Ask an expert: Managing migraines
What is “migraine brain”? Could some sinus headaches actually be migraines? Is there any way to head off chronic migraines? Hubert Leonard, M.D., Ph.D., neurologist and headache specialist, answers questions about migraines.
What is “migraine brain”?
The migraine brain is most often inherited. About 90 percent of people with migraines can look in their family tree and find at least one relative who also suffers from migraines. The migraine brain, due to genetics, is hypersensitive and hyper-excitable. This makes it much more likely to react to things that can trigger headaches.
For the migraine brain, the headache process might be activated by internal factors such as changes in hormones (in women), stress or sleep habits, or external factors such as weather changes, alcohol consumption or exposure to flickering lights. Most people’s brains can manage these types of changes, but the migraine brain simply has a lower threshold for tolerating these triggers. A person’s accumulated life experiences can alter the brain and lower this threshold even further.
Could a person diagnosed with recurring sinus headaches actually have migraines?
It happens all the time. People with occasional nasal pain, drainage and congestion may understandably assume that they are experiencing sinus headaches – especially if their symptoms are triggered by weather changes. But all of these factors are common in migraines, too. One study of 3,000 people diagnosed with sinus headache found, on further questioning, that nearly all of them – 96 percent – met the rigid diagnostic criteria for migraine.
The critical obstacle to treating migraines is how frequently they are misdiagnosed as something else. Besides sinus headaches, they’re often misdiagnosed as tension headaches, allergies, or headaches caused by neck or TMJ pain. In children with undiagnosed migraines, the first instinct is often to take them to an eye doctor for glasses.
The key to effective treatment is to arrive at the right diagnosis, and that requires questioning further, beyond the assumptions. While sinus headaches and migraines do share some symptoms, for example, sinus headaches usually aren’t severe. Migraines usually are.
How can you tell if a headache is a migraine?
Migraine headaches are usually moderate to severe, and are frequently disabling. They can last anywhere from four hours to three days. They often are described as throbbing, may occur on just one side of the head (in about 60 percent of people), and may be exacerbated by routine activity. But migraine is more than just pain – it is a syndrome, meaning that it is characterized by a group of symptoms. Those may include any or all of the following:
- Visual auras right before the headache (in 15 to 18 percent of people)
- Sensitivity to light and sound, and sometimes to smell
- Nausea and/or vomiting
- Inability to think clearly
- Neck pain (in 75 to 80 percent of people)
- Pain in the face, the upper back, or along one side of the body
- Anxiety, changes in mood and other psychiatric changes
In addition, people who get migraines are highly likely to have one or more accompanying conditions, known as co-morbid conditions. Some of the most common are:
- Anxiety disorders
- Social phobias
- Bipolar disorder
- Irritable bowel syndrome
- Sleep disorders
It takes a complete history of a person’s symptoms and co-morbid conditions to ensure the right diagnosis. One excellent tool that can help with this process – and provide some valuable insights into your headaches – is the online questionnaire found at promyhealth.org/headache.
What can be done to stop migraines, or at least to make them more manageable?
Migraines can’t be cured, but they can be managed to make life better. Treatment is a multi-step process that usually requires several approaches:
- Medications to stop headaches in progress: A class of medications called triptans is the gold standard for stopping headaches in their tracks. These abortive medications should not be used more than two days a week. One exception: headaches that occur only during menstruation can be treated on each day of the period.
- Medications to prevent migraines: For people who are starting to have headaches more than two days a week, who are using more and more abortive medications, and whose headaches are severe and disabling, preventive medications are available. These medications can increase the migraine threshold in the brain and reduce both the number and severity of attacks. These must be taken every day.
- Cognitive and relaxation therapies: Strong evidence shows that biofeedback, relaxation therapy and cognitive behavioral therapy can be very useful in helping to manage migraines.
- Getting co-morbid conditions under control: The higher a person’s “disease load,” the harder migraines are to treat. It’s important to do everything possible to manage other conditions, such as depression and anxiety, to reduce the risk of sliding into chronic migraine (15 or more headaches per month).
- Improving sleep: Especially for people with chronic migraines, getting on a regular sleep cycle can help reduce migraine problems.
- Managing weight: Obesity increases the risk of chronic migraine. If this is an issue, it’s important to work on weight reduction and to look for alternatives to any medications that increase appetite.
- Managing stress: Resolving stressful life situations and learning how to manage stress can significantly reduce the risk of chronic migraine.
- Education: The more a person understands her own headaches, triggers and treatments, the better control she will have over her headaches and her life.
The migraine brain is truly different from others – it is extra sensitive and overreacts to all kinds of stimuli inside the body and outside in the world. To date, we don’t have a way to take the migraine out of the brain, but we do have tools for making life with the migraine brain more manageable. I tell my patients to remember that treatment is a process – and sometimes that process is trial and error. If one treatment doesn’t work, something else might. Learn everything you can, be patient with the process, keep your expectations realistic, and keep trying.
Dr. Hubert Leonard is the only physician in Oregon certified in headache medicine by the United Council of Neurologic Subspecialties. He practices at Providence Medical Group-Neurological Specialties, which is part of Providence Brain and Spine Institute