The Migraine Brain

by Bernstein, Carolyn; McArdle, Elaine

  Casinos. It’d be hard to invent a worse migraine hell than a casino: the brightly lit rooms, slot machines with their flashing lights and relentless clanging, cigarette smoke, the lack of natural light, and the free alcoholic beverages.

  I have a patient who went along with some friends to a casino just to see what it was like. Within ten minutes, she had one of the worst migraines of her life but had nowhere to go to sleep it off or rest.

  If you like casino gambling and it’s worth the migraine risk, I suggest monitoring your alcohol intake, drinking lots of water, limiting your time there, and being prepared to abort or recover from a migraine attack.

  CHAPTER 15

  Migraine Makeover: Creating Your Own Personal Migraine Plan

  To minimize how seriously migraine affects your life, you have to devise your own treatment plan, since your Migraine Brain is different from everyone else’s. Even if your migraine story is similar to a friend’s, your triggers, symptoms, lifestyle, and treatments that work will rarely be the same.

  Still, you may find it helpful to read the migraine makeovers of others, to see if there’s anything that might help you to create your own plan. Keep in mind that your migraine profile can change over time: New triggers may arise, old ones may no longer bother you, a drug that worked may become ineffective, and you’ll need to adjust your plan.

  At the end of this chapter is a worksheet to help you to devise your plan. Read this chapter with a pen or highlighter. Underline everything that reminds you of yourself, and use the tips and advice in these examples as you fill out your worksheet.

  Also at the end of the chapter is a Migraine QuikList, which you can review daily to make sure you’ve covered all the bases in caring for your Migraine Brain.

  A Pregnant, Busy Mom

  Tammy, twenty-eight, is three months pregnant and has a two-year-old toddler. She also works full-time as a magazine editor. She was getting migraines at least every week until last year, when she began taking a daily preventive medication, a beta blocker. It prevented most of her migraines. For the few it didn’t stop she took a triptan, which ended the migraine attack before she got a headache.

  When Tammy got pregnant, her headaches began to flare up again. She’s getting more, and they really hurt. She told her obstetrician that she got migraines and informed him of the meds she takes. She was relieved to learn she could continue taking her preventive med, but she can’t take the triptan since they are not proven safe for fetuses.

  Tammy came to me very worried that she would end up with terrible migraines throughout her pregnancy if she couldn’t use the triptan. I tell my pregnant patients—and this is the only time I say this to anyone—that they’ll have to endure more pain than normal for a while. Of course they don’t have to put up with excruciating pain, but probably more pain than usual for the sake of a healthy baby. This is the time to learn to rely on nondrug treatments to treat your migraines. The good news is that many women find that their migraines go away entirely after their first trimester of pregnancy and stay away at least until the baby is born, and sometimes longer.

  Here is the plan we devised for Tammy:

  She continued taking the beta blocker but stopped taking the triptan.

  She will consult with a nutritionist to improve her eating habits. She’ll increase her fluids and be vigilant about scheduling healthy snacks so she doesn’t get hungry and trigger a migraine due to a drop in her blood-sugar level.

  She will stay physically active during her pregnancy. She will take half-hour to forty-five-minute walks every night after work, either with her toddler in a stroller or after he’s in bed while her husband watches him. She will enroll in a Pilates class, and attend twice a week.

  For acute treatment of a migraine, she’ll use ice massage, placing ice on her face and head to relieve the inflammation, throbbing, and pain. She’ll keep icepacks in the refrigerator at work and at home.

  If she gets a really bad migraine with terrible pain, she’ll use Tylenol with codeine, a prescription drug. For many women, this drug is safe during pregnancy so long as it isn’t overused.

  Emergency plan: If she gets an unbearable migraine that won’t go away, she’ll go to the emergency room at her local hospital.

  On this plan, Tammy got only a few migraines during her pregnancy, all of them during her first trimester, and most were successfully treated with ice massage. She had only one migraine for which she needed the Tylenol with codeine, and she never had to go to the ER. After the baby was born and she weaned him, she returned to using the triptan as her acute migraine medication. She did not use it while she was breastfeeding because her doctor felt there wasn’t enough good data yet on whether triptans affect breast milk.

  If you are pregnant and worried about how to treat severe migraine pain when you can’t take many medications:

  Be sure to tell your obstetrician at the initial appointment that you suffer from migraines, and make migraine wellness a key part of your pregnancy. Be sure, also, to tell your headache specialist that you are pregnant.

  Minimize medications because many of them are unsafe for the developing fetus.

  Avoid your triggers more diligently than ever.

  Focus on wellness more than ever. Put your health first.

  Keep up your exercise program or switch to another that’s more comfortable while you’re pregnant, but keep moving for general wellness, a healthier pregnancy, and to reduce the number of migraines you get.

  Eat well, don’t get hungry, stay hydrated.

  Sleep! Getting adequate sleep when you’re pregnant is important, especially because you can’t use medication except in emergencies. Many women have trouble getting good-quality sleep when they’re pregnant, and it’s even harder if you have a toddler and have to be up at night or early in the morning. If you can afford it, consider hiring a “night nanny” who will stay at your home and get up with your toddler at night and in the morning. Most women can’t afford this, though, so perhaps family or your partner can help out more to ensure you get enough sleep. Take naps when your toddler does, if possible. If you have a job outside the home, set aside a ten-minute period twice a day to take cat naps, which are medically demonstrated to be effective at rejuvenating you, increasing your energy and alertness.

  Cut back on unnecessary tasks. This isn’t the time to try to be Super-woman. Get your partner to chip in more. Make things easy: Buy prepared dinners, or do a meal trade with friends (where four or five of your friends, say, take turns making meals for all of the group to eat in their own homes).

  For treating an acute migraine, try ice massage. Put an ice pack on your face, head, neck, or anywhere else where it soothes the inflammation.

  For truly terrible pain, use a safe rescue medication. Ask your obstetrician if there is a painkiller that’s safe to use while you’re pregnant. Assure her you’ll use it sparingly, and keep your word. It’s important for your baby.

  If you are vomiting a lot while pregnant, be sure to tell your obstetrician. Vomiting will dehydrate you and can trigger migraines. Ask your doctor if she is willing to give you intravenous fluids at such times, which will probably require an outpatient visit to the hospital. It’s well worth it to avoid a monster migraine.

  Occasional Migraines, Often at Work, Triggers Unknown

  Gary is a fifty-three-year-old scientist who gets migraines sporadically. They’re really unpredictable. Right now, they seem to come just a few times a year. He’s had them since his early twenties but he’s been unable to identify any clear triggers, even by keeping a careful headache diary, so it’s very hard to know when they’ll arrive. He’s had several attacks while giving presentations at work; they were agonizing, and he had to leave the room to vomit. Typically, his migraines last at least two days. Gary is an avid exerciser who works out at the gym at least three times a week. He eats too many fatty and junk foods, although these don’t seem to be triggers. His stress at work doesn’t vary much even when he has to make p
resentations.

  Here’s the plan we devised for Gary:

  His migraine disability will be monitored every month by using the MIDAS scale. At this time, since he gets migraines only a few times a year—or, at worst, every month—I’d be unlikely to prescribe a daily preventive medication. However, since they are so disabling, if they increase to once a month or more, a preventive medication might be warranted. The MIDAS scale is invaluable in helping to keep track of this.

  He’ll eat healthier foods, heavy on whole grains, low-fat proteins, and fruits and vegetables. Even though poor diet doesn’t seem to be a trigger, better eating will contribute to his overall health and help him avoid heart and other problems.

  For acute treatment of migraine attacks, he will use a triptan that comes as a tongue melt, because he won’t need water to take it. He can use it unobtrusively during a work meeting, and it gets absorbed quickly. Gary had not tried a triptan before, and it worked really well, stopping his migraines immediately.

  I prescribed an antinausea drug in suppository form. Gary vomits severely during his migraine attacks so a pill won’t help him.

  This plan is working for Gary. He continues to get just a few migraines a year and the triptan melt works.

  If you have sporadic migraines that you can’t predict and are unable to identify your triggers:

  Make sure you’ve tried to figure out your triggers by using a headache diary, but some people just don’t make any clear connections. Gary tracked his food, hydration, sleep, and stress levels, weather, odors, and other potential triggers, and still couldn’t figure out why he got sick when he did. However, tracking his nutrition and hydration did make a difference in his overall health. He stopped eating so much fried food, drank more water, and had fewer migraines.

  For acute treatment of sporadic headaches, triptans are excellent for most people (unless you have heart problems, are pregnant, or have other contraindications). Sometimes it’s a matter of finding the right one, since each works a little differently on your brain chemistry. See Ch. 9. If you haven’t tried a triptan, or if you tried one that didn’t work, talk to your doctor.

  If you have a problem with vomiting and nausea during your migraine attacks, you’ll have to treat this symptom at the same time as the head pain. A triptan may take care of this, but if you use a pill or even a tongue melt, you may vomit before it can be absorbed. In this case, you may want to treat the vomiting first by using an anti-nausea drug in suppository form.

  Once the vomiting is treated, you can take a triptan via a tongue melt. Only two of the triptans—rizatriptan benzoate and zolmitriptan—currently come in a tongue melt. Most people can hold them down even if they are nauseous.

  If one of these doesn’t work in stopping your migraine, you should try the other, since each works a bit differently.

  If you’re throwing up so much that even a tongue melt doesn’t have time to act before you expel it, ask your doctor about using an injectable triptan. Sumatriptan comes in this form. Your doctor can inject you, or you can learn to inject yourself with an autoinject kit.

  Keep your medicine with you at all times! Medication won’t do you any good if it’s home in your bathroom medicine cabinet. Carry your meds in your purse, briefcase, or wallet.

  Don’t wait to see how bad the headache gets before taking your acute medication, especially if your headaches are always really painful, like Gary’s. Triptans typically work only if you take them early in the migraine attack.

  If you are unable to use triptans, try another acute medication. Or try the easiest migraine drug of all: caffeine, especially if you need to be alert for work.

  Keep track of your headaches in a headache diary. If you want to keep it really simple, just mark a calendar with a big “M” when you get one. If they start to come more often, talk to your doctor and retake the MIDAS scale. If your disability score has increased and you are getting migraine frequently, or they are really disabling, you may want to consider taking a daily preventive medication. See Ch. 10.

  Lots of Triggers, Doesn’t Want to Use a Preventive Med

  Siobhan, forty-two, is very healthy; she exercises at least five times a week, eats healthy foods, and is generally happy at work and home. But she gets three or four migraines a month, sometimes more. Before triptans came along, her headaches were so bad she’d curl up in bed weeping or stand in a cold shower, banging her head against the tile. Fortunately, triptans have been a miracle drug for her. She takes a triptan in pill form but sometimes doesn’t take it soon enough, and ends up vomiting and in terrible pain.

  Siobhan is aware of many of her triggers, and her Migraine Brain is extremely sensitive. She gets migraines when she misses meals or doesn’t eat enough protein, when she doesn’t get eight hours of solid sleep each night, or is under tremendous stress. Weather changes are triggers, as are other things that trouble her sinuses including allergies and dust. She has TMJ, grinds her teeth at night, and often wakes up with a migraine. If she misses exercising more than three days in a row, she’ll feel a migraine coming on. Air-conditioning can give her a migraine, as can strong perfumes and odors including cleaning products. And she can’t drink more than a glass of wine or one beer without being severely sick the next day. Siobhan has her work cut out for her in avoiding migraines. Luckily, she’d done a lot of her own homework in figuring out her own body.

  Since she gets so many migraines and scored high on the MIDAS scale, I suggested she consider a preventive drug, but Siobhan doesn’t want to take a daily medication. Instead, she wants to figure out how to avoid her triggers and use a triptan when an attack arises.

  Here’s the plan we devised for Siobhan:

  She eats breakfast with protein every day and healthy snacks on a regular schedule. She favors lower-calorie options like fruits and vegetables but consumes enough protein at every meal so that she doesn’t provoke a migraine. Breakfast can be an egg sandwich on whole wheat bread or yogurt with protein powder. Whenever possible, she eats lunch and dinner at around the same time each day. And when it’s truly not possible to keep a meal on schedule, she eats a high-protein snack. She carries protein bars with her at all times.

  She tries to go to bed and get up at the same time every day, even on weekends, since oversleeping can cause a migraine, too. When traveling on vacation or business she agrees to follow the steps in Chapter 14, to get sufficient high-quality sleep.

  There’s not much she can do about the weather so she’ll be more careful about her other triggers. For allergies, she’ll use an over-the-counter allergy remedy or ask her doctor for a prescription. She bought a Swiffer and dusts her house at least three times a week, and puts dust-mite covers on her mattress and pillows, which help a lot. She has gotten rid of rugs in her home, which makes it easier to get rid of dust and other allergens.

  For her TMJ, Siobhan visited her dentist, who fitted her with a mouth guard to wear at night to keep her from grinding her teeth and clenching her jaw. It cuts out many of her morning migraines.

  Siobhan rarely uses air-conditioning in her own home. Instead, she relies on cross-ventilation, opening the windows throughout her home and using ceiling fans. She can tolerate air-conditioning elsewhere if she isn’t there for longer than a day.

  Siobhan doesn’t wear perfume and uses fragrance-free body products including deodorant, cosmetics, shampoo and conditioner, and also fragrance-free laundry detergent. If someone gives her a gift of perfume or scented body lotion, she regifts it to a friend. For cleaning her home, she uses organic or natural cleaning products, which don’t make her sick.

  She drinks at least eight glasses of water a day. If she has a glass of alcohol, she drinks three glasses of water as a chaser, or a 3:1 water-to-alcohol ratio.

  She tries to be vigilant about potentially stressful situations at work and home before they arise. She has learned several relaxation techniques, including deep breathing, which can be done anywhere at any time. She has begun regular meditation, keeps a j
ournal of daily feelings, and reaches out to friends whenever she is upset about something. These have all helped significantly to reduce her migraines.

  Over a few months, Siobhan’s efforts reduced the number of migraines she gets. They haven’t been eliminated, but Siobhan is happy with the plan, since the triptan fully ends the attacks she does get.

  If you get frequent disabling migraines but don’t want to use preventive meds:

  Keep a scrupulous headache diary even if you think you know your triggers, and review it with your doctor. You may uncover a trigger you weren’t aware of.

  Review Chapter 4 to find ways to address each of your triggers. Avoid as many as you can, and don’t be apologetic about it. If you need lots of sleep, don’t worry about being the one in your group who goes to bed at 10 each night if it means you feel great the next day. Your friends will get used to it, just as they’ll get used to your eating protein bars at odd times.

  If a triptan stops working, talk to your doctor about switching to a different brand. If you can’t take triptans due to heart problems or other issues, there are a few other acute meds you can use, the simplest being caffeine. For a really severe headache that won’t go away, talk to your doctor about a shot of a steroid. See Ch. 9. This option should be used only occasionally, but it’s safe.

  Migraines with Her Period

  Emily is a twenty-five-year-old graduate student who gets horrible migraines without aura every month at the start of her period. She often gets a midcycle “ovulation” headache as well. Otherwise, she is migraine free.