The Migraine Brain

by Bernstein, Carolyn; McArdle, Elaine

  The Reality: Migraine Is a Chronic Illness You Were Born With

  “Sometimes I’ll lose my peripheral vision. It’s really scary, so I started taking the subway more because I couldn’t drive. Once, I was so sick I had to throw up in my briefcase, and I thought, ‘People will think I’m drunk, throwing up at three o’clock in the afternoon on the train.’ That’s when I knew migraines were taking over my life.”

  —Felicity, 29, college professor

  What’s the difference between an ordinary headache and a migraine? Headache is pain in the head that occurs randomly and sporadically but it’s not a disease. Migraine, by contrast, is a chronic, neurological illness that you were born with. It’s something you live with, a presence in your life like arthritis, although you usually can’t predict when it will leap up to consume and ruin your day (or days). Migraine usually includes head pain, often excruciating, but unlike other headaches, it almost inevitably includes a number of other symptoms, too.

  Almost everyone will have an ordinary headache at some point in their lives. Sometimes, the head pain can be quite severe. But migraines are an entirely different experience. People who get a generalized headache—a tension headaches, a headache from the flu, a muscle contraction headache—don’t remember the specific details of the experience the way that migraineurs do. Migraineurs can often describe their worst attacks in vivid detail. Some keep logs of their attacks, or paint or draw their experiences of the pain and other symptoms. Unlike headaches, a migraine attack can bring your world to a complete halt. The pain, nausea, and overall sense of sickness can be completely debilitating.

  For many migraineurs, it is liberating to learn that what they are experiencing is a neurological illness with a specific name, a biochemical basis, and roots that trace back thousands of years to the beginning of medical history. When they learn their illness is something they were born with and that is shared by so many others, they no longer blame themselves, try to hide how bad they feel, or worry about dying.

  I have a male patient whose migraines begin with a tingling feeling in his fingers that marches up his arms and into his jaw, at which point he gets an excruciating headache. He has what’s called a “complicated migraine,” because it includes “focal” or localized symptoms. Until he became my patient, he had no idea what was wrong with him because his symptoms were so strange. Once he had a name for his experience, he felt relieved and vindicated. He could explain to his family and friends that he has a nonfatal, neurological illness that causes his brain to act differently than other people’s, and that it’s one of the oldest and most common human diseases known. His disease is real, it’s painful, and he’s doing the best he can to treat it. He’s certainly not inventing or exaggerating his symptoms.

  Your Migraine Profile: Everybody Is Different

  “I got them all through my teens and twenties and thirties. Then they went away when I was in my forties, and I’ve never had another one.”

  —Yvette, 81, homemaker

  “I’m just the opposite. I never got one until I turned fifty, and now I get them all the time.”

  —Teresa, 51, her daughter-in-law

  No two people have exactly the same migraine experience or history. Migraine varies enormously from one person to the next. That’s why it’s often hard to compare your migraines to someone else’s and recognize them as the same disease. Your migraine probably has different triggers than a friend’s. For example, there’s a widespread myth that migraineurs should avoid chocolate and foods with MSG (monosodium glutamate, a common food additive). It’s just not true. Chocolate or MSG can trigger a migraine in some people—but not in everyone. Each of us has a different, highly individualized migraine profile: a different menu of symptoms, a different group of triggers that sets off attacks, different treatments that work or don’t, and a different story as to when your migraines began, how many attacks you have, and when you stop getting them.

  In this book, we’re going to help you develop your own personal migraine profile, so you’ll have all the information you need to prevent and counter an attack and lead a healthier life. To do so, you’re going to have to understand your own body and the particulars of your personal migraine.

  You may or may not feel nauseated or vomit during a migraine attack. You may or may not have trouble talking or notice weird smells before the head pain arrives or have sensitivity in your scalp. A small minority of migraineurs sees flashing lights, zig-zag patterns, or other strange visual signs before a headache begins. Some people get runny noses at the start of an attack, some stumble as they walk. Some get relief after a deep sleep, while others feel so sick that they can’t sleep at all. Some people’s migraine attack ends once they vomit; for others, vomiting only makes them feel worse. Some get especially frightening symptoms that mimic serious health issues such as stroke. Children can get basilar migraines, during which they pass out and can’t move their arms or legs, which is terrifying for the parents or teachers who witness it.

  Successfully managing your migraines is 50 percent education and 50 percent treatment.

  Some migraineurs have even more bizarre symptoms. I have a patient whose left side became paralyzed during migraine attacks, with her tongue hanging out of the left side of her mouth. When she was rushed to her local hospital, emergency personnel were certain each time she was having a stroke—until a CT scan showed that she wasn’t. Because some migraine symptoms can be signs of stroke or seizure, doctors justifiably react by assuming the worst until they can establish that the patient isn’t in danger. Today, this patient carries a letter from me, explaining to ER workers that her odd symptoms aren’t signs of a stroke, but mean that she is having a migraine attack and recommending specific treatments that work for her.

  To make it more confusing, once you’ve figured out the individual characteristics of your migraine and created your migraine profile, the symptoms and triggers may change! You may suddenly get a lot more attacks or many fewer. Your treatment plan may no longer work. Stay alert to any changes in your migraine pattern. Keeping on top of your migraine profile and being aware of change is part of successfully managing your disease. (Remember—always report any changes in your migraine pattern to your doctor, to make sure something more serious isn’t happening.)

  Why You Need to Know if It’s a Migraine

  Treatments for other kinds of headaches won’t work very well for migraines, if they work at all. Over-the-counter medications may help the pain for some people, but for many others, these treatments don’t even make a dent. And prescription painkillers are not the optimal treatment, because, unlike triptans and other migraine-specific treatments, they won’t stop the migraine from progressing and making you sicker. To get the best treatment possible and feel better, you have to know whether you’re experiencing a migraine.

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  Migraines, Stroke and Heart Disease

  As a chronic disease, migraine can have effects on a number of aspects of your health. New research suggests a link between migraine and both stroke and heart disease, which provides yet another reason for you to take excellent care of your health.

  If you get migraines—especially migraines with aura—you are at an increased risk of stroke, although your overall risk is still most likely very, very small. The exact reason that migraines seems to increase stroke risk isn’t clear. Research by scientists at Seoul National Hospital found that, compared with other people, migraineurs with aura have lower levels of endothelial progenitor cells, which help stabilize the lining of blood cells. We’re not sure what this means yet, but it may be that people with lower levels of these cells are more likely to develop high blood pressure, which can increase risk of heart disease. It may be that ht expansion and contraction of blood vessels caused by migraine lead to buildup of plaque in your blood vessels, which in turn can lead to stroke or heart attack.

  Women who get migraine with aura most likely should not take birth control pills or supplemental estrogen bec
ause these may increase the stroke risk even more. Since every person is different, however, this is something you should discuss with your doctor. See Ch. 5.

  You and your doctor should make it a priority to reduce all stroke and heart disease factors in your life. You should not smoke, you should exercise regularly, you should eat healthy foods. If high blood pressure, stroke, or heart attack run in your family, you should be especially vigilant. You and your doctor should discuss whether you should take stroke or blood pressure medication.

  * * *

  Distinguishing migraine from ordinary headaches can be difficult and time consuming because there’s no easy, inexpensive diagnostic test. (A recent study found that the brain of long-term migraineurs looks different. But it’s unlikely—at least anytime soon—that doctors will order brain scans for the purpose of diagnosing migraine.) Sometimes people suffer from migraines in conjunction with other types of headaches: for instance, a tension headache or flu headache can trigger a migraine, which makes it more confusing.

  Diagnosing migraine is a bit of an art that requires that patient and doctor trust each other. We doctors have to trust that you’ll be open with us and share the details and history of your migraine disease, so we have all the information we need to keep you safe and healthy. In turn, you must trust that we are listening carefully and accepting what you say without judging you. Many doctors don’t have the time or experience to diagnose and treat migraine successfully, which is why I recommend that you find a headache specialist to work with you. See Ch. 8.

  While finding the right doctor is important, you know your body—and your headache—better than anyone else. With The Migraine Brain as a complete resource handbook, you will understand your illness, and, when you finish reading it, you’ll have all the information you need to find a good doctor and work with her or him to ensure you have the right diagnosis. And you’ll also have explored the various treatment options, to find the best ones for you.

  The Migraine Checklist

  While there are exciting breakthroughs in understanding migraine, there is still much for us to learn. At this time, there is no diagnostic tool that can scan your brain or analyze your blood and prove that you are a migraineur. Instead, I use a checklist of common migraine symptoms to help my patients and me arrive at a diagnosis.

  Here are the most common characteristics of migraine. Check off any that apply to you:

  Your head or face pain is throbbing or pulsating (you may feel it with each beat of your heart) rather than steady.

  The pain lasts from 4 hours to 72 hours.

  The pain is on one side of your head or face (it may change sides from one attack to the next, or even within a single attack).

  The pain is so severe it may wake you from a deep sleep.

  You have nausea and/or vomiting.

  You feel dizzy or have vertigo (feel like the room is spinning or otherwise feel off-balance).

  You have a sensitivity or aversion to light, known as photophobia.

  You have a sensitivity or aversion to sound, known as phonophobia.

  You have ringing in your ears—and/or noises sound louder than normal, known as hypacusia.

  The pain gets worse with physical exertion such as walking around or bending over.

  You get warning signals before the migraine arrives, such as tingling in your scalp or face.

  Your migraine is preceded by “aura,” such as strange visual changes like flashing lights or zig-zag lines before your eyes, or nonvisual aura like smelling strange smells.

  You slur your speech or your body becomes paralyzed before the migraine.

  Someone in your family got migraines or “sick” headaches (keep in mind that they may never have been diagnosed as migraines).

  If you experience several of these symptoms at least a few times, this is highly suggestive of migraine, and you should see a doctor to get a diagnosis. See Ch. 8. If none of these applies to you, you probably have some other type of headache.

  Going Deeper on Migraine Symptoms

  “It’s almost like there is a dictionary of migraine symptoms, certain words that people with migraines use. It’s like this secret society none of us really want to be in. Somebody talking about a regular headache will say, ‘It’s painful,’ but someone with a migraine says, ‘It’s like someone takes a vise grip and is squeezing behind your eyeball.’”

  —Felicity, 29, college professor

  Throbbing or Pulsating Pain. About 85 percent of migraineurs describe their migraine pain as throbbing, pulsating, or pounding. You may feel the pain with each beat of your heart. Some say it feels like someone is stabbing a knife in and out of their head. In contrast, the pain of a tension headache is often a dull ache that doesn’t rise and fall but stays constant.

  Why is migraine head pain like this? One component of migraine may be vascular dilation, where blood vessels expand and contract. Like much about migraine, we don’t fully understand this yet, but throbbing or pulsating pain is one significant hallmark.

  Pain Lasts Four to Seventy-two Hours. Unlike other kinds of headaches, which can be brief and resolve with a couple of aspirin, migraine tends to last several hours or longer, up to three days (if they aren’t treated, that is).

  Unfortunately, sometimes people have migraines that last even longer than seventy-two hours, a condition called status migrainosus. Although this is a rare condition, it can be serious. If you get a migraine that lasts more than seventy-two hours (three days), you should seek medical attention, not only to ease your pain but also to ensure you don’t become dangerously dehydrated due to vomiting, inability to hold down liquids, or diarrhea. There are effective treatments for status migrainosus, but you need a thorough medical evaluation to determine which is right for you.

  One-Sided Head or Face Pain. A striking characteristic of migraines is that the head pain typically is on one side of the head only. But for many people, this isn’t true. While 64 percent report one-sided head pain, the rest feel migraine pain on both sides, in their necks, or at the front or back of their heads. Some people feel pain in their face only, not their head, which may confuse doctors who don’t recognize this as a migraine symptom.

  The Pain Is So Severe It May Wake You from a Deep Sleep. Migraine headache pain can awaken you suddenly from a deep sleep. This rarely happens with other kinds of headaches. While the pain of a tension headache can be moderate to quite painful, it rarely wakes you up while you’re sleeping.

  Caution! A stroke also can wake you up from a deep sleep. The first time you awaken from a deep sleep with a terrible headache, call your doctor. And if the headache is accompanied by numbness, weakness, visual changes, or any other symptom that’s in any way different from your usual headache, call 911 to take you to the emergency room right away.

  You Have Nausea or Vomiting. Nausea and vomiting are a very common hallmark of migraine. In fact, 80 percent of migraineurs feel nauseated during an attack, and about 33 percent vomit. The nausea and vomiting of migraine are directly related to the neurochemical changes in the brain during an attack.

  You Feel Dizzy or Have Vertigo. Dizziness and vertigo (losing your balance, feeling like the room is spinning, etc.) are common symptoms of migraine. About 25 to 35 percent of migraineurs experience episodes of vertigo. Many migraineurs with vertigo are particularly sensitive to motion sickness and may have been carsick as children. For women, the dizziness may often occur during their period. Migraineurs have a higher rate of anxiety disorders, including panic disorder, than other people, and dizziness can be a symptom of panic disorder (also called panic attacks). Migraineurs may sometimes get dizzy spells independent of head pain. Some continue to have dizziness long after they’ve stopped getting migraine headaches.

  Interesting note: Some migraineurs get vertigo but never get head pain, in which case the diagnosis of migraine is made by excluding other possible medical causes for vertigo, and also noting whether there is a family history of migraine, which would suggest mi
graine as the likely cause.

  Photophobia—Sensitivity to Light. Sensitivity or aversion to light is one of the most striking characteristics of migraine. I have yet to meet anyone who can stand bright lights—or any light at all—during a migraine attack. According to studies, nearly 90 percent of migraineurs are sensitive to light. During a migraine, most people crave a darkened room or need to wear sunglasses or light-blocking eyeshades. Why? Because they are experiencing a heightened sensitivity to any kind of stimulus—light, sounds, touch, taste, and smell. For some migraineurs, lights can trigger a migraine—bright lights, fluorescent lights, flickering lights, computer screens, even the sunlight flickering behind venetian blinds.