Our first article of 2001 is "About Migraines". It is some old, and some new information, at least to me; and I hope that anyone who is interested in this subject gets something out of it.
First, some general information: a migraine can consist of four separate components, or phases: 1) prodrome, 2) aura, 3) headache, and 4) postdrome.
PRODROME
The prodrome, or "pre-headache," may occur anywhere from hours to days before an actual migraine strikes -- a warning of an impending migraine. Not all migraineurs experience prodromes (only about 30-40%), but those who do are fortunate in that they have time to take steps to abort the migraine. Common prodrome symptoms include: food cravings, constipation or diarrhea, mood swings, like depression or irritability, muscle stiffness (often in the neck), fatigue, and increased frequency of urination.
AURA
The aura differentiates migraines from other headaches, follows the prodrome, and is normally over within an hour. Auras have a wide range of symptoms including: 1) visual aberrations -- flashing lights, wavy lines, spots, blurry vision, and partial loss of vision; 2) olfactory hallucinations-- smelling imaginary odors; 3) tingling or numbness of the face or extremities on the side where the headache occurs; 4) difficulty in speaking (sort of like dementia where one has difficulty finding the right word); 5) confusion; 6) vertigo; 7) partial paralysis; 8) auditory hallucinations; 9) hearing deficiency or loss; 10) reduced sensation; and 11) hypersensitivity to feel and touch.
Auras are only experienced by about 20% of migraineurs, but they, like prodromes, can be a warning of an impending headache and provide time for preventative measures. It should be noted that not all migraineurs experience all four phases, and it is even possible to get an aura, but no headache.
HEADACHE
The headache phase of a migraine is typically the most debilitating, but oddly enough it isn't just the head that can ache. Sometimes pain is experienced elsewhere in the body, but it's still a migraine [more about this later]. Migraine headache pain is excruciating, and may exhibit any of the following characteristics:
This phase immediately follows the headache, and may last for several days. A postdrome can be characterized as a kind of lethargy; it has been variously described by those who have experienced it as "feeling like a zombie," or "hungover."
Postdrome symptoms include: 1) lowered mood levels -- depression or feelings of wellness and euphoria fatigue, 2) impaired concentration and comprehension, and 3) lowered intellect levels.
The bottom line is it is clear that migraines are complex events, not just headaches; and that not every migraine episode includes all phases. And for any individual not even every episode follows the same pattern. It is important to learn these phases so that some preventative action can be taken before the pain manifests itself -- a form of migraine management, as it were.
Now that we understand the four potential phases of a migraine episode [I have to get used to the term "migraine episode" now, especially since a headache might not even be included.] let's move on to more specific information.
How about comorbidity and migraines for starters? Morbidity is "a diseased state," so comorbidity is simply two diseases at the same time, but with a wrinkle -- they are related, not just separate and concurrent.
We are talking about psychiatric disorders like bipolar disorder, general anxiety, major depression, neuroticism, and social phobia. In addition, there are links between migraine and epilepsy, asthma, essential tremor, and increased risk of stroke in young women.
Because of the comorbidity between migraine and other neurological disorders (epilepsy, essential tremor, and depression), there is a focus on finding common biological/neurological factors. One result is that drugs designed for epilepsy, depression, etc. are now being used to treat migraines. It is a goal to try to treat comorbid conditions with the same drug. Examples are treating a patient with migraine, hypertension, and ischemic heart disease with beta blockers or calcium channel blockers; or treating someone with migraine, mania, and epilepsy with a mood-stabilizing antiepileptic drug (AED) like divilproex, topiramate, or gabapentin. The combination of migraine and depression may be treated with a tricyclic anti-depressant, or a selective serotonin reuptake inhibitor (SSRI). It also seems that drugs designed for one condition are sometimes being used for migraines even without comorbidity (i.e., Botox, anticonvulsives (epilepsy), or antidepressants). Although one reason for using antidepressants for migraineurs is that the two condi tions have a bidirectional relationship (i.e., migraine patients have a higher than normal risk for developing depression, and patients with depression have a higher risk of having migraines).
But there can be risks with this type of treatment. Medications for one condition can sometimes aggravate others (e.g., some anti-depressants can cause increased rate of seizures in epileptics; and beta-blockers can increase depression).
Migraine and epilepsy seem to have a special relationship; both conditions can exhibit the same symptoms. And auras can trigger seizures -- not so good for the patient, or the physician trying to diagnose the problem. Also, migraines occur more often in epileptics, and similarly, epileptics are more likely to get migraines. This relationship seems to support the growing use of AEDs for treating migraines.
Status Migraines are an example of the variety of migraines that exit. When I first got started on this subject, a few years ago, I thought a migraine was a migraine; but that was a definite misconception. We have already briefly discussed the possible separate phases of a migraine, and comorbidity; now it is time to discuss some different categories of migraines -- first, status migraines, which are characterized by lasting from 72 hours to several days, or even weeks.
The treatment of choice to stop a status migraine is a corticosteroid. Other options include Ergotamines, Sumatriptan, and IV DHE. However, ergotamines shouldn't be used on the second, third, or fourth day of a migraine attack to maintain a four day abstinence between days of use.
DHE (dihydroergotamine) can be used according to what has been called the Raskin Protocol. Dr. Raskin, who is or was practicing in San Francisco, CA, has effectively used 0.5 mg IV (DHE) with 10 mg metoclopromide in doses administered every eight hours for two days. He has also reported successful treatment of status migraines with both dexamethasone or methylprednisone.
Confusional migraines are the next order of business. This type of migraine includes a confusional state that occurs in only about 5% of migraineurs. The confusion is characterized by inattention, distractibility, and difficulty with speech and motor activities; and may last anywhere from 10 minutes to 20 hours, and commonly ending in deep sleep. Confusingly, this confusion may be unaccompanied by a headache, making the condition even more confusing. Confusional migraines may result from head trauma, and commonly do not recur. Midrin, Imitrex, and Zomig have all been used to successfully halt this type of migraine.
Menstrual migraines is our next topic. Most of you know that hormonal changes can trigger migraines -- very often estrogen, so menopause, birth control pills, and more, as well as menstrual cycles, affect hormones (estrogen) and thereby trigger migraines.
It is important to identify menstrual migraines (as opposed to other types) because the trigger is typically lowered estrogen levels, which can frequently be treated by small doses of estrogen during the seven days of menstruation. Other drugs, like Sumatriptan may also be used effectively.
For women who are already taking a medication for migraines, it might be effective to just increase the dose during periods. For women who aren't already taking migraine medication, taking preventative medications just before periods may be effective.
Other preventative measures that may be effective are to take NSAIDs or transdermal estrogen starting two to three days before the period, and continue through the period, or whenever is the most likely time of getting a migraine. Other less frequently used therapies include: ergotamine tartrate, bromocriptine, danazol, and tamoxifen.
If you are planning on a pregnancy, be sure to tell your doctor -- he/she may want to try something like biofeedback rather than drugs. And note that pregnant women must not take ergots.
Older women should be sure to inform their doctor of any other current medical conditions they have because of potential problems with drug interactions. [Actually that is pretty standard advice for anyone taking other medications.]
Young children and migraines is a subject that I hadn't dreamed existed until recently when I discovered that children as young as 6 weeks old have been diagnosed with migraines. [I wonder how they describe their auras?] But about half will stop having them by the end of adolescence, and another quarter will stop by early adulthood.
Children's symptoms are much like those experienced by adults, but with some differences, like in the case of an "abdominal migraine." [Also known as a "migraine equivalent," to be discussed later.] That's right, some children experience migraine pain in their abdomens. Children's migraines may exhibit nausea and vomiting, mood changes, dizziness, blurred vision, unexplained fatigue, food cravings, or loss of appetite.
Another uniquely children's migraine is called a "basilar migraine," which is accompanied by numbness on one or both sides of the body, vision problems, temporary balance problems, or dizziness.
Parents should be aware of crankiness or complaints of discomfort just after they wake up, since that is a prime time for children to experience migraines.
When in an aura phase, children may have trouble speaking or maintaining balance, may behave oddly, or have difficulty focusing their eyes. These symptoms all point to a coming migraine so parents should learn to recognize them as migraine precursors, and have their children lie down in a dark, quite area. Relaxation or sleep are important at this time.
The same medications used by adults are generally also effective for children, but are given in smaller doses, adjusted for body weight. But because of their smaller body weight, side effects can be worse than with adults, so many physicians won't prescribe adult medications for children. They choose instead to recommend OTCs like Tylenol, or to use biofeedback for muscle relaxation -- techniques that are effective for many children. NOTE that children under age 16 should not be given aspirin unless directed by a doctor, because of the link between Reye's Syndrome (a potentially fatal disease) and aspirin.
Children's migraine triggers are roughly the same as for adults. Parents can help their children migraine sufferers by learning to recognize and avoid triggers (most commonly: stress, fatigue, anxiety, and some foods). Other causes include:
Sleep is often the very best treatment after a migraine has started, and compresses -- either hot or cold -- may be effective to facilitate sleep.
Parents need to provide psychological support. Parents need to be fully supportive -- don't worry that your child is trying to "use" you. That is highly unlikely, and the whole family needs to be involved and supportive. Don't let anyone feel left out.
Migraine equivalents -- Okay, it's time to explore this subject. At one time "migraine equivalent" was used by physician's as a kind of catch-all for symptoms they couldn't diagnose. Abdominal migraines have since been afforded legitimacy, although all syndromes under this umbrella remain difficult to diagnose/treat.
Examples of migraine equivalents include:
The treatment of migraines in primary care is problematic because of the variability of symptoms, and the changeability over time. Patients experiencing multiple episodes over time may find that their headaches are transformed from episodic migraines, to tension migraines, to mixed headaches, and eventually to chronic daily headaches. This transformation may result from a variety of factors: genetic, biologic, overuse of acute treatment medications (more than two days a week), head or neck injuries , or headaches that haven't been effectively treated (one of the reasons for not trying to selftreat chronic headaches).
A problem for primary care physicians is something called the "kindling effect," a condition characterized by prolonged or frequent pain, that results in CNS (Central Nervous System (brain and spinal cord)) changes that can lower one's threshold for triggering headache attacks. In this case, under-treatment of migraines can result in more frequent attacks. Some primary care physicians are still under the mistaken impression that migraine treatment should be treated with the most benign medications first, and then progressively step up to more potent treatments as necessary; however, this concept is out-of-date. It is currently recommended to treat migraines aggressively right away to keep from falling into daily patterns of pain. Essentially any analgesic can cause this transformation process into daily pain, and that is the justification for recommending limiting treatment by medications to no more than twice a week.
Early treatment may include: behavioral modifications, biofeedback, or triptan therapy.
For patients who have progressed (regressed?) to moderate to severe pain, rescue treatment is the next step, may include subcutaneous triptans, or combinations of triptans with NSAIDs. Or even phenothiazines, narcotics, corticosteroids, or nerve blocks.
When acute pain requires medications more than twice a month. preventative therapy is in order, including: tricyclic antidepressants, beta-blockers, and anticonvulsives. After two failed attempts at this level, it is time to call in a neurologist -- maybe earlier, depending on your tolerance level.
That's enough about migraines for this issue, let's move on.
EXERCISE CORNER in this issue addresses the seated calf raise. The muscle worked is the soleus, one of the two major calf muscles, which lies beneath the gastrocnemious (i.e., deeper into the leg). This muscle is important because it works all the time, while the two-jointed gastrocnemius does not; and should therefore be strengthened to increase efficiency of the calf. The gastrocnemius stretches from above the knee to below the ankle, which makes it most effective when the knees are straight; while the soleus attaches below the knee, which makes it most effective in a flexed position. This exercise is best done on a machine specifically designed for this exercise and can be found in most gyms; although it can be done at home by setting a weighted object on your lower thighs, and using a board (or?) as a platform for your feet.
Perform the exercise by raising your heels as high as you can, holding that position for 1-6 seconds, then lowering your heels (under control) until they are below the level of the balls of your feet. Repeat these actions until your set is complete.
(Q) I had high blood pressure that is now under control as long as I take my anti-hypertension medication. Before taking the medication, my risk for a heart attack or stroke was elevated, but now that I'm "normal" again, is my risk reduced to where it was?
M.F., Roseburg, OR
(A) Unfortunately, the answer is no. Once you have been diagnosed with hypertension, you're stuck with it for life, even though it has been reduced by medication. You can expect your risk to be lower than it was before the drug therapy, but a treated patient still has a risk twice that of someone who has never had high blood pressure.
(Q) I have just started an exercise program to reduce facial wrinkles -- tighten up my skin. Do you think it will work?
N.J.L., Santa Cruz, CA
(A) No. Facial muscles don't have anything to do with skin. It is connective tissue that keeps your skin tight. Keep your weight under control, avoid overexposure to the sun, use sunscreen, don't smoke, and use a moisturizer; that's about the best you can do, outside of cosmetic surgery. The primary causes of wrinkled, saggy skin are aging (connective tissue loses its elasticity as we age), genetics, and sun exposure.
(Q) I have insomnia, and am thinking about taking St. John's Wort. I hear a lot of opposing opinions about this herb. What's yours?
J.R., Staten Island, NY
(A) I think the uncertainties outweigh the proposed benefits. This plant contains 10 known compounds that can have pharmacological (act like drugs) effects. Dangerous interactions with other drugs is well-known. In addition, there is the general fact that you just can't be sure what you're getting with herbal supplements.
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