Emily’s situation is pretty straightforward since her migraines are triggered exclusively by her menstrual cycle and the fluctuations in her hormones over the month. Of course, migraines can change and she may find herself getting migraines at other times, triggered by other things. If so, she’ll need to adjust her plan.
This is our treatment plan for Emily:
She takes an oral contraceptive that gives you just four periods a year. The fewer times a year Emily gets her period, the better, since the fluctuation in hormones is such a problem for her. There will be just four times a year when she has to worry about migraines. I consulted with Emily’s gynecologist, who thought this was a wonderful option for her, with the added benefit of providing more reliable birth control, since Emily had been relying solely on condoms, which have a higher fail rate.
With oral contraceptives, you don’t ovulate, so Emily’s midcycle migraines also will stop.
In the four time periods when she is susceptible to a migraine, Emily takes naprosyn, a strong anti-inflammatory drug, to try to prevent the inflammatory cascade that triggers her migraines.
She has a triptan as an acute abortive medication in case she does get a migraine.
If your migraines are almost entirely limited to your menstrual cycle:
Please reread Chapter 5. Make sure you keep a headache diary on which you mark your migraines and when you get your period each month. If you get a migraine midcycle, this is probably an ovulation migraine.
Consider limiting the number of periods you get by using certain oral contraceptives. You’ll cut down on migraines related to getting your period, and eliminate midcycle or ovulation periods altogether. If you get your period only four times a year, these are the only times you need to prepare for a migraine attack.
If you get aura with your migraines, you may not want to take oral contraceptives as they may not be completely safe. Make sure your doctor knows your symptoms.
You should not take oral contraceptives if you smoke, have high blood pressure or certain other health issues. Be completely open with your doctor about your health history and habits, including whether you smoke.
If you had a bad experience in the past with oral contraceptives, talk to your doctor. The new oral contraceptives have much lower doses of estrogen with fewer side effects, and they are also less likely to cause weight gain and bloating. However, if your headaches do worsen after taking an oral contraceptive, talk to your doctor as soon as possible to discuss other treatment options. Don’t forget to choose another form of birth control if you are sexually active.
If you get hormonal-related migraines but you can’t take oral contraceptives due to other health issues, here’s a plan: Two days before your period, take frovatriptan, a long-lasting triptan, which may stop the migraine from arising.
You could take a strong anti-inflammatory like naprosyn or ibuprofen around the time of your period, which may block the migraine.
You’ll also need a good abortive medication if you get a migraine, such as one of the other triptans. But you can’t take two different kinds of triptan within twenty-four hours of each other. If the frovatriptan didn’t work, you have to wait at full day to take a different triptan.
If you are getting two severe migraines a month, one at the time of your period and one mid-cycle, check your MIDAS score (see Ch. 7) to see how disabled you are. If you are missing six days of work each month due to migraines, your MIDAS score is high. You may want to consider taking a daily preventive medication.
Exercise, good nutrition, sleep, and relaxation aren’t going to prevent menstrual migraines, but they should be a top priority anyway to promote your overall health and help you better endure the migraines you get.
Two Severe Migraines a Month, No Time to Herself
Leah is a thirty-eight-year-old mother of four children with a high-stress job. She has multiple migraine triggers and gets at least two severe migraines a month that lay her up for at least a day or so. She says she has no time for herself, can’t exercise, and doesn’t get enough sleep.
This is a very common migraine profile: A busy mom who works outside the home, has many migraine triggers, and whose schedule is packed with work and family demands. Leah really needs to make some lifestyle changes if she’s going to get fewer migraines.
Here’s the plan we created for her:
Since Leah’s MIDAS score was really high because she got two or more severe migraines each month, we put her on a daily preventive drug, in a low dose to start off with, to see if this made a difference in preventing migraines. I assured her it was not a drug she would have to take the rest of her life but it made sense right now when her headaches were so disabling and she needed to be able to function better to care for herself and her family. We’ll continue to monitor her and reevaluate her plan over time.
She takes a triptan in melt form for abortive therapy. The convenience of the melts means she doesn’t need a glass of water to take them if she’s at the playground with the kids and feels a migraine coming. She can simply pop it under her tongue and it will work quickly.
Leah worked with a nutritionist to create a healthy eating plan that would stabilize her blood-sugar levels and prevent migraines triggered by low blood sugar. The nutritionist also convinced Leah to drink eight glasses of water a day.
Exercise is essential. It will improve Leah’s cardio health, reduce her stress, and give her some much-needed time alone. Instead of trying to squeeze in a gym membership, we decided to break Leah’s exercise plan into manageable portions: Three times a week, she’ll take the kids out for a brisk walk after dinner for at least half an hour. Twice a week, she’ll get up early in the morning and go for a twenty-minute jog, with a five-minute walking warm-up and cool down. Her husband agreed to watch the kids on these mornings, since he’s eager to see Leah feel better.
Biofeedback training has taught Leah to reduce her stress levels. Despite being really busy, Leah agreed to invest in four one-hour sessions. Over the next few months, she found that biofeedback helped her migraines by helping her respond to stress in healthier ways.
Once a month, she gets an hour-long therapeutic massage to loosen tense muscles, one of her triggers, and also reduce stress, another trigger.
If you are busy running a family and/or working outside the home with countless demands on your time, if you feel you have little time to exercise or think about good nutrition, and your headaches are frequent and disabling enough that they bring your life to a grinding halt, causing more problems for you, here are recommendations for a plan for you:
Take a daily preventive medication. Remember, you don’t have to take it forever. But if you’re in a particularly difficult stretch in your life where you can’t afford to be sick, talk to your doctor about this option for you.
Take a half hour to exercise or relax each day. See Ch. 12. You have a chronic illness, and you’re trying to avoid as many flare-ups as possible. Taking care of yourself is even more important than for the average person. The less you are out of commission from migraines, the better for your family.
Practice meditation, yoga, and deep breathing, which are medically demonstrated to relax you and improve your mood and health. All of these will make a huge difference in how you feel. Write yourself a prescription for ten minutes of relaxation every day. Use a meditation CD, or take a relaxing walk and concentrate on your breathing.
Eat healthfully. Review Chapter 12 on healthy eating. If you need to lose weight, a nutritionist can help you do so without triggering more migraines through eating too little food or not enough protein or fiber.
Doesn’t Want Medications
Lori is a forty-four-year-old therapist who gets chronic headaches every day, some of which are tension headaches and some of which are migraines. She is in some degree of head pain all the time but she does not want to take any medication, ever. No over-the-counter meds, no prescriptions meds. She doesn’t want to put anything into her body she doesn’t a
bsolutely have to.
Lori is going to have to emphasize wellness and self-care to stay as healthy. She’s open to all types of complementary and alternative treatments. We talked about yoga and how certain positions seem to be really helpful to some people in alleviating headaches. We discussed other CAM treatments, too.
Our treatment plan for Lori is this:
She takes private yoga classes and group classes to decrease stress and muscle tension, two of her triggers, and to promote overall wellness.
We suggested acupuncture to see if it will prevent headaches.
She takes 400 mg of magnesium supplements each day. Since this is a natural mineral that the body needs, this doesn’t feel like a drug to her.
She has a prescription for a painkiller. If she gets a truly terrible headache and is in disabling pain, she’ll have it on hand. Of course she doesn’t have to take it, I assured her. But it can take the edge off her headache and help her get to sleep. For some people, knowing they have a painkiller on hand is very comforting, even if they choose not to use it.
This plan worked really well for Lori. The acupuncture alone significantly reduced the number of headaches she got. She’s feeling better in general due to the yoga and self-care, and so far she has not had to use the painkiller.
If you have more than one type of headache—a daily tension headache, say, with sporadic migraines on top of that—and prefer not to take medication, or can’t take migraine meds or painkillers because you have other health issues, here are my recommendations:
Try complementary and alternative treatments, some of which are medically supported in preventing or treating migraines. See Ch. 11.
Acupuncture is very helpful for many people. Make sure you find a certified acupuncturist.
Yoga is terrific for stress release, reducing muscle tension, learning to relax, and other things that can directly affect how many migraines you get. Take a yoga class from a certified instructor to learn correct posture and breathing; then you’ll be able to do yoga almost anytime you want.
Take daily magnesium supplements. See Ch. 11.
Make exercise, good nutrition, sleep, and other wellness a key part of your plan.
Be especially vigilant in avoiding triggers.
Consider having a rescue medication on hand for occasions when the pain is truly awful and is interrupting your life. You don’t have to take it, but you may find that you are less worried knowing there is a safety net in bad situations.
Junk Food, Sedentary Lifestyle, Low Mood and Energy
Jennifer, thirty-five, works as an administrative aide at a large law firm. She gets intense migraines three or four days a week, without aura but with intense head pain and vomiting. She has poor eating habits and keeps a bowl of candy on her desk, which she often dips into. Just before a migraine attack arrives, she craves doughnuts, bagels, and candy. She gobbles a lot of over-the-counter painkillers—at least five or six—on the days she has a migraine.
Jennifer is divorced, has no kids, and lives alone. She sleeps poorly, waking several times a night. She eats junk food often, but otherwise doesn’t eat much and isn’t hungry, she says. She doesn’t exercise and spends her evenings alone at home. She reveals that she is very sad, and feels lonely and hopeless. I had her sit at my computer and fill out an online depression index. The results showed she was moderately to severely depressed. Jennifer was surprised, but at the same time, relieved. The online test was comforting because she’d suspected something was wrong. With a name to it—depression—we could begin to help her get better.
Lots of aspects of Jennifer’s life are out of whack: nutrition, exercise, social contacts. All of them are connected and contribute to her depression and migraines. The fact she is overweight leads her to avoid people, which depresses her, which causes her to sit inside and eat. The good news is there are many things she can do to feel better and decrease her migraines.
Here is the plan we agreed on:
Jennifer met with a psychiatrist to confirm if she was suffering from depression and began weekly therapy sessions.
She started taking citalopram, an antidepressant that helps some people with chronic pain as well as depression. Since there is often a connection between migraine and depression, this drug may help treat both.
Jennifer consulted with a nutritionist to develop a healthy eating plan. Poor nutrition contributes to depression. Eating junk food made it almost impossible for her body to have stable blood-sugar levels, and migraines were the inevitable result. She keeps healthy snacks at her desk instead of candy, and eats regular meals at least three times a day, including breakfast.
She joined an exercise class. Exercise improves depression, sometimes as effectively as antidepressants. A class also gives Jennifer social contact and the opportunity to meet new friends. Jennifer tried yoga and found she loved it. She enjoys having a class where she meets people, and likes having a routine in her after-work life.
She takes naprosyn, an anti-inflammatory, when she gets a migraine and uses ice, too. Because she’s on an antidepressant, she should not take a triptan because there is the possibility of a syndrome called seritonergic syndrome.
Do you have regular migraines along with a poor diet, a stressful job, no exercise, and few social contacts? Even if you have social contacts or otherwise take care of yourself, do you feel sad, have a lack of energy, or find yourself less enthusiastic than you used to be? Here are my recommendations:
Take an online self-test to see if you have the signs of depression. If so, make an appointment to talk with your doctor or a therapist.
Consider taking an antidepressant.
Add vigorous exercise into your life. Exercise is a proven antidepressant. If social isolation is an issue for you, join a gym like Curves or a class where you will meet people.
Visit a nutritionist to develop a healthy eating plan, since depression can also result from or be exacerbated by poor nutrition. If you want to lose weight, consider joining Weight Watchers, a healthy weight-loss program where you’ll meet people, or Overeaters Anonymous, a twelve-step program with significant community and support.
Is your job so stressful that it’s making you miserable, or leaving you with little time for yourself? If so, consider looking for new work. This can be difficult if you’re depressed. But as you start to feel better through therapy, medication, and exercise, give yourself permission to make a major life change like leaving a job or relationship that makes you very unhappy.
Migraine Makeover: My Personal Treatment Plan
I want to stay as healthy as possible with as few migraines as possible. So I need to make caring for My Migraine Brain a priority. I need the understanding and cooperation of my family and friends so that I can have more time with them, do well at work, and enjoy life. To stay migraine-free, I need to do certain things. This isn’t being self-indulgent, this is staying healthy.
1. What are my migraine triggers? (See Chapter 4, and your worksheet there. You can also use the Headache Diary in the appendix to determine potential triggers.)
Trigger
Can I avoid this one?
How?
2. What is my MIDAS score? (See Chapter 7.)
3. Am I willing to take medication? (See Chapter 9.)
Yes
No
If so, am I able to take medications? Do I have any health issues that would contraindicate medications (e.g., pregnancy, heart problems)? I will tell my doctor every health issue I have and all medications I currently am on.
a. Do I need a daily preventive med? (see MIDAS score—if above 14 or 15, moderate to severe disability, you may want to consider a preventive)
Yes No
If so, which one will I take (talk to my doctor)?
____________________________
b. What abortive meds will I take during a migraine attack? Am I able to take triptans?
Yes No
If so, do I want to try one? Which one will I take? Why?
&nbs
p; ____________________________
c. What rescue meds will I take when I get a painful migraine?
____________________________
If any of my medications stop working, I’ll return to my doctor to talk about other medicines.
4. Do I want to use complementary and alternative treatments? (See Chapter 11.)
Yes
No
If so, which ones will I use (e.g., biofeedback, yoga, acupuncture, yoga, meditation, others)?
CAM treatment
How often will I go?
Date I started
Do I like it?
Is it helping?
5. Exercise
I need to exercise half an hour a day, five days a week, to stay healthy and reduce migraines. How will I do this? (See Chapter 12.)
Choosing my exercise:
Do I like to exercise in groups? Choices include: a women’s fitness center, a gym class, Jazzercise, yoga class, walking in a group, cycling group, organized sports, etc.
Do I prefer to exercise alone? Running, walking, swimming, cycling, etc.
Do I like to mix it up, e.g., run 2 days, yoga 2 days, walk with family, etc.
The Migraine Brain Page 35