The Migraine Brain

by Bernstein, Carolyn; McArdle, Elaine

  Surgery and Other Options

  Besides medication, there are other options for treating migraine including:

  Transcranial magnetic stimulation—This is a nonsurgical option in which a device is attached to the back of the patient’s head to send magnetic pulses through the skin and stop a migraine by changing electrical impulses in certain parts of the brain. This device—for use with migraineurs who get aura—is currently in clinical testing and is showing excellent early results. It may someday be a good option for someone who can’t or doesn’t want to use drugs.

  Electrode implants—In another experimental treatment, electrodes are implanted surgically under the skin in areas where a person’s migraines typically begin. The electrodes are connected by wires under the skin to a small battery pack implanted under the person’s collarbone. Through a hand-held remote control, the patient controls the number and intensity of electrical impulses, which block pain signals to the brain.

  Endoscopic nasal surgery—Some migraines may be caused by a problem in the nasal passages, where surfaces in the nasal cavity press against each other, stimulating the trigeminal nerve. Endoscopic surgery to correct this problem resulted in significant reduction in the number and severity of migraines in patients with this problem, according to a study published in the medical journal Cephalagia. This is another option to keep in mind if other treatments are not working for you.

  Surgery to muscles—In this rather drastic option, muscles in the head and face involved in migraine pain are surgically altered, eliminating headaches for 35 percent of the patients studied and reducing the frequency, intensity, and duration of headaches for 92 percent, according to a study published in January 2005 in Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. I haven’t known any patients who have tried this option, and given potential downsides (see Ch. 2), and the success we have with drugs, I would reserve discussion of this for the most intractable migraine cases.

  CHAPTER 10

  When You Have to Go to the Emergency Room

  One pleasant morning at work, even though you’re well rested after a good night’s sleep, you begin to get the warning signs of a migraine. Your scalp begins to tingle, you slur a sentence. You feel that familiar throbbing start to pulsate down the side of your head. You immediately take the triptan medication your doctor prescribed for you, and fifteen minutes later, the pain begins to subside.

  But a few hours later, the throbbing returns on the side of your face. For some reason, the migraine didn’t leave. And it’s aggressive. The pain gathers force and you start to feel nauseated. You take another pill, but it’s too late—the migraine is locked in, and you know what’s coming next. A half-hour later, you’re huddled over the toilet bowl in the office bathroom, vomiting violently. A co-worker calls a cab to take you home. By this point, your headache pain is a 10 out of 10, and the cab ride is a nightmare. You have your eyes tightly closed, praying you don’t throw up again.

  You stagger in your front door, unplug your phone, and open your medicine cabinet, desperate for relief. You have an over-the-counter pain medicine, nausea medicine, and your prescribed rescue medicine, a powerful painkiller. You swallow the prescription med but immediately vomit it up and can’t stop vomiting. You crawl to bed, your head like a swollen pumpkin being smashed with a hammer. The pain is so bad you want to cry, but crying would hurt too much. You’re so weak you can’t stand up, but you continue with the dry heaves since there’s nothing left in your stomach to throw up.

  It’s time. You call your best friend to take you to the emergency room. In another car ride from hell, you rest your head on the dashboard as you moan in pain. Your friend drops you at the entrance to the ER and goes to park the car. As an ambulance screeches to a halt before you, you clutch a door frame while a patient is unloaded and wheeled by you on a stretcher. You stagger into the crowded waiting room with the brightest lights you’ve ever seen, and kids screaming, the TV howling, and the P.A. system barking announcements. There are no empty seats. You lean against a wall, then slide onto the floor, your head clutched in your hand, your eyes screwed shut tight.

  You’re in Dante’s Inferno for migraine sufferers.

  Your friend appears and gently pulls you to your feet, guiding you to triage. A nurse takes your blood pressure, measures your heart rate, and asks why you’re here.

  “I’m having a migraine,” you croak.

  “Take a seat,” she says, nodding you back to the waiting room.

  “How long will it be?” you beg.

  “Some people have been waiting four hours—and they’re a lot sicker than you,” she replies.

  You lurch over to the only open seat but pause. “I’m going to throw up,” you murmur, and your friend grabs a wastebasket just as you lose the last contents of your stomach. You slump into the chair with your friend’s sweater wrapped around your eyes, and you wait. And wait. And wait. You’re so dizzy and sick you force your eyes open, surveying the carpeted floor, wondering if it would be too weird to lie down in the middle of the waiting room and sleep. Instead, you remain slouched in the chair, the wastebasket by your side.

  Five hours and fifteen torturous minutes later, you hear your name. An attendant guides you to a cubicle, where you climb into bed and close your eyes. A nurse takes your blood pressure and heart rate, then ties a tourniquet around your arm. As she inserts a needle and an IV line to treat your dehydration with fluids, you don’t even wince. In fact, the sharp pain is a welcome distraction from the hammer beating inside your head. After another forty-five minutes, a doctor arrives and asks for your medical history. You struggle to speak loudly enough for her to hear, but you are desperate to sleep. When you tell her you have a migraine, she gives you a shot of a powerful painkiller. Within ten minutes, the pain starts to subside but your nausea gets much worse. Since there’s absolutely nothing left to throw up, you don’t even roll to your side as your stomach heaves and heaves, and the taste of bile coats your mouth.

  After another hour, just as you are starting to fall blessedly asleep, the nurse announces they need your bed for another patient. Your friend is told to take you home, and you’re instructed to call your doctor in the morning. It’s 4 a.m., and you head into the night like a drunken zombie, knowing you’ll miss work tomorrow and spend the day trying to recover.

  Raise your hand if you’ve been there.

  Nobody ever wants to go to an emergency room, although about 24 percent of migraineurs have ended up there during a migraine attack. The ER is the last place you want to be. One of my top priorities is to help you avoid ending up there. You’re unlikely to get immediate or optimal treatment—or even much sympathy. One of my patients who went to an ER in Cambridge lucked upon a triage nurse who herself got migraines and led her to a small conference room with a couch, and let her lie down with the lights off. But you can’t count on getting a nurse who’s this empathetic.

  Even if you do find sympathy in the ER, you’re going to be a low priority compared to heart attacks, car accidents, and other life-threatening emergencies. ERs are set up to take care of the sickest patients first. You may wait hours before getting any relief, and you won’t get any medication for pain relief until a doctor assesses you. If you’re a new patient with no medical history on record at that hospital, the doctor may want to test to ensure your headache isn’t an aneurysm or stroke. He may order a CT scan or MRI. That’s more time in agony before you get pain relief.

  And it’s unlikely you’ll get optimal treatment, unless you’re in the rare ER familiar with migraine patients. It’s very possible you’ll be given a shot of meperidine (Demerol), a powerful narcotic that can make you nauseated (if you aren’t already) and will totally zonk you out so that you won’t be able to do much of anything, including drive home. So, after spending hours waiting to be evaluated and treated, where will you be? Too out of it to go to work or school. You’ll have to head home to sleep it all off, and you’ll lose at
least one entire day of your life.

  Your best bet for staying out of the ER is to take good care of your health and to make your migraine wellness a top priority. Still, it’s very possible that you may have to go to the ER, even if you’ve been very careful in managing your migraines. Maybe you’re traveling and you unexpectedly run out of meds, or those meds suddenly stop working. You may get a migraine that for some reason continues to snowball, becoming worse and worse until you’re vomiting relentlessly and are in such excruciating pain that you have no choice but to head to the hospital for some relief.

  Never hesitate to go to the ER if you need to. And don’t feel ashamed that you’re there for a migraine and not something “more serious.” Migraine is a real illness, and your pain and inability to function are not imagined or minor. You are sick, perhaps very sick, and you deserve help just as much as someone with a broken finger or an asthma attack.

  Remember—it’s your right to be treated compassionately and taken seriously.

  “I ended up in the emergency room lying on a gurney. I pulled a sheet over my head because I couldn’t bear the light. They said I had to take the sheet off my head because I looked like a corpse and they didn’t want to scare the other patients!”

  —Trina, 53, writer

  In the scenario that started this chapter, the patient did the right thing by going to the ER. The dehydration she had from continuously vomiting made it impossible for her to get ahead of the pain. Her migraine was only going to get worse, and she had no way to stop it. If you’re throwing up, you’re not going to be able to take a pill to stop your headache pain. (This is where the French have a better approach to medication, because they use suppositories for many medications, even acetominophen. Americans tend to avoid suppositories, even though absorption of medicines in suppositories is faster than ingesting them orally.)

  * * *

  When Should You Go to the ER?

  If your headache feels different in the type or location of the pain, if your usual symptoms have changed, or if your headache includes a stiff neck, fever, or comes on extremely suddenly, you could have a serious health problem. (See Ch. 1 for a full list of warning signs).

  When your migraine isn’t going away despite your usual treatments, and the pain is bad.

  Whenever the migraine has lasted more than three days. You may have “status migrainosus,” a migraine that won’t quit without medical intervention.

  * * *

  If you are really sick but decide not to go the ER, you’re probably in for a very rough time. You may become so weak you’re unable to drink, which means you’ll get more dehydrated, which can lead to dizziness and the inability to walk. Your head pain—aggravated by the dehydration—may get worse and worse. You may end up losing several days trying to recover—and suffer terribly all the while.

  How to Make Your ER Visit Successful—A Signed Doctor’s Form

  You need to be prepared for the rare time—and I do hope it’s rare—that you end up in the ER. I give my patients a form, which I’ve signed as their treating physician, that they are to take with them if they must go to the ER. If your doctor doesn’t offer such a form, ask for one. It will be invaluable when you seek treatment in an ER. The form should indicate that you are a migraine patient under the care of a physician and offer the ER doctor a suggested plan for treating you. Standard ER treatment for someone with severe pain such as a migraine is to give a narcotic, which can make you nauseated—the last thing you need.

  On the form, I may recommend that the ER doctor give my patient an injection of ketorolac tromethamine (Toradol), a strong anti-inflammatory that doesn’t make you tired or woozy and will often get rid of pain in ten to fifteen minutes. If nausea and vomiting are part of your problem, your ER treatment form may recommend that you receive IV fluids and/or an antiemetic, a medicine for stopping nausea.

  My patients tell me they have a more positive reception and an easier time in the ER when they present these forms. If your headache doctor doesn’t make these forms a regular part of her treatment plan, be assertive. Bring a copy of the form in the appendix to your doctor and ask her to prepare one for you.

  “People in the ER were sympathetic and kind but it was treated like it was not a serious thing. I was completely and totally incapacitated, I could barely walk, but it was hours before I was actually treated. It was late at night, there were no long lines. I just felt the ER did not give it due urgency. I got a shot of Reglan, an antinausea medication, and I learned later that Reglan was given to people with migraines because too many people come in only wanting pain medication. So I think I was treated skeptically, like maybe I wasn’t suffering as badly as I appeared to be. So now I carry around a note Dr. Bernstein gave me that I can present to the ER if I have to, that says I am a migraine sufferer, I do not have a problem with addictive pain medication, and that I should be treated with Toradol.”

  —Brian, 32, computer programmer

  If you don’t have a signed form with you, don’t get angry at the ER staff if they seem skeptical of you, as upsetting as this is. Hospitals are naturally very wary of drug-seekers, a serious problem for them.

  What to Take with You to the ER—Your ER Kit

  Because you may be in for a long wait in the ER, I recommend that you keep an “Emergency Room Kit” tucked away in a closet. Pack it up and hope that you never need it. But if you do, you’ll be grateful it’s ready to go.

  Include in your kit:

  The emergency room form signed by your headache doctor

  One or two bottles of water

  An eye mask or sunglasses

  Earplugs

  Money in case you need to take a taxi home (for example, if you are treated with a narcotic and should not drive)

  A list of all medications you are taking; give this to the ER doctor.

  A list of anything you are allergic to

  Names and phone numbers of your doctor, friends and family, and your employer

  I also recommend that you have a friend take you to the hospital and act as your advocate. When you’re in the middle of a severe migraine attack, you may barely be able to talk. A friend to care for you and explain your problem to the doctor is invaluable.

  If You Are Admitted to the Hospital

  On rare occasions, you may be moved from the ER and admitted to the main hospital. Let’s say that twelve hours have gone by after the ER doctor has treated you, and the pain of your headache remains severe while you continue throwing up. Your cubicle in the ER may be needed for another patient, so the doctor may decide to admit you to the hospital. This doesn’t happen much with migraine patients but it isn’t unheard of.

  You’ll want to have your migraine ER kit with you, with your list of phone numbers. The hospital physician will probably want to call your headache specialist or G.P. If you’re staying in the hospital, you’ll need a support system of friends or family to take care of your affairs: to feed the cat, change your answering machine message, and tell your employer why you’re not at work. If you’re prepared ahead of time, you already have a migraine buddy or friend who knows the drill and will handle these things for you. If not, ask for help from the hospital. Most hospital staffs include a social worker whose job it is to assist you with these things.

  Ask a friend to bring your pajamas to the hospital so you’ll be more comfortable. If you didn’t bring a migraine ER kit, there are a few other things your friend should gather for you. To me, the most essential item is a pair of sunglasses or an eye cover. Bright hospital lights can make your migraine worse. Hospitals are also notoriously noisy; ask your friend to bring you ear plugs so you can try to sleep.

  If there’s any way you can get a private room, all the better, but you may have to share a room. If so, ask your nurse to explain to your roommate that you need quiet, and that loud TVs, loud phone calls, and loud visitors will make you sicker. Do not feel guilty about asking for these accommodations—if you were an asthma sufferer, you wouldn�
�t hesitate to ask your roommate not to wear perfume.

  For the first twenty-four hours of your hospital stay, you’ll be lying in bed as doctors and nurses work to get your pain under control. But, in truth, they have limited options in trying to help you. You will probably be given more painkillers, perhaps by injection. You may be given a “PCA,” a patient-controlled device that lets you administer painkiller to yourself through an IV by pressing a button whenever you want more. This is often better than having to wait for a shot or calling the nurse whenever you want more pain relief. Your physician will put a cap on the total amount you can receive, so the device will gradually taper off the amount of painkiller.

  One caveat about narcotics such as meperidine: they can cause severe constipation. Talk to your doctor or nurse about this potential side effect, and ask whether they can give you medicine to avoid constipation. I’ve had patients who returned home so constipated that, in straining to move their bowels, their migraine returned.

  The ER doctor may order a CT scan or MRI to ensure that nothing more serious than a migraine is going on. If you have a signed ER form from your doctor, as I recommend, these brain scans may not be necessary, since the form will also note that past brain scans were negative, but your doctor may order them nonetheless to be cautious.