The Migraine Brain
Page 12
Your Personal Top Ten Migraine Triggers
Once you’ve identified your triggers, create a chart like the sample below (there’s a blank form in the appendix). Your Trigger Prevention Chart is a very helpful tool in avoiding as many migraines as possible. (Later, we’ll add this to your personal Migraine Profile that you began developing in Chapter 3.)
Trigger
How Serious?
Avoidable?
Solutions
1. Lack of sleep—I need 8 hours
Always triggers migraine (anytime I get less than 6 hours of sleep)
Most of the time, except when I travel
Go to bed on time; make my room quiet and dark. When traveling, use migraine travel plan.
2. Not eating enough (getting too hungry)
Always, especially if I skip breakfast (need to eat 3 meals a day, with some protein at each, and protein snack in between)
Yes. Requires planning and discipline
Always eat 3 meals, especially breakfast. Carry protein bar in purse and car glove compartment.
3. Airplane travel
Always
Travel isn’t avoidable but getting sick is
Migraine travel plan
4. My period
50 percent of the time, I get a migraine
I’m not going to limit how many periods I get…
…but I can keep track of my period and be ready for a migraine.
5. Red wine
Sometimes, mainly in conjunction with other triggers
Yes
Don’t drink red wine when I’m traveling, on my period, haven’t eaten enough, or didn’t get enough sleep. Drink 1 or 2 glasses of water to every glass of wine.
6. Stress or emotional upset
Sometimes. I can’t tell when stress or being upset will trigger a migraine, though
Not avoidable…
…but a stress-reduction plan helps a lot: exercise 4–5 times a week, daily meditation, psychotherapy when needed, and simple things like talking to a friend, a yoga class, or a bubble bath.
7. Weather changes
Sometimes, not always. Not sure why this is.
No
Avoiding other triggers at the same time is helpful. I may try a saline rinse if my sinuses feel pressure.
8. Dust
Avoiding other triggers at the same time is helpful. I may try a saline rinse if my sinuses feel pressure.
Yes
Swiffer my house at least every week. Wash my comforter regularly. Stick with bare floors, not rugs.
9. Onions
Only sometimes. Not sure why.
Yes
Avoid all onions or foods with onions in them like salsa. But…I like onions. I think I can risk it sometimes, if I’m not exposed to other triggers at the same time.
10. Diet drinks with aspartame
Sometimes
Yes
Avoid these drinks. Drink water instead, or drinks with a different kind of sweetener.
CHAPTER 5
Female Hormones and Migraines Through the Life Cycle
“It was the time I started getting my period that I started getting migraines. That’s the connection.”
—Kristen, 22, nursing student
Some years ago, researchers studying migraines noticed an intriguing thing. Among children, boys get more migraines than girls—until the onset of puberty. Once girls begin menstruating, many who have not suffered from migraines suddenly begin to experience them. The tables have turned: from puberty onward, migraine becomes a predominantly female disease and remains so for the rest of the human life cycle.
Scientists have noticed other interesting links between migraine and menstruation. Women are twice as likely to have migraines around the time of their menstrual period as at any other time, according to a recent study reported in the journal Neurology. The biggest danger time is two days before the period starts, when a migraine is 71 percent more likely to occur. And the most painful, severe migraines occur when a woman has her period—on days one to three of menstruation, women are nearly five times more likely to experience vomiting along with their migraines.
A wealth of other evidence connects hormones and migraines. Some women get their first migraine when they begin taking birth control pills, which contain female hormones, while others find that birth control relieves their migraines. Some women go their entire lives without a migraine until they enter perimenopause, the time frame before menopause when their hormones begin to change significantly. For most women, it’s the other way around: those who get migraines throughout their lives find they taper off or end entirely once they go through menopause.
Obviously, there is an important link between the female reproductive cycle and migraines, although this connection doesn’t explain all migraines. The latest research shows that women may be significantly more susceptible than men to cortical spreading depression, the wave of brain excitation that leads to migraines, for reasons that may be unrelated to the menstrual cycle.
In this chapter, we’ll discuss more fully the connection between hormones and migraines. We’ll examine migraine and its consequences at various points during your reproductive years and pregnancy, after childbirth, while you are breastfeeding, in the very busy years of middle age and perimenopause, and at menopause and beyond. We’ll discuss how your migraines may change during these different phases and how your treatment plan may need to change, too. And we’ll discuss treatments that can reduce the number and severity of migraines—and reduce the impact of this disability on your life.
The Role of Female Hormones
“The minute I start feeling the twinge of a migraine, I go into the bathroom, and I literally say, ‘Oh, look at that! I got my period.’”
—Flannery, 37, veterinary technician
For years, it was theorized that the female hormone estrogen was the culprit behind the migraine attacks that coincided with a woman’s periods. We now know that estrogen itself isn’t to blame. The problem is that estrogen levels rise and fall over a woman’s monthly cycle, and those fluctuations lead to migraines.
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Tell Your Ob-Gyn About Your Migraines
Be sure to inform all your doctors, especially your ob/gyn, that you get migraines. This is critically important information that can affect other aspects of your health, including drugs you should or shouldn’t take for other health issues. Make sure you tell your doctor again about your migraines if you become pregnant or are trying to become pregnant.
* * *
Your monthly menstrual cycle is regulated by several hormones, including LH (luteinizing hormone) and FSH (follicle stimulating hormone). Certain hormone levels increase in the middle of the menstrual cycle in order to trigger the release of an egg from the ovaries for ovulation. This surge is the very kind of change the Migraine Brain doesn’t like, and it can trigger a migraine, which we call an “ovulation” or “mid-cycle” migraine. Once your brain adjusts, it calms down again, but about two weeks later, around the time your period begins, hormone levels change again. Your Migraine Brain isn’t happy and may react with a migraine.
Each month, your brain repeats this cycle: rising hormone levels followed by a sudden drop around your period. For a large number of women, this cycle means that each month they get a migraine during their period—and perhaps another when they are ovulating.
Two types of migraines are connected to the menstrual cycle. One is called a menstrual migraine, and the other a menstrual-related (or hormonal-related) migraine. Sometimes these terms are used interchangeably but they are a bit different. A woman who suffers from a true menstrual migraine gets migraines only around the time of her period and at no other time, not even when she is ovulating. About 10 to 14 percent of women get menstrual migraines.
Menstrual migraines, by definition:
begin sometime during a time frame starting two days before your period up until three days into your period;.
tend to run in fa
milies—if your mother got them, you may, too (and so may your daughters);
are cyclical, like your menstrual cycle.
If you get headaches only around the time of your period, you have true menstrual migraines.
But if you get migraines around your period and at other times, you have menstrual-related migraines. Some women get a migraine around the time of their period and then a second migraine when they are ovulating (about fourteen days into their monthly cycle). And some get migraines during their period and at random other times throughout the month because fluctuations in female hormones are just one of their migraine triggers.
Unfortunately, many women who get menstrual or menstrual-related migraines may not recognize these headaches as separate illnesses that may need different kinds of treatment from other menstrual-related issues. As a result, they may continue to receive outdated or incorrect medical information from their doctors. You may have to help your doctor recognize the connection between your cycle and your migraines. Fortunately, it’s not difficult to do so. By using a calendar to track your migraines alongside your menstrual cycle, a pattern may emerge that we can use as an invaluable diagnostic tool.
One of my patients, Diana, a fifteen-year-old girl with wild red hair and an abundance of freckles, gets menstrual migraines. She experienced her first one when she was thirteen, about a year after she began menstruating. She remembers it vividly. On the second day of her period, she was in her bedroom reading a book when her head began to pound relentlessly. She described it to me as “an excruciating, hammering on the right side of my forehead, as though a truck were grinding its huge wheels into my skull.” She’d had headaches before, and she could tell immediately that this one was profoundly different. Soon, she felt as though she were going to faint from the pain. Instinctively, she shut the lights in her room and lay down on her bed but the pain grew worse and she began panicking. She started to cry but that only placed more unbearable pressure on her head. Her parents were out for the evening, and her seventeen-year-old brother was entertaining friends in the living room. She was too embarrassed to reveal that she was in this much pain, so she went into the kitchen, thinking eating sugar might ease the torture. She ate a Nestlé chocolate bar, which made her completely nauseated, and she ran to the bathroom and threw up. She returned to her bedroom and sat in the dark until her parents came home. Not knowing what to do, Diana’s mother gave her daughter a Valium. It put her to sleep, and she woke up the next morning in a groggy cloud.
When it happened again the following month, Diana’s mother brought her daughter to see me. I asked her many questions about her lifestyle so that I could develop a specific treatment plan: Did she experience a lot of stress in school? Was she drinking enough water? Was she eating enough protein? Was she able to get the necessary eight hours of sleep each night, especially during her period? Did she stop exercising during her period? We devised a plan whereby she took a triptan medication during her period. I also asked her to keep a diary and stay attuned to her lifestyle and foods that could be triggers. Diana is now fine and thriving in high school.
Are Your Migraines Related to Menstruation?
To determine if you get menstrual or menstrual-related migraines, you’ll need to track your headaches with your monthly menstrual cycle. You can simply mark this information on a typical calendar. However, keeping a detailed headache diary is probably the preferred method since it lets you recognize not just the menstrual connection but other triggers for your migraine. For best results, keep this calendar for at least three months. Every time you get a migraine, mark it on the calendar. Include these details:
When the migraine started
How long it lasted
The intensity of pain, on a scale of 1 to 10
Symptoms that preceded the headache (such as visual changes or nausea)
Symptoms of the migraine itself (throbbing headache? stomach pain?)
What you ate in the two hours before the headache
Other possible triggers such as lack of sleep or a stressful event
What medications you took, if any, and whether they helped
Other treatments you tried, such as an ice pack, and whether they worked
On this same calendar, mark down the details of your menstrual cycle, including:
When your period started
How many days it lasted
Any premenstrual symptoms: skin changes (such as acne), food cravings, cramps, mood changes, fatigue
With this information on your calendar, you are looking for two possible times when you may find a link between your headaches and your monthly cycle: one around the time you start bleeding, and a second about fourteen days before you get your period, which is the time of ovulation.
Eve, whose headache calendar is on the opposite page, is a twenty-five-year-old woman who works as a hairdresser. Notice that Eve got a migraine two days before her period started. She also got a migraine on the 29th day of the month, fourteen days into her menstrual cycle, when she likely was ovulating. This data tells me that at least some of her migraines are related to the hormone fluctuations of her menstrual cycle.
What if you have migraines throughout the month, in what seems to be a random fashion? It may mean you have menstrual-related migraines as well as migraines triggered by other things such as weather or food. On Eve’s chart, in addition to her menstrual-related migraines, she got a migraine on the fourth day of the month, possibly triggered by drinking red wine, or by a combination of wine and lack of food.
Eve continued to track her migraines against her menstrual cycle for another two months. Each month, she got a migraine just before her period started and another when she was ovulating. We also learned that she got one every time she drank red wine. All of this information was invaluable. In this case, I would recommend one treatment approach for her menstrual-related migraines, and another for her migraines caused by red wine. Since her periods are regular and we can predict when she ovulates each month, I would prescribe a triptan two days before period that stops the chemical chain reaction that leads to migraine.
The red-wine migraines require a different approach. She might try to avoid red wine completely, especially if she hasn’t eaten that day or gotten enough sleep. But if a migraine nonetheless appears, through another of her triggers or because she can’t resist a glass of cabernet at her best friend’s bridal shower, I would tell her to take her triptan medication at the first signs of an impending migraine attack, which for her includes lightheadedness, feeling tired, and sensitivity in her face and scalp. That way she can stop the migraine chain reaction in its tracks.
If you get menstrual or menstrual-related migraines, you may also want to consider taking a daily magnesium supplement. A recent double-blind study found that a magnesium supplement reduces menstrual and menstrual-related migraines. See Chs. 11, 12.
Will Your Daughter Inherit Migraines?
If you suffer from menstrual or menstrual-related migraines, it’s quite likely your daughter may be susceptible once she begins to menstruate. If so, you can be a wonderful resource and support for her, since treatments that work for you may very well work for her, too. However, if your daughter is young, you (or she) may not want her to take medications, and complementary and alternative treatments may be the best option See Ch. 11. In any event, please be sure to tell her pediatrician or family practitioner that you get migraines, so her doctor can be on the lookout for symptoms in her. If the doctor isn’t familiar with treating children with migraines, please direct him or her to this book and the resource list in the appendix.
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Serena Williams
Serena Williams, who ranks as one of the top female tennis pros in history and has won more than two dozen tennis championships including two Wimbledon titles and the 2007 Australian Open, is a longtime migraineur who for years endured misdiagnosis of her headaches. Renowned for her physical and mental toughness, Williams began experiencing severe headaches a
t age eighteen, with excruciating pain across her forehead, dizziness, fatigue, and a tremendous sensitivity to light. She recognized that her headaches came around the time of her period, but doctors insisted that her pain was psychosomatic; they believed she was making herself sick through stress and worry. She tried massage and herbal medicines but got very little relief. She simply suffered through the pain.
It wasn’t until she was twenty-three and suffered a sudden migraine that caused her to lose a match she was heavily predicted to win that Williams finally got an accurate diagnosis—and relief. A doctor friend suggested that her headaches were menstrual migraines and recommended that she try frovatriptan (Frova), a triptan that can help prevent migraines. Williams has said that she now takes this medicine when she realizes her period is coming, before there’s any sign of a headache.
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Treating a Menstrual Migraine
Since menstrual and menstrual-related migraines can be among the most severe and painful, it’s fortunate that there are very effective treatments that have a high success rate with many women.
In treating menstrual and menstrual-related migraines, you can take either or both of two basic medical approaches: