Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, M.D.
 30 March 2005

THE MIGRAINE PROBLEM

            Migraine headaches are one of the least well understood medical problems.  To many people a migraine headache means “a bad headache”.  While migraine headaches are generally described as very bad, by no means are all bad headaches due to migraine syndrome.  This column is devoted to helping identify those individuals who have a true migraine syndrome and what can be done to help with that problem.

            The migraine syndrome was recognized many years ago and has very distinctive characteristics.  By no means do all patients have all of the characteristics of the migraine syndrome.  This makes the diagnosis of migraine headache much more difficult when only part of the syndrome or a variant of it occurs.  Listed below are the characteristics most common in patients with a migraine headache:

            1.  The headaches are recurrent.  They tend to come on at various intervals for various durations.  People that get one true migraine headache generally will have more than one.

            2.  There may be triggering events for some people such as wine or cheese or chocolate but there is no uniform event that will predictably cause a migraine headache in all individuals.  Stress or fatigue is often faulted for the onset of a migraine headache but this is inconstant.

            3.  The headache is one-sided.  Most frequently the headaches occurs more in the face or in the front of the head more than in the back.  Either side may be affected with one side affected in one occurrence in a patient then the other side affected in that same patient at another time.

            4.  There is an aura or some event that signals the onset of the headache coming.  This can be a strange odor often indescribable.  Alternatively the individual may have bright rings of light around the eye or flashing lights that appear in only one eye or the person may hear a strange noise such as buzzing or a ringing.  This often precedes the headache by an hour or so.  Fortunately, this gives the headache sufferer a warning of what is coming and allows them to prepare.

            5.  Most patients with true migraine syndrome will develop nausea and vomiting.

            6.  The headache will often be associated with abnormal watering of the eyes or of the nose or on rare occasion even of the mouth.

            7.  The person usually is highly uncomfortable with brighter lights.  They prefer a dark room.

            8.  The problem generally lasts 18-36 hours and once it disappears, the person’s function returns to normal depending how much fatigue has occurred from the pain, nausea and vomiting during the headache episode.

            You would think that a clinical syndrome as well defined as the migraine syndrome would have an identified specific cause for the problem by this time.  Unfortunately, that is not the case.  It is current medical theory that arteries in the surface of the face and brain dilate and cause the pain.  As a general biological rule, whenever a tubular structure in the body is stretched or dilates abnormally, severe pain is an expectation.  It has been theorized that the basic cause of the migraine syndrome is dilatation of facial and scalp arteries as mentioned.  This theory is contested by many authorities and to this time, I am not aware of a uniformly accepted explanation of the basic problem in the migraine syndrome.

            Several years ago the only treatment for the migraine syndrome was narcotic pain injections, a dark room, three days of rest, and for some people a dangerous medication called ergot.  Frequency estimates of the migraine syndrome suggested as many of ten million migraine sufferers.  This got the attention of multiple pharmaceutical companies and now there no fewer than six separate products called the “-triptans”.  The first of these was Imitrex (sumatriptan).  It comes as a nasal spray, an injectable form and a pill form.  It seems to work wonders for some people with migraine syndrome but not all.  Over the past six years, there are now six different products available including Maxalt (rizatriptan), Relpax (eletriptan), Zomig (zolmitriptan), Amerge (naratriptan) and Axert (almotriptan).  All six of these products have the same business end of the molecule but with different doodads stuck on it that change the way the drug is absorbed or metabolized or binds.  The reason that there are six products out there is the response to the different products is variable.  One person finds one drug very helpful while other individuals get no help from that particular product.  Some people find the pills very helpful but if the migraine syndrome strikes quickly and nausea and vomiting prevents taking a pill, then an injectable or nasal product obviously has an advantage over pills.  All of these pills are relatively expensive but for the person who receives relief from their migraine syndrome, they are most generally described as “worth the price, whatever it is”.

            The “-triptan” family of drugs are described as agonists (substitutes) for a neuro transmitter called serotonin.  Another reason that there are so many drugs on the market is that there are at least four separate receptors for serotonin in the body.  Some of these seem to involve depression problems and are treated with the SSRI’s (Prozac, Paxil, Zoloft, Lexapro).  The “-tryptan” family seems to work on a different serotonin receptor to cause vasoconstriction of the culprit blood vessel causing the headache.  If the headache problem is truly due to an artery in the face of the brain being dilated, scientists reasoned that a product that would vasoconstrict the dilated portion of the artery might effectively treat the migraine syndrome. Indeed, this has been seen to occur in a large number of people.

            A word of caution is order in regard to the “-tryptan” family of drugs.  As mentioned above, they are “vasoconstrictors”.  They tend to make blood vessels squeeze down into a smaller size than they were.  This maybe wonderful for a person with a migraine headache but it can be a disaster for a person with marginal blood supplies to the legs or the heart or the brain.  If one squeezes down those arteries, there may not be enough blood to get to the brain or the heart and a stroke or a heart attack can occur.  If a person is taking a type of anti-depressant called monoamine oxidase inhibitor, “-triptans” should not be used because they can cause strokes.  Since these drugs are vasoconstrictors, they may make high blood pressure worse.  Amerge should not ever be used in patient’s that have kidney impairment and the other drugs should be used with caution in people that have kidney or liver impairment.

            Fortunately, the migraine syndrome tends to occur in young otherwise healthy individuals and the above contraindications are usually not critical in the patient management.  The use of the “-tryptan” family of drugs in individuals over age 50 should be done with great care and consideration for possible blood vessel problems.

            The last question to consider is how long these drugs could be used and how often.  They are recommended for use at the time of the onset of the migraine headache.  However, some individuals use these drugs on a frequent basis often for 2-3 weeks at a time to prevent the headache from ever coming.  The FDA instructions for use of this family of drugs do not approve daily use of the medication to prevent the headaches.

            Finding the right product and dose schedule to deal with the migraine syndrome that a person may have can be very frustrating.  In spite of the many characteristics of the migraine syndrome, individuals frequently have only some of these or variants of some of them which makes the diagnosis very difficult.  The providers at your local clinics are well aware of these problems and can help work through the various considerations to first arrive at the proper diagnosis of the migraine syndrome and secondly to arrange a treatment program to provide relief as can be done.