Profoundly painful and infamously stubborn, migraines have probably been around as long as the human brain. Even the ancient Egyptians suffered from the wretched ache; they attributed it to an evil spirit and struggled to exorcise it with incantations. Today doctors know better. Migraines hit when the brain sends signals out to the nerves that cause inflammation of the blood vessels and sensitivity of nerve endings. The nerves then send electrical signals into the brain. What patients end up experiencing is a sharp, often one-sided pounding that lasts for hours or even days and a bevy of associated problems, such as queasiness, sensitivity to light and sound, and, in 20 to 30 percent of sufferers, an aura (a transient sensation, like flashes of light or tingling in one arm). Thirty-seven million Americans are all too familiar with migraines, and women are three times more likely to suffer from them than men, possibly due to monthly hormonal fluctuations that exacerbate pain. What’s worse, the headaches aren’t just rare occurrences. For many, they hit frequently: More than 2 million migraine patients suffer from chronic migraines (15 or more days with headaches each month). The rest experience the pain less often but still quite a lot. According to a 2004 American Migraine Prevalence and Prevention study, the average migraine sufferer has 8.3 episodes in a three-month period (in other words, almost three a month).
Fortunately, there are more options than ever to treat and prevent migraines. With recent innovations in functional magnetic imaging, doctors can now study exactly what happens in the brain in the midst of an episode. In addition, scientists are uncovering gene variations that raise a person’s likelihood of developing migraines. “The hope is that, with these recent discoveries, we’ll soon identify new therapies or find ways to use current therapies more effectively,” says Elizabeth Loder, M.D., the president of the American Headache Society. For now, read on to find the latest information on every doctor-approved weapon in the modern arsenal, so when your next migraine attacks, you’ll be ready to fight back.
What Causes Them
Migraines can be triggered by any number of things—some stranger than others. Sometimes they’re spurred on by chewing gum (as a 2013 Pediatric Neurology study found); sometimes by a colleague’s button-down shirt. (A 1989 Archives of Neurology paper identified 82 percent of migraine sufferers as “stripe sensitive.”) Keeping a journal of your daily habits, stress levels, and migraines for a few months may help to pinpoint flare-up patterns, says Jason D. Rosenberg, M.D., the director of the Johns Hopkins Headache Center at Bayview, in Baltimore. Here are the areas to monitor.
Migraine-sensitive brains relish routine. So, for many, going to bed and waking up at the same time, including on weekends, can keep episodes at bay. And don’t skimp on the shut-eye. A 2010 study conducted at Missouri State University, in Springfield, reported that a lack of REM sleep led to increased levels of proteins in nerve cells that contribute to migraine pain.
Food triggers vary, but for some a substance called tyramine may be a culprit. It’s produced by an amino acid in some foods as they mature, which explains why aged cheeses, dried fruit, fermented foods, and sometimes even leftovers can wreak havoc. As with sleep, a set eating regimen helps; skipped meals and heavy meals may promote attacks. Staying hydrated may be important, too. In a small 2005 study published in the European Journal of Neurology, migraine patients who increased their water intake by a little over six cups a day experienced 21 fewer hours of pain during the two-week study than did those who had taken placebo drugs.
Obesity increases your risk of certain migraines by 81 percent, according to a 2013 study published in the journal Neurology. While it’s still unclear why this is, one theory holds that fat cells release inflammatory particles into the bloodstream, which may contribute to the pain of migraines.
A 2009 Neurology study found that the risk of migraines jumps by 8 percent with every rise of 9 degrees Fahrenheit in the air temperature relative to the usual temperature for that day of the week and month, even in winter. Experts are unsure why this happens, but weather has long been thought to contribute to migraines.
Loud sounds, strong aromas, dazzling visuals: It’s unclear why many migraine sufferers can’t tolerate high intensity of any sort, though it may be because the nervous system has trouble filtering out sensory input. A 2010 study published in the journal Nature Neuroscience also suggests that, in the case of visually charged migraine attacks, light activates a pathway of non-image-forming retinal neurons, which means that light can add to migraine pain, even in blind patients. While nothing practical will shield you from the noise and smell issues, you can don a pair of tinted glasses to tone down bright lights, which exacerbate migraine pain for more than 80 percent of sufferers. Wear the glasses when you’re out in the sun or in an office with harsh fluorescent bulbs. Models by TheraSpecs and Axon Optics are designed to minimize pressure on sensitive points of the face, and their specifically formulated rosy tint (called FL-41) blocks the blue-green light shown to trigger and worsen migraines. (Just don’t wear them while driving; they can make seeing traffic signals difficult, says Robert Cowan, M.D., the director of the headache and facial-pain program at the Stanford University School of Medicine.) A 1991 study conducted at the University of Birmingham, in England, found that the FL-41 tint decreased the average migraine frequency from 6.2 episodes a month to 1.6. While these tinted glasses don’t require a prescription, your insurance may require one for coverage.
The Best Medicines
These are most effective for episodic attacks, defined as less than 15 a month.
If you are new to migraines or suffer fewer than two attacks a week, nonprescription migraine-specific NSAIDs (nonsteroidal anti-inflammatory drugs) may be all you need. Their active ingredients are similar to those in non-migraine-specific drugs (such as regular Advil and aspirin). But they also contain substances thought to reduce nerve irritation (such as caffeine in Excedrin Migraine and potassium salt in Advil Migraine). You should be able to resume normal activities two hours after taking a dose. If you find that the medication brings little or no pain relief, or that the pain relapses or intensifies, make an appointment to see a headache specialist. Don’t pop extra pills. More than two doses a week can trigger an overuse headache (which feels identical to a migraine), as well as other side effects, like stomach ulcers.
Patients who don’t find relief with over-the-counter drugs typically turn to a class of prescription therapies known as triptans, which include sumatriptan and frovatriptan. Available as pills, injections, nasal sprays, and patches, these medications work best when taken at the first sign of pain. “When taking triptans, you shouldn’t wait to see if the headache is going to be a bad one,” says Cowan. How do they work? Triptans mimic the activity of serotonin at specific receptors on cells and release other substances that cause changes in certain nerves and help to relieve pain. The drugs are nondrowsy and nonaddictive, although patients may experience side effects, such as heaviness in the chest, tingling in the toes, and rapid heart rate.
Taken every day, regardless of whether you have an attack, these drugs are intended to reduce the frequency and the intensity of migraines and to improve your response to pain relievers like triptans. Typically geared to those suffering more than one or two episodes a week, the drugs fall into a variety of categories. Three of the most popular: beta-blockers (such as timolol), which target blood pressure; antiseizure drugs (like topiramate), which may calm overexcitable nerves in the brain; and antidepressants (such as amitriptyline), which activate serotonin receptors. Finding your best pain-reliever and pain-preventer combination can be a process of trial and error, says Paul-Henri Cesar, M.D., the director of headache medicine at New York–Presbyterian Hospital/Columbia University Medical Center, in New York City. “It may take several months,” says Cesar.
Time for an Intervention
The most stubborn migraines require a direct hit to the pain source: the nerves in your brain. Here are the latest offerings.
When a migraine has lasted several days (and counting) and you’ve exhausted the obvious options at the pharmacy, a nerve block will bring temporary relief and, in most cases, will be covered by insurance. Using a thin needle, a neurologist injects a local anesthetic and, sometimes, a small dose of steroids around the nerve thought to be contributing to the pain. The duration of this dampening effect varies from patient to patient and can last several days to several months. Because it requires a trip to the doctor, a nerve block is not a first line of defense. Nerve blocks are designed for people who have yet to find the right combination of drugs and need immediate relief.
OnabotulinumtoxinA Injections (a.k.a. Botox)
The famed wrinkle fix also happens to help relieve migraine pain. A relatively new treatment, Botox is pricier than the aforementioned preventive medications in pill form (such as topiramate), and insurance companies usually require patients to have tried and failed several other treatments before moving on to the needle. The treatment is approved for chronic migraine sufferers, defined as patients who have 15 or more episodes a month for three consecutive months, each lasting at least four hours. According to 2010 clinical trials, subjects who received two cycles of Botox experienced about a 25 percent greater reduction in the monthly frequency of their migraines than did patients who received placebo injections. Potential side effects include neck pain and muscular weakness. Alas, given that the injection sites aren’t the places where wrinkles normally appear, cosmetic side benefits are unlikely, says Loder.
In this experimental procedure, a scalpel is used to remove some of the muscle that presses on migraine-triggering nerves. In a 2011 study published in Plastic and Reconstructive Surgery, 88 percent of patients who underwent this surgery experienced an approximately 50 percent decrease in the duration, frequency, and intensity of their migraines for at least five years post-op. Unfortunately, long-term side effects have not been well studied. Until larger, longer studies have been conducted, the American Headache Society urges caution. If you are considering this surgery, seek out a physician who is conducting a clinical trial (ask your neurologist for assistance) to ensure proper protocol and follow-up.
More Help Is on the Way!
Coming soon to a pharmacy near you: less invasive, yet more direct, ways to manage migraines. Here are just three of many new treatments.
Approved by the Food and Drug Administration (FDA) last year, this prescription patch, placed on an arm or a leg, bypasses the gastrointestinal tract for quick relief and is a blessing for those unable to take pills or a nasal spray due to nausea. A 2012 study in the journal Headache showed that Zecuity eased pain in 53 percent of patients and nausea-related symptoms in 71 percent.
Cerena TMS (eneura.com)
This prescription device, about the size of a large hardback book, is held at the back of the head for a mere second. There it releases a pulse of magnetic energy to help relieve pain from migraines with auras. Among clinical-trial subjects, 38 percent reported relief two hours after use and 34 percent remained pain-free a day later. The device was FDA-approved this past December.
Invented at the University of Liège, in Belgium, and now under FDA review (though currently available over the counter in Canada and in Europe), Cefaly promises to treat or prevent migraines with an electrode that is placed on the forehead for 20 minutes at a time, a few times each week, at home. A 2013 study in the journal Neurology reported a 30 percent drop in migraine frequency and no adverse effects after three months of use.