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Medical Edge Newspaper Column from Mayo Clinic
PREVENTING MIGRAINE HEADACHES REQUIRES A MULTIFACETED EFFORT
DEAR MAYO CLINIC: What can I do about very frequent migraine headaches? I sometimes get a 24-hour break from these attacks, but then they return. Eating certain foods may trigger them, though not always, and I’ve found that being constipated often does the same. Do you have advice for me?
ANSWER: A migraine headache is distinguished by throbbing pain that can be so severe as to incapacitate. Usually confined to one side of the head, the attack may also include nausea, extreme sensitivity to light and sound, and other symptoms. Physical activity is not only difficult, it often makes the situation worse.
Migraine attacks can be prompted (though not fundamentally caused) by a wide variety of triggers. You mention two types in your case — certain foods and constipation. Obviously, it’s important that you avoid those foods and prevent constipation by maintaining a high-fiber diet.
But the list of potential triggers is long. Stress can initiate a migraine headache, as can sensory stimuli such as unusual smells — both pleasant (perfumes) and unpleasant (paint thinner). Too little sleep or too much sleep can provoke an attack, and so can environmental shifts — changes of weather, season, altitude, barometric pressure or time zone, among others.
It’s clear that avoiding triggers when possible is only a partial solution. Many migraine attacks do not appear to be externally triggered at all.
The best way to treat patients who suffer from frequent migraine headaches is through selective medications that prevent attacks by addressing their potential neurological causes. Numerous drug classes, based on different nervous-system mechanisms, are available to choose from:
Cardiovascular drugs such as beta-blockers (atenolol, for example), developed to treat high blood pressure and coronary-artery disease, can also reduce the frequency and severity of migraine headaches. Similarly, the calcium-channel blocker verapamil can be useful for migraine prevention.
Another helpful class is antidepressants. Most effective are the tricyclics, such as amitriptyline, which work by affecting the level of serotonin and other brain chemicals. You don’t have to have depression, by the way, to benefit from these drugs.
Some antiseizure drugs (such as gabapentin and topiramate) that are used to treat epilepsy also seem to prevent migraine headaches.
Botulinum toxin type A (Botox), currently in clinical trials for treatment of migraine, has shown promise.
Other types of drugs can be valuable as well. But while the armamentarium is large, deciding which agents to try, and in what order, is not yet the informed scientific process we hope it will be in the future. Selection at present is often an educated guess, based on the patient’s history and other conditions. Regardless, the goal is to get him or her as close to normal with the minimum medication. We start the patient off with a very low (subtherapeutic) dose and slowly increase it to the clinical range, while looking for reduced frequency and intensity of migraine attacks. This process also permits the body to gradually adjust to the medication, thereby minimizing side effects.
Then, if the experience with a particular drug is beneficial and the patient has been on an effective dose for a number of months, the next step is to slowly reduce that dosage — in some cases, down to zero. Such reversal often works because the therapeutic process has essentially led the nervous system into “unlearning” the abnormal hypersensitivity responses that underlie the migraine headaches.
You can see that various options are available to reduce or even eliminate migraine headaches. The choice, dosages and timing of specific medications must be discussed with your doctor. Meanwhile, complementary lifestyle changes such as regular exercise, stress reduction and stopping smoking also can help prevent these attacks — and confer numerous other health benefits as well.
— F. Michael Cutrer, M.D., Neurology, Mayo Clinic, Rochester, Minn.
Additional Resources:
Migraine Headaches
Appointment Information
More Information on Migraine Headaches
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© 2005 TRIBUNE MEDIA SERVICES, INC.
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