What causes migraines, and how do you cure them?

Question by zarf: What causes migraines, and how do you cure them?
i hate getting them! they just stop me from doing things

Best answer:

Answer by ai_nacco_2000
Migraine is a neurological disease, of which the most common symptom is an intense and disabling episodic headache. Migraine headaches are usually characterized by severe pain on one or both sides of the head and are often accompanied by photophobia (hypersensitivity to light), phonophobia (hypersensitivity to sound) and nausea. The word migraine is French in origin and comes from the Greek hemicrania (as does the Old English term megrim). Literally, hemicrania means “only half the head.”

Migraine is irregularly episodic, so there needs to be some explanation for why a particular migraine episode occurs at a particular time and not at another time. A migraine trigger is any factor that on exposure or withdrawal leads to the development of an acute migraine headache. Triggers may be categorized as behavioral, environmental, infectious, dietary, chemical, or hormonal. The trigger theory supposes that exposure to various environmental factors precipitates, or triggers, individual migraine episodes. Many people report that one or more dietary, physical, hormonal, emotional, or environmental factors precipitate their migraines. The most-often reported triggers include stress, over-illumination or glare, alcohol, foods, too much or too little sleep, and weather. Sometimes the migraine occurs with no apparent “cause.”

Migraine patients have long been advised to try to identify personal headache triggers by looking for associations between their headaches and various suspected trigger factors. Patients are urged to keep a “headache diary” in which to note what they eat and when they get a headache, to look for correlations, and to try to avoid headache by avoiding factors they identify as triggers. Typically this advice is accompanied by a list of trigger factors.
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Food

Authors who in 2005 reviewed the medical literature[2] found that the available information about dietary trigger factors relies mostly on the subjective assessments of patients. Some suspected dietary trigger factors appear to genuinely promote or precipitate migraine episodes, but many other suspected dietary triggers have never been demonstrated to trigger migraines. The review authors found that alcohol, caffeine withdrawal, and missing meals are the most important dietary migraine precipitants. The authors say dehydration deserves more attention, and that some patients are sensitive to red wine. The authors found little or no demonstrated evidence that notorious suspected triggers chocolate, cheese, or that histamine, tyramine, nitrates, or nitrites normally present in foods trigger headaches. The artificial sweetener aspartame (NutraSweet®) has not been shown to trigger headache, but in a large and definitive study monosodium glutamate (MSG) in large doses (2.5 grams) was associated with adverse symptoms including headache more often than was placebo. The review authors also note that general dietary restriction has not been demonstrated to be an effective migraine therapy.

On the other hand, several headache clinics have had good results with individually tailored dietary restriction as a therapy. Dr. Ian Livingstone, director of the Princeton Headache Clinic, recommends eliminating the following common headache triggers from the diet: Aged Cheese, Monosodium Glutamate, Processed fish and meats containing nitrates (such as hot dogs), dark chocolate, aspartame, certain alcoholic beverages (including red wine), citrus fruits, and caffeine. After a period of a month or two, these foods can be reintroduced one at a time to determine their trigger potential for that individual. Adding a lot of the suspected trigger in a short time will generate a response that is easy to observe.

Dr. David Buchholz, who treats headaches as a neurologist at Johns Hopkins, has a longer list of suspected migraine triggers. Once again, he recommends eliminating the triggers from the diet altogether, and then reintroducing them slowly after many weeks to measure the effects. His list includes: Caffeine (including decaf), chocolate, monosodium glutamate, processed meats and fish (aged, canned, preserved, processed with nitrates, and some meats which contain tyramine), cheese and dairy products (the more aged, the worse), nuts, citrus and some other fruits, certain vegetables (especially onions), fresh risen yeast baked goods, dietary sources of tyramine (including the foods listed above), and whatever gives you a headache.
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Weather

Several studies have found some migraines are triggered by changes in weather. One study[3] noted that 62% of the subjects in the study thought that weather was a factor, in fact 51% were actually sensitive to weather changes. While those whose migraines did occur during a change in weather, often the subjects picked a weather change other than the actual weather data recorded. Most likely to trigger a migraine were, in order:

1. Temperature mixed with humidity. High humidity plus high or low temperature was the biggest cause.
2. Significant changes in weather
3. Changes in barometric pressure

Another study[4] studied whether chinook winds (warm westerly winds occurring in Alberta, Canada) are a migraine trigger. Many patients had increased incidence of migraines immediately before and/or during the chinook winds. The number of people reporting migrainous episodes during the chinook winds was higher on high-wind chinook days.

Conventional treatment focuses on three areas: trigger avoidance, symptomatic control, and preventive drugs. Patients who experience migraines often find that the recommended treatments are not 100% effective at preventing migraines.
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Trigger avoidance

Patients can attempt to identify and avoid factors that promote or precipitate migraine episodes. Moderation in alcohol and caffeine intake, consistency in sleep habits, and regular meals may be helpful. Beyond an often pronounced placebo effect, general dietary restriction has not been demonstrated to be an effective approach to treating migraine.[1]
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Symptomatic control to abort attacks

Migraine sufferers usually develop their own coping mechanisms for intractable pain. A cold or hot shower directed at the head, a wet washcloth, less often a warm bath, or resting in a dark and silent room may be as helpful as medication for many patients, but both should be used when needed. A simple treatment that has been effective for some, is to place spoonfuls of ice cream on the soft palate at the back of the mouth. Hold them there with your tongue until they melt. This directs cooling to the hypothalamus, which is suspected to be involved with the migraine feedback cycle, and for some it can stop even a severe headache very quickly.

For patients who have been diagnosed with recurring migraines, doctors recommend taking painkillers to treat the attack as soon as possible. Many patients avoid taking their medications when an attack is beginning, hoping that “it will go away”. However in many cases once an attack is underway, it can become intensely painful, last for a long time (sometimes even for several days), and become somewhat resistant to medical treatment. In contrast, treating the attack at the onset can often abort it before it becomes serious, and can reduce the frequency of subsequent attacks in the near-term.

The first line of treatment is over-the-counter abortive medication. Doctors start patients off with simple analgesics, such as paracetamol (known as acetaminophen in the U.S.), aspirin and caffeine. They may provide some relief, although they are not effective for most sufferers. Some patients find relief from taking Benadryl or anti-nausea agents.

Narcotic pain killers (for example, codeine, morphine or other opiates) provide variable relief, but their side effects, the possibility of causing rebound headaches or analgesic overuse headache, and the risk of addiction contraindicates their general use.

If over-the-counter medications do not work, the next step for many doctors is to prescribe fioricet or fiorinal, which is a combination of butalbital (a barbiturate), acetaminophen (in fioricet) or acetylsalicylic acid (more commonly known as aspirin and present in fiorinal), and caffeine. While the risk of addiction is low, butalbital can be habit-forming if used daily, and it can also lead to rebound headaches.

Anti-emetics by suppository or injection may be needed in cases where vomiting dominates the symptoms. The earlier these drugs are taken in the attack, the better their effect.

Until the introduction of sumatriptan (Imitrex®/Imigran®) around 1985, ergot derivatives (see ergoline) were the primary oral drugs available to abort a migraine once it is underway. However, ergotamine tablets (usually with caffeine), though sometimes effective, have fallen out of favour. Absorption is erratic unless taken by suppository or injection. Dihydroergotamine (DHE), which must be injected or inhaled, can also be effective. These drugs can be used either as a preventive or abortive therapy.

Sumatriptan and related selective serotonin receptor agonists are now the therapy of choice for severe migraine attacks that cannot be controlled by other means. They are highly effective, reducing the symptoms or aborting the attack within 30 to 90 minutes in 70-80% of patients. Some patients have a recurrent migraine later in the day, and only one such recurrence in a day can be treated with a second dose of a triptan. They have few side effects if used in correct dosage and frequency. There have been some rare instances of cardiac arrest in patients using triptans. Some members of this family of drugs are:

* Sumatriptan (Imitrex®, Imigran®)
* Zolmitriptan (Zomig®)
* Naratriptan (Amerge®, Naramig®)
* Rizatriptan (Maxalt®)
* Eletriptan (Relpax®)
* Frovatriptan (Frova®)
* Almotriptan (Almogran®)

Evidence is accumulating that these drugs are effective because they act on serotonin receptors in nerve endings as well as the blood vessels. This leads to a decrease in the release of several peptides, including CGRP and Substance P.

These drugs are available only by prescription (US, Canada and UK) although Sumatriptan is to be available in the UK over the counter from mid-June, 2006. [2] It is also expected to become eligible for generic status in the United States in 2007. Many migraine sufferers do not use them only because they have not sought treatment from a physician.

Regarding comparative effectiveness of these drugs used to abort migraine attacks, a 2004 placebo-controlled trial (Cephalalgia. 2004 Nov;24(11):947-54) reveals that acetylsalicylic acid, sumatriptan and ibuprofen are equally effective.

Triptan therapy has been shown to result in a reduction in lost productivity. Sumatriptan has been shown to result in an average of 0.5 fewer missed workdays during the first three months of therapy and 0.7 fewer missed workdays within the first six months, as well as a reduction in the number of days spent working while symptomatic. The average reduction in lost productivity has been estimated at $ 1,249, at a cost of $ 25 per day of disability avoided. The annual net savings in reduced health care costs and lost productivity, over the increased cost of triptan therapy, has been estimated at between $ 114 and $ 540 per patient; thus the use of these pharmaceuticals represents a cost savings as well as an improvement in the patients’ quality of life.
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Preventive drugs

Patients who have more than two headache days per week are usually recommended to use preventatives and avoid overuse of acute pain medications.

Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. It is used only if attacks occur more often than every two weeks. Supervision by a neurologist is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next.

The most effective prescription medications include several classes of medications including beta blockers such as propranolol and atenolol, antidepressants such as amitriptyline, and anticonvulsants such as valproic acid and topiramate.
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Alternative approaches

Because the conventional approaches to migraine prevention are not 100% effective and can have unpleasant side effects, many seek alternative treatments.
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Physical therapy

Many physicians believe that exercise for 15-20 minutes per day is helpful for reducing the frequency of migraines. [3] (PDF)

Massage therapy and physical therapy are often very effective forms of treatment to reduce the frequency and intensity of migraines. However, it is important to be treated by a well-trained therapist who understands the pathophysiology of migraines. Deep massage can ‘trigger’ a migraine attack in a person who is not used to such treatments. It is advisable to start sessions as short in duration and then work up to longer treatments.

Chiropractic adjustments to the upper cervical spine are very effective in treating migraine headaches. There is research to support these claims. One study found that the upper cervical adjustment was just as efective as drug therapy for chronic cases. It is also noted that routine spinal adjustments help prevent the frequency, duration, and intensity of the headaches.[citation needed]
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Prism eyeglasses

At least two British studies have shown a relationship between the use of eyeglasses containing prisms and a reduction in migraine headaches.

Turville, A. E. (1934) Refraction and migraine. Br. J. Physiol. Opt. 8, 62-89, contains a good review of the literature and theories existing in 1934, and includes the vascular theory of migraine that is popular today. In that study, Turville suggests that many patients were provided with complete relief from migraine symptoms with proper eyeglass prescriptions that included prescribed prism.

Wilmut, E. B. (1956) Migraine. Br. J. Physiol. Opt. 13, 93-97, replicated Turville’s work. Both studies are subject to criticism because of sample bias, sample size, and the lack of a control group.

Neither study is available online, but another study which found that precision tinted lenses may be an effective migraine treatment and which references the Turville and Wilmut studies can be found here. [4] (PDF)

Turville’s and Wilmut’s conclusions have largely been ignored since 1956 and it is widely believe that vision problems are not migraine triggers. However, a casual search of the usenet archives maintained by Google Groups shows many anecdotal reports demonstrating a relationship between migraines and eyeglasses. [5]

Most optometrists avoid prescribing prism because, when incorrectly prescribed, it can cause headaches. Prism has been proven effective at relieving motion sickness, which itself has many symptoms that are similar to the aura that accompanies migraine.[6]
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Herbal and nutritional supplements

50 mg or 75 mg/day of butterbur (Petasites hybridus) rhizome extract was shown in a controlled trial to provide 50% or more reduction in the number of migraines to 68% of participants in the 75 mg dose group, 56% in the 50 mg dose group and 49% in the placebo group after four months. Native butterbur contains some carcinogenic compounds, but a purified version, Petodolax®, does not.[citation needed]

Cannabis was a standard treatment for migraines from the mid-19th century until it was outlawed in the early 20th century in the USA. It has been reported to help people through an attack by relieving the nausea and dulling the head pain. There is some indication that semi-regular use may reduce the frequency of attacks. Further studies are being conducted.

Supplementation of coenzyme Q10 has been found to have a beneficial effect on the condition of some sufferers of migraines. In a well-controlled trial, Young and Silberstein found that 61.3% of patients treated with 100 mg/day had a greater than 50% reduction in number of days with migraine, making it more effective than most prescription prophylactics. Fewer than 1% reported any side effects. [7]

The plant feverfew (Tanacetum parthenium) is a traditional herbal remedy believed to reduce the frequency of migraine attacks. Clinical trials have been carried out, and appear to confirm that the effect is genuine (though it does not completely prevent attacks).

Kudzu root (Pueraria lobata) has been demonstrated to help with menstrual migraine headaches and cluster headaches. While the studies on menstrual migraine assumed that kudzu acted by imitating estrogen, it has since been shown that kudzu has significant effects on the serotonin receptors. Kudzu Monograph at Med-Owl.

Magnesium citrate has reduced the frequency of migraine in an experiment in which the magnesium citrate group received 600mg per day oral of trimagnesium dicitrate. In weeks 9-12, the frequency of attacks was reduced by 41.6% in the magnesium citrate group and by 15.8% in the placebo group.[8]
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Non-drug medical treatments

Botox has been used by some sufferers in an attempt to reduce the frequency and/or severity of migraine attacks (Botox for Migraines).

Spinal cord stimulators are an implanted medical device sometimes used for those that suffer severe migraines several days each month[5].
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Other alternatives

Some migraine sufferers find relief through acupuncture which is usually used to help prevent headaches from developing. Sometimes acupuncture is used to relieve the pain of an active migraine headache. In one controlled trial of acupuncture with a sham control in migraine, the acupuncture was not more effective than the sham acupuncture but was more effective than delayed acupuncture.

Biofeedback has been used successfully by some to control migraine symptoms through training and practice.

Diet, visualization, and self-hypnosis are also important alternative treatments and prevention approaches.

Bruxism, clenching or grinding of teeth, especially at night, is a trigger for many migraineurs. A device called a nociceptive trigeminal inhibitor (NTI) takes advantage of a reflex limiting the force of clenching. It can be fitted by dentists and clips over the front teeth at night, preventing contact between the back teeth. It has a success rate similar to butterbur and co-enzyme Q10. Massage therapy of the jaw area can also reduce such pain.

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