imitrex has revolutionized migraine treatment (it has been a miracle for me). Seventy to 80 percent of migraine sufferers who take the pill find their headaches ease within one to four hours; with the injection, relief is about 30 to 60 minutes away. If a migraine recurs after a few hours, as it does for 10 to 15 percent of sufferers, it’s safe to take a second dose.
The downside: This drug is a potent blood vessel constrictor and can be dangerous if taken by someone with heart disease. In others, it can cause mild side effects such as tingling, a sensation of pressure or heaviness, drowsiness or dizziness. It’s also expensive ($9 to $12 per pill; $35 to $40 per injection).
Other serotonin imitators Zomig, Maxalt and naratriptan—all of which also mimic the effects of serotonin—are all slated for Food and Drug Administration approval, and five similar drugs are in development. (Zomig may be approved as early as this year.) It’s hoped that one or more of these will work faster or offer longer-lasting pain relief than Imitrex, says Alan Rapoport, M.D., codirector of the New England Center for Headache in Stamford, Connecticut. Competition among these drugs should also bring prices down.
DHE45 This self-injectable drug constricts blood vessels and also helps regulate serotonin levels, relieving migraine pain in about 80 percent of sufferers. It may take 15 or so minutes longer than Imitrex does to stop pain, and the injection is more painful, but migraines are less likely to recur within a few hours. A quick-acting nasal spray is likely to be released this year.
The disadvantage: When injected, DHE45 can cause severe stomach upset, so many doctors prescribe it with an antinausea drug. Cost: $15 per dose.
Lidocaine When applied with a Q-Tip in the nasal passages nearest the pain, this anesthetic works quickly—within about five minutes—for about half of migraineurs, reducing pain as well as nausea and sensitivity to light. Lidocaine has few side effects and is inexpensive (a $15 bottle will “last you a lifetime,” says one pharmacist).
The disadvantages: Headaches recur for about half of sufferers within an hour. While it’s safe to redose lidocaine, it may be best as a stopgap until another drug kicks in, says Dr. Rapoport.
Not every migraine needs to be treated with a big gun like Imitrex, says Stephen D. Silberstein, M.D., codirector of the Comprehensive Headache Center at Germantown Hospital and Medical Center in Pennsylvania. Prescription drugs such as Midrin, Norgesic Forte, Fiorinal, Fioricet and Wygraine have been around for years and can be effective and inexpensive choices. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen or ketoprofen—albeit at much larger doses than recommended for nonprescription use (up to 550 milligrams per day of naproxen, for instance)—are particularly good for treating menstrual migraines.
Home remedies can limit your need for medication and, by relaxing you, even speed pain relief. Some women obtain relief from heat or hot showers, ice packs, head massage, putting their hands on a warm pad to draw blood away from the brain, or practicing visual imagery or relaxation techniques. Biofeedback in particular gets high marks: “It’s the most effective nondrug technique,” says Frederick Freitag, D.O., associate director of the Diamond Headache Clinic in Chicago, “but it’s underused because you have to commit to practicing it 20 minutes twice a day.” It takes up to 10 sessions to master the technique, he says, and the cost of training (about $500) may not be covered by insurance.
Changing your diet by eliminating trigger foods and adding vitamins and minerals is another strategy to prevent or reduce pain. Preliminary research conducted by Alexander Mauskop, M.D., director of the New York Headache Center in Manhattan, indicates that about half of migraine sufferers are deficient in the mineral magnesium. An intravenous infusion of magnesium during an attack often works within minutes, and relief lasts for 24 hours. While studies to confirm magnesium’s value are ongoing, and current formulations of oral magnesium aren’t absorbed well by the body, experts say it’s safe to take 400 to 600 milligrams of the mineral daily. Research also suggests that 100 to 200 milligrams per day of riboflavin (vitamin B2) can reduce migraine intensity for some people. It may take one to two months to see an effect with supplements.
Fat may prove to be another factor in migraines. In the first study of its kind, researchers at Loma Linda University in California found that patients who ate 20 or fewer grams of fat per day for 12 weeks (about 10 percent of total calorie intake) decreased the frequency of their migraines by 71 percent, intensity by 66 percent, duration by 74 percent and medication intake by 72 percent. Says lead researcher Zuzana Bic, M.D., “A restrictive diet may work because it prevents fat in the bloodstream from damaging platelets, which can lead to the serotonin loss that precipitates migraines.”
Stopping Migraines Before They Start
If you get more than three headaches a month, doctors may suggest taking drugs every day to prevent them. Among the options:
Try taking ibuprofen or another anti-inflammatory each day for a week or more before and during your period to help prevent menstrual migraines. These drugs stop the release of prostaglandins—compounds that are produced as the uterine lining is shed each month—that cause pain and dilate blood vessels. On the downside, high doses of NSAIDs can cause stomach upset and, with frequent use, even ulcers.
Heart disease drugs such as Inderal and Calan help to regulate blood vessel activity, thus preventing attacks in a significant number of migraineurs. Side effects include fatigue, constipation, heartburn and low blood pressure.
Two categories of antidepressants may help to prevent migraines when taken daily: tricyclics such as Elavil, and selective serotonin reuptake inhibitors (SSRIs) such as Prozac. Tricyclics can cause dry mouth, constipation, tiredness and weight gain. The SSRIs have fewer side effects but don’t work as well.
The epilepsy drug Depakote is the newest preventive treatment and has been shown to reduce migraine episodes for half of the people who try it. Depakote has some nasty side effects, however, such as nausea, diarrhea, weight gain and hair loss.
A preliminary study published in the journal Neurology this year reports that bromocriptine, a drug that mimics the actions of the brain chemical dopamine, decreased menstrual migraine pain for 72 percent of women when combined with other therapies that aren’t effective alone. The medication may cause nausea and lightheadedness.