The Migraine Brain
Page 8
Stage One: Prodrome
“The other day, I was on the phone with my boyfriend and I started slurring my words. And he said, ‘I’ll send a taxi, you’re starting to get a migraine.’ And I was.”
—Bethany, 32, graduate student
Prodrome is changes in your body that are connected to the beginning of a migraine. Some of them are quite odd: frequent yawning, a sudden increase in appetite or craving for junk food, changes in your mood such as irritability or depression. One of my patients gets intense hunger pangs several hours before her migraine strikes, which have become her alarm bell that it’s time to take her medication and block the pain before it starts.
Prodrome probably occurs due to chemical changes in your brain at the start of the migraine. It appears a few hours or up to two days before the pain stage of the migraine. About 40 to 60 percent of migraineurs experience prodrome, according to the most current research. Many more migraineurs may have a prodrome but aren’t aware of it. They don’t connect their prodrome symptoms to the headache that follows some time later, especially since many of the symptoms—such as fatigue or yawning—are commonplace.
You probably already recognize some of your migraine warning signals, so they will be easy to check off on the list below. But we’d like you to think about other possible prodrome symptoms, too, to see whether you may experience them as well.
You want to be aware of as many symptoms as you can so you can use them to your advantage in beating back a full-blown migraine attack. The next time you get a migraine, think back on the hours and days preceding it, and look at the list below. Check all that apply to you:
Prodrome Symptoms
Yes, I get this
Mood changes—feeling depressed? Irritable? Excited? Euphoric?
Increased appetite
Specific food cravings—did you suddenly want high-carbohydrate foods such as candy, cookies, other junk foods?
Unusual fatigue or drowsiness
Tense muscles, especially in the neck
Constipation or diarrhea
Abdominal bloating or rumbling
Difficulty concentrating
The urge to urinate frequently
Frequent yawning
A problem understanding words or finding words you want to use
Slurring your words or other problems speaking
Stumbling or other difficulties when you walk
Other
Stage Two: Aura—Visual and Other Changes
“I never throw up, I never get nauseated. I don’t get those symptoms. I get aura: I see outlines of shapes around objects. They don’t last very long, and then I just go to blurred vision. The minute my vision starts blurring, I know I have a limited time to get down, to get into bed with the lights out, or else I’m going to be really, really sick.”
—Tom, 44, lawyer
“All of a sudden, the hearing will just ‘go out’ in one of my ears. I can’t hear at all from that side. Sometimes I’ll get ringing in that ear, too. It was only recently that I realized that this was a sign that a migraine was on its way.”
—Fiona, 49, writer
Weird visual images are perhaps the best-known symptom of migraine. But they aren’t that common. About one in five migraineurs, or 20 percent, get some kind of aura, with visual aura being the most prevalent type. Aura are changes in any of your senses, speech, balance, or physical perceptions, and they encompass a pretty wide variety of changes in your body. You may have strange alterations in the way you smell, taste, feel, or hear. You may have trouble speaking, or experience dizziness or mental confusion. These are all types of aura, the second stage of a migraine attack.
If you’ve read Alice’s Adventures in Wonderland, you may remember the part where Alice suddenly grows in size, then shrinks, and has other fantastic perceptual experiences. Lewis Carroll, the author, was a migraineur who experienced aura. We call it “Alice in Wonderland” syndrome when migraineurs’ perceptions of their own body or other people’s bodies are distorted: arms and legs appear misshapen, or larger or smaller than normal (called macropsia/micropsia).
The aura stage is the result of changes in your brain chemistry that can affect any or all of your senses and perceptions. Aura gradually appear over a period of five to twenty minutes, usually last less than an hour, and typically fade away once the pain phase appears. They leave no permanent damage. For some people, however, the aura extends into the pain phase, and they get a double whammy of serious headache and nausea along with strange perceptual or sensory changes. Warning: if your aura last longer than an hour, contact your doctor. Although it’s rare, this can be a sign that you are in danger of a migraine-related stroke, a very uncommon disease.
We have a lot to learn about aura, but some researchers currently believe that the part of the brain called the occipital cortex—where your visual centers are located—undergoes changes during this phase of a migraine attack. When these changes spread to other parts of the brain, they may result in problems with speech, walking, smell, or touch. You may not necessarily get aura with every migraine attack, and, as we’ve discussed, you may get visual aura without ever getting a headache.
Having your eyesight suddenly fail or smelling strange odors that aren’t really there can be really frightening—until you learn that they almost always are harmless. However, if you suddenly experience aura but have never had it before, please see a doctor to make sure they are nothing more than a symptom of your migraine.
Aura is a very important stage in treating a migraine. If you choose to treat your migraine with migraine medication called triptans, you should do so during or before the aura stage—because once the headache arrives, it’s usually too late for triptans to work effectively.
For migraineurs with aura, a new treatment called transcranial magnetic stimulation, currently in clinical testing for use in migraine, may be helpful. This option doesn’t require surgery but uses magnetic devices attached to the back of the head to change electrical impulses in certain areas of the brain related to migraine. Early test results are very encouraging, and this may prove an excellent option for patients who can’t or don’t want to use drugs.
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Migraine Aura and Heart Disease
Recent studies show that women in middle age and older who experience migraine with aura have twice the incidence of heart disease as women who don’t get migraines and also have an increased rate of stroke. But don’t panic: The risk of death from heart disease was still low among this group. Only 130 women out of 28,000, less than 0.5 percent, in the study of women migraineurs at Brigham and Women’s Hospital in Boston died from heart disease over a ten-year period. Women who get migraines without aura don’t have increased risk for heart disease, the study showed. (A recent study of men and the migraine–heart disease connection is discussed in Chapter 6.)
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Types of Aura
Various types of aura affect different senses:
Visual Aura. Visual aura are the most common type of aura, and I’m fascinated by my patients’ rich descriptions of these visual changes. One patient says that, when she’s having a migraine attack, people’s faces appear to be broken into pieces, like a Picasso painting. Another sees sizzling, black-and-white sparklers on the edges of her eyesight but loses her vision entirely directly in front, as if she’s peering into a dark tunnel.
We aren’t sure why a migraine attack affects some people’s vision, although it’s possibly due to vision cells being hyperstimulated and then suppressed. Visual aura include a number of possibilities:
sparkling or twinkling lights (called scintillations)
area of lost or decreased vision (called scotoma)
zig-zag lines
white spots
wavy lines
spots
blurry vision
tunnel vision or missing parts of your vision field (called scotoma)
mosaic vision (what you’re looking at appears to be blocked o
ff in pieces or different colors)
distortions in perception (“Alice in Wonderland” syndrome, where people or items appear distorted, out of proportion, or misshapen)
Auditory Aura. A small group of migraineurs gets auditory aura. These are changes in your hearing, including:
hearing sounds that aren’t really there (such as water dripping or a beating drum)
sounds that appear louder than they really are
losing hearing in one ear
tinnitus (ringing in your ears)
Olfactory Aura. These are changes in your sense of smell, such as:
smelling smells that aren’t really there
smells that seem stronger or more powerful or unpleasant than usual.
Sometimes, changes in your sense of smell can be associated with seizures. Make sure you discuss olfactory auras with your doctor, to ensure that they are migraine-related and not something else.
Sensory Aura. These are changes in your sense of touch, including:
numbness or tingling in your skin
allodynia: hypersensitivity or pain in reaction to mild stimuli
partial paralysis of one or more of your limbs (being unable to move one of your legs, for example). The first time you experience this, you should see a doctor immediately to make sure you aren’t having a more serious medical problem such as a stroke. If you experience full paralysis, contact your doctor right away.
Speech and Language Aura. These include:
difficulty speaking
difficulty finding the right words to express what you want to say
slurring your words
Other Aura. You may experience other neurological changes during the aura phase, such as:
vertigo (being dizzy or off balance). The first time you experience vertigo, make sure to call your doctor. Vertigo can be a sign of other neurological illnesses besides migraine, and you will need a thorough evaluation to rule those out.
mental confusion
Stage Three: The Main Migraine or Pain Phase
“I can’t overemphasize how debilitating it is when the pain is in full swing. I’m literally in a fetal position, writhing around, groaning, rolling around the bed. It’s all kinds of throwing up, all kinds of misery. I can almost feel the optic nerve from my eye going back into my head. I’ve had heart surgery, so the fact this really puts me down like that really impresses people. They know I’m not a baby about things.”
—Kent, 38, probation officer
The third stage is the primary migraine phase or pain phase. This is typically the worst part. For most people, it includes severe head pain, nausea and vomiting, and an intense, almost excruciating reaction to light and noise. The head pain is usually throbbing or pulsing, so that you feel it with each beat of your heart. You may want to retreat to a dark, quiet room and block out everything.
Some people also get constipated or have diarrhea. Some have cold hands or feet, a stuffy or runny nose, or a swollen face. Some have even stranger reactions, including bloodshot eyes, frequent yawning or sighing, or frequent urination (which can also occur during the prodrome stage).
The headache or pain phase lasts from four hours to seventy-two hours. But for some really unfortunate people, a migraine may go on and on.
“I was at college and got a migraine that lasted eight days. The doctors had no idea what to do. My mom, who also gets migraines, finally came up and just stayed with me and took care of me until it went away.”
—Belinda, 20, college student
If you have a headache that lasts more than seventy-two hours (three days), you should see a doctor. You may be experiencing something called “status migrainosus,” a severe migraine that can last over a week without any relief. It isn’t necessarily dangerous. However, it’s a very good idea to call your doctor if this happens to you. Treatments that may bring you complete relief include steroids, anti-inflammatory drugs, and/or certain narcotics. The emergency room is not the place to go in this situation, since you probably won’t be a high-priority patient, but if you can’t get in to see your regular doctor and must go to the ER, you’ll want to take a letter from your doctor explaining how to treat you in this situation. See Ch. 9.
During the pain phase of the migraine, do you experience the following? Check all that apply to you:
Pain Phase Symptom
Do I get this?
Always
Often
Rarely
Never
Headache
Nausea and/or vomiting
A sense of seasickness (you may need to stay still so you don’t become nauseated)
An aversion to food
The head pain gets worse with physical exertion
Intense sensitivity or aversion to light
Intense sensitivity to noise
Diarrhea
Runny nose
Stuffy nose or congestion
Eyes tearing up
Very sensitive scalp or skin, so that you can’t stand being touched or your clothes feel tight
Vertigo
Hot flashes or chills
Fluid retention, such as a swollen face or hands
Dehydration
Cold, clammy skin
Pale skin
Reddish skin
Bloodshot eye(s)
Facial sweating
Goose bumps
Mental confusion or an inability to concentrate
Emotional reactions—a wide range are possible, including irritability, depression, anxiety
Other
Your “Migraine Face”
“I showed up at a friend’s house to drop off my daughter for a play date, and when my friend answered her door, I thought, ‘I didn’t know she got migraines!’ Her face was gray and everything was sort of ‘off.’ Her face was sort of deflated. I said, ‘I can tell you’re having a migraine, so I’ll take the kids today.’ She said, ‘Oh, my God, thank you. How did you know?’ I said, ‘You look like I do when I’m having a migraine.’”
—Maddy, 41, home-schooling mom
During a migraine attack, many of us just look…different. And, to be honest, we don’t look our best. Maybe your skin turns pale, or perhaps it gets rosier. Many find that their faces get swollen. Your eyes may tear up or they may be droopy, especially on the side of your face where you’re feeling the pain. Your nose may get stuffy and begin to run. You just don’t look like yourself.
This is what I call your “migraine face.” The changes in some people’s faces can be very striking. When I look in the mirror when I’m in the throes of a migraine, I almost can’t recognize myself. My face looks like it is twisted in knots.
Here’s something that may be helpful to you in recognizing how much migraine affects your body and the way you appear. Take a close-up photo of your face someday when you’re feeling fine. Then, the next time you’re in the middle of a migraine attack, take another close-up photo. Compare the two. There’s probably no better proof of the radical changes your body goes through during a migraine attack. (Of course, if your migraine is really bad, you aren’t going to care at all about what you look like at the moment and may not want to pick up a camera and deal with that flash!)
Stage Four: Postdrome, or the Migraine Hangover
“An ongoing one can last for three days. After these long migraines, I get very tired. My neurologist told me it was a postdromal symptom.”
—Olivia, 37, journalist
“I get silly when a migraine is over. I laugh at everything. I have a feeling of euphoria, but I’m also exhausted. I’m just so glad it’s over.”
—Maddy, 41, home-schooling mom
It’s a huge relief when the head pain and nausea of a migraine finally go away. But the migraine isn’t quite over. There’s a fourth stage to the migraine process, called postdrome. It’s the post-headache stage, or what many call the migraine hangover, and it usually lasts several hours to a few days, until your body returns to normal.