The Migraine Brain

by Bernstein, Carolyn; McArdle, Elaine

  Why does pregnancy change your migraine? As soon as you become pregnant, your estrogen levels start to rise and continue to do so throughout the first trimester, until they reach a level about 100 times higher than they were prepregnancy. These rapidly rising estrogen levels in themselves can make some women sick. Your body is also hypermetabolic, running at a much higher rate, which may annoy your Migraine Brain. Eventually your estrogen levels stabilize and remain stable throughout the second and third trimesters, which is why so many women experience a migraine-free hiatus. Once the baby is born, however, your estrogen levels plummet. As we know from studying the menstrual cycle, when hormone levels fall suddenly, many women get migraines. In fact, in the first week after delivering a baby, two-thirds of women migraineurs experience a migraine attack. (We know there is a relationship between migraine and depression, so there may be a correlation between migraine and postpartum depression. More research is needed.)

  How do you treat a migraine if you’re pregnant? In Beth’s case, after she had suffered a couple of bad migraines during her first months of pregnancy, she decided to make some lifestyle changes that would allow her to deal with her migraines without drugs. She took a day off from work each week during most of her first trimester so she could relax at home and keep her work-related stress levels down. She also started swimming regularly and tried to be in bed each night by 9:30 in order to get at least eight hours of sleep. She ate a good diet and drank lots of fluids. She still got some migraines, usually in the morning when she woke up, and she would call in sick and stay in bed most of the day, applying ice packs to her head and taking the occasional Tylenol. It was a tough couple of months, but close to the end of the third month, her migraines stopped altogether.

  For most women, Beth’s approach might not be practical. You may not have the flexibility to take so much time off work, or you may have other children to care for. Read the wellness chapters in this book carefully and be creative in finding ways to take care of yourself to try to avoid migraines during pregnancy.

  Once you know you’re pregnant, inform your gynecologist or obstetrician about your migraines, if you haven’t already, and inform her about any medications you are taking for migraine or for other medical conditions. If she is unfamiliar with treating migraine, you may want to recommend that she read this book or go to one of the many excellent websites maintained by migraine medical organizations, listed in the appendix. Make sure you also inform your headache specialist that you are pregnant, so she can consider adjusting your treatment plan to keep you and your baby healthy.

  As a general rule, no drug is a good drug when you’re pregnant (with the exception of a prenatal vitamin), especially during the first ten weeks of gestation, when the brain and spinal cord of the fetus are developing. During that time, avoid all medications, if possible, including caffeine. See Chapter 11 for a variety of safe treatments for migraine that can be very effective, including biofeedback and ice massage. In the first trimester especially, you’ll also want to try to avoid your migraine triggers, including stress. Explain to your employer that you’ll need to rest more frequently during this time in order to minimize your stress and your chances of getting a migraine, but that you expect to feel much better after this first three months of pregnancy are over (See Chapter 14 for other ways to adapt your workplace to stay healthy). Try not to plan major projects or travel until you see how you are reacting to the pregnancy.

  As we’ve noted previously, triptans are probably not safe while you are pregnant, especially during the first trimester, and I strongly recommend that you avoid them. Some painkillers may be one safe but you must discuss this with your doctor. If you choose to take painkillers, I strongly urge you to use them sparingly. In all cases, your headache specialist and ob-gyn should be closely involved in choosing which medications you take during pregnancy.

  During pregnancy, absolutely avoid taking aspirin or ibuprofen because these drugs can interfere with the development of your baby’s lungs. You may think they are safe because they are over-the-counter drugs, but this isn’t true, and they are an important illustration of why you should consult with a doctor before taking any drugs while pregnant.

  If you experience nausea while pregnant, ginger tea may help you, and it is safe for your baby. You can also talk to your ob-gyn about other safe choices for treating nausea. Metoclopramide, an antinausea drug, may be safe for you to take; you and your doctor can discuss this choice. You can always rely on very safe standbys: Crackers such as Saltines, toast and other bland foods, and ginger ale can help settle your stomach. Some pregnant women experience hyperemesis gravidarum, a severe form of morning sickness in which they vomit over and over. The resulting dehydration can trigger migraines. If you suffer from profuse vomiting and get migraines as a result, alert your doctor. She or he may be willing to prescribe IV fluids for you, which you’ll have to go to the hospital to receive.

  As always, be very vigilant about any headaches that become especially severe or whose characteristics are different than usual. If that happens, talk to your ob-gyn and your headache specialist as soon as possible. Severe or changing headaches while you are pregnant can signal a more serious health problem that merits an evaluation by a physician. Your doctor may want to order a brain-imaging study. She may decide to wait as long as possible before doing such a test so the baby can be further developed. But if a test is needed sooner, don’t panic. This kind of test is usually safe for a pregnant woman and her fetus when extra safety precautions are used. Make sure you ask your doctor to explain why the test is necessary at this time and how the fetus will be protected.

  Our goal is for you to lead as healthy a life as you can, with as little migraine pain as possible. You don’t have to suffer just because you are pregnant.

  Breastfeeding

  “Ella is almost a year old, and I had no migraines at all once I got pregnant with her. But I’ve just started weaning her, and I guess my hormones are going crazy, because the other day I started to get a migraine. I got that confused feeling, tingling in my fingers, and a very dull headache.”

  —Nancy, 34, homemaker

  Breastfeeding provides many wonderful benefits to both mother and baby, and here is one: Breastfeeding may delay the return of your migraines after childbirth. Prolactin, the hormone that helps your body produce milk, suppresses ovulation and thus menstruation. While you are nursing a child, you are unlikely to have a menstrual period, especially if you nurse frequently including during the night. Breastfeeding may keep you migraine-free. On the other hand, there are plenty of potential migraine triggers that new mothers face, including stress and lack of sleep.

  Lactation doesn’t suppress ovulation in every woman. And, once you reduce the number of nursing sessions—when you return to work, say, or when your baby begins to eat solid foods—prolactin levels drop and your migraines may return. After you wean your baby, your menstrual cycle should return, and there’s a good chance your menstrual or menstrual-related migraines will come back, too.

  If you get migraines while you are breastfeeding, you should take special precautions. Every nursing mother is worried about the substances she puts into her body and whether they may be passed on through her milk to her baby. You’re right to be vigilant. Don’t assume that any substance is safe to ingest while you’re nursing. As with pregnancy, the safest option for your child is to try nonmedical treatments such as biofeedback or ice. But if you are experiencing a severe migraine, you may feel it’s necessary to consider a medication.

  There isn’t much data yet on the effect on breast milk of triptans, so you need your doctor’s advice. Some drugs are probably safe for your baby if you take certain precautions; for example, by taking the drug immediately after you finish a nursing session, then pumping your milk afterward and throwing it away (the next feeding for your baby is then via bottle with previously pumped, safe milk). But the safety of the drug depends on a number of factors including how long it stays in your sy
stem. This is such an important decision that I strongly urge you to discuss it with your pediatrician or family practitioner.

  Do not assume that herbal or “natural” treatments are safe for your nursing baby. Some herbal treatments including feverfew, used to treat migraine, are dangerous to the baby, and all herbal and natural treatments have significantly less government oversight and regulation. See Ch. 13. Do not use these products without talking first to your pediatrician or family practitioner.

  An excellent resource for guidance on what meds are safe to use during breastfeeding is Medications and Mothers’ Milk, by Thomas Hale, a professor of pediatrics at Texas Tech University School of Medicine. The book explains a variety of factors that influence whether a drug is safe, including how long it lasts in your system, when it reaches peak concentration in your blood, and how long it lasts in the baby’s system. Hale notes which drugs have not yet been tested enough for a determination. He also maintains a website with up-to-date information, http://neonatal.ttuhsc.edu/lact/

  Middle Life

  When you’re in your thirties and forties, your life typically is at its busiest. You may be raising children, working on your career, caring for aging parents. Unfortunately, this is often the time that migraines reach their peak in women. We’re not entirely sure why. Perhaps it’s because we are trying to balance so many competing demands, and so our stress levels are high. Whatever the reason, managing migraines at this point can be particularly challenging, since you have less time to tend to yourself.

  I want to encourage you not to make yourself the last priority on your list. Your migraine disability is real, and it has a real effect on you and your loved ones. Find time for yourself and for relaxation, exercise, and health. If you take prescription drugs, make sure your prescription is up to date and handy, and stay on top of your other treatments or prevention methods. Have your partner pitch in and take over when you feel a migraine coming on. Try to fit stress relief into your schedule, and try to get enough sleep at night. You’re not indulging yourself—you’re trying to avoid getting sick.

  Perimenopause

  Perimenopause is a time of transition for your body as you begin to head toward menopause, the end of menstruation. Perimenopause can begin as early as your mid-thirties, and can last as long as fifteen years, although you may not be aware that you are in this stage of your life cycle (the only irrefutable diagnosis is through a test of your hormone levels.) The average age of menopause is fifty-two, and so most women notice some perimenopausal symptoms when they are in their forties. These symptoms include hot flashes, irritability, a decreased interest in sex, night sweats and hot flashes, insomnia, and irregular periods.

  These changes in your body are a result of intense hormone fluctuation during this time of life. Your overall levels of hormones begin to decline, but you can also have unpredictable upward swings. Your hormone levels are no longer foreseeable over the course of each month, and your periods can become quite irregular: you may get a period after twenty-one days, say, then the next one doesn’t arrive for thirty-six days, or you may get a period that lasts for months on end. Since your hormones aren’t stable and because night sweats and insomnia may affect your sleep, your susceptibility to migraine can increase. Add to this the other stresses in your life and you have a potent brew of environment and physiology, which is why many women find they have more and worse migraines at this time.

  During perimenopause, the typical migraine treatments including triptans may be appropriate. But there’s also another choice: hormone replacement therapy (HRT), in which you take supplemental estrogen, testosterone, or progesterone to replace what your body no longer produces. While HRT is controversial because it has been linked to an increased risk of breast cancer and other problems, you may want to discuss it with your doctor. Forty-five percent of women find HRT helps their migraines, but an equal number find it makes them worse.

  Menopause

  “I don’t have my period anymore, and I thought migraines would end when I went into menopause. But they haven’t.”

  —Tina, 64, retired kindergarten teacher

  Tina is in the minority. For most migraineurs, there’s good news about menopause. When you stop menstruating, your body produces much less estrogen, and your hormone levels even out. This may mark the end of your illness. About 67 percent of women find that their migraines go away or improve significantly after menopause.

  Women who continue to get migraines can still use the usual preventive and abortive treatments. However, people sixty-five or older need to talk to their doctor about whether triptans are still safe for them. The doctor should perform a cardiac risk evaluation based on such factors as blood pressure, whether the person is a smoker, the levels of both good and bad cholesterol, and family health history. If a person’s cardiac risk is elevated, triptans may not be safe to take.

  As with perimenopausal women, another option is hormone replacement therapy, which brings significant migraine relief to almost half of those who try it. But there are also significant risks for some women, and HRT should be discussed fully with your doctor before you move forward.

  Some patients ask about having a hysterectomy in order to stop their migraines. Stop right there. A hysterectomy—which is surgical menopause—actually makes migraines worse for two-thirds of women.

  CHAPTER 6

  Men’s Migraines

  “I’m a Dead Head–trial lawyer–martial artist, and I bow to nothing—except migraines. They rule the roost. The truth is, when it hits a breaking point, I can’t do anything—I can’t drive a car, I can’t work, I just have to go to bed and sleep.”

  —Tom, 44, lawyer

  During the Vietnam War, Robert, a retired firefighter and engineer who is now sixty-three, got a notice to report to his local draft board. On the medical form, Robert wrote that he was in excellent health but for one thing: he’d suffered from periodic migraines since his early teens. Robert was okayed for service and recommended for Officer Candidate School. But in a physical exam for officer candidates, Robert’s migraines raised concerns with doctors. They rated his physical condition as 2A, or below average, and he was dismissed from military service. All these years later, Robert says he still has mixed feelings about not being able to serve. “I was very patriotic,” recalls Robert. “I wanted to go for the experience.”

  Being bumped from military service was the most dramatic consequence of his migraines, but not the only one. They also prevented him from pursuing a lifelong dream to become a pilot. “I never took flying lessons, something I always wanted to do,” says Robert. The problem was his vision. During his migraines, he gets visual aura that blind part of his vision field. If he’s driving a car, he’s forced to pull over. “It’s very frightening,” he says.

  For the past forty-five years, hoping to master his illness, Robert has kept meticulous records of his migraine attacks, trying to figure out what triggers them. He records every detail of each attack: the date, time, and day of the week; what he ate beforehand; vivid descriptions of the symptoms including the visual changes; the type and amount of every drug doctors prescribed. Robert got his first migraine at age fourteen while watching a movie in a theater: part of his vision field suddenly disappeared, followed by a terrible headache, and he vomited on the bus on the way home. From that point, he’d get attacks several times a year, although some years he had none. A series of doctors, including a world-renowned neurologist, had no idea what was wrong with him. They did brain imaging, performed spinal taps, and made a series of misdiagnoses including convulsive disorder. They prescribed one medication after another including nitroglycerin and Dilantin, but nothing worked.

  Like the doctors, Robert was mystified by the attacks—but determined to figure out what was wrong. “I was trained as an engineer, where everything has to be action and reaction,” he says. “Things don’t happen without cause, generally. So I was always trying to figure, ‘What was different? What could possibly be the trigge
r mechanism?’” He read everything he could about the human brain, teaching himself physiology and biochemistry. Finally, “I figured it out myself,” he says, with a laugh. “I diagnosed myself.” A neurologist confirmed Robert’s self-diagnosis of migraines.

  By carefully examining every factor in his life, Robert realized that certain foods were a factor in his migraine attacks. In the 1980s, he gave up eating processed sugar and other processed foods and found that keeping his blood-sugar levels constant worked really well. “I wouldn’t eat a donut now if you paid me,” he says. Robert made other lifestyle changes that helped, including exercising regularly.

  Still, despite his disciplined efforts and considerable success in managing his disease, Robert continues to get migraines. Whenever he conquers one trigger, another one seems to arise. “It’s like that game in Chuck E. Cheese’s, where you whack the gophers. Whenever you whack one down, another one comes up. When I went off sugar, I had a good long period with nothing happening. And then I’d get them again. Maybe the demon finds a new route. I just don’t know. It’s almost like [the body] wants to have a migraine.” To stay well, Robert says, “You just have to keep chasing it. It’s one of those things that’s elusive.”

  Today, more than 7 million American men suffer from migraines. Throughout history, the roster of men with migraines includes many of the greatest leaders, visionaries, and artists including Sigmund Freud, Charles Darwin, Alfred Nobel, Frederic Chopin, Claude Monet, and Georges Seurat.