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MIGRAINE HEADACHE

By Dr. Keith E. Lewis
May 22, 2008


What is a migraine headache?

A migraine headache is a form of a vascular headache. Migraine headache is caused by a combination of vasodilatation or the enlargement of blood vessels and the release of chemicals from nerve fibers that coil around the blood vessels.

During a migraine attack, the temporal artery that is the bigger artery that lies along the side of your head in the temple area just beneath the skin actually enlarges.  Enlargement of this artery stretches the nerves that coil around the artery and causes the release of chemicals. These chemicals that are released cause inflammation, pain, and even further enlargement of the artery. 

This increased enlargement of the artery magnifies the pain, so typically once a migraine begins; the symptoms worsen and worsen as times goes on. Migraine attacks commonly affect the sympathetic nervous system in our body. The sympathetic nervous system is the part of the nervous system that really just controls the basic functions in our body. The functions we do not have to really think about. The increased sympathetic nervous activity can cause nausea, vomiting, and diarrhea in the way that it affects the gastrol/intestinal tract. Sympathetic activity also delays emptying of the stomach into the small intestine, thereby preventing oral medications from entering the intestine and being absorbed. So many times we find our patient at the first signs of a migraine, when they first start experiencing their aura, many times they will take a supplement or take a medication even and try to get ahead of the migraine and a lot of times by doing this, they actually get absorption of the medication or the supplement into their system and actually reduce the severity or frequency or intensity of that migraine headache.  The impaired absorption of oral medications is a common reason, however, why they are very ineffective in treating migraine headache.  The increase sympathetic activity also decreases circulation of blood.  This leads to a paleness or pallor of the skin, cold hands, and cold feet.  The increased sympathetic activity also contributes to the increased sensitivity most patient experience with light, very, very sensitive to sound as well as having visual disturbance or blurred vision. 

Migraine affects approximately 28 million American with the majority of those being female.  However, migraine headache is often misdiagnosed and it is believed that probably 50% of all migraine sufferers have been missed to yet diagnose which would double the number of migraine sufferers in America. 

What kind of symptoms is associated with migraine headache?


Migraine headache is a chronic condition, but with recurring attacks.  This does not happen one time and never have one again.  These oftentimes occur very frequently, sometimes daily, sometimes weekly, sometimes multiple times during the month.  Migraines are usually described as being very intense, throbbing, or pounding type pain that involves one temple or the other.  Sometimes patient relate the pain is located in their forehead around one eye or the back of their head.  The pain usually is one sided or unilateral, but a third of the time it can be bilateral.  The unilateral headaches typically change sides from one attack to another.  Rarely, we find migraine sufferers experiencing headache on the same side of the head time and time again.  If that is the case, certainly further evaluation should be performed in ruling out possibility of organic brain disease as a possible cause of the head pain. 

Typically, migraine headaches are aggravated by any kind of activity like walking up the stairs, walking around the block. Nausea, vomiting, diarrhea, cold hand, cold feet, sensitivity to light and sound commonly accompany migraine headache.  As result of the sensitivity to light and sound, many migraine sufferers pretty much are flat on their back; they cannot do any function during the repeat of the migraine attack.  Typically migraine attacks last between 4 and 72 hours.  Approximately, 50% of migraines attacks are preceded by what is called an aura or some symptoms that may preclude or at least occur in advance of an onset of migraine.  Some of the symptoms may include a listlessness or some irritability or fatigue, yawning, craving for sweet or salt, visual change or visual disturbance. Approximately 20% of patients have other type of symptoms that precede a headache, but they sometimes do occur at the same time.  Brightly colored lights, a zigzag pattern usually starting in the middle of the visual field and progressing outward, or a hole in the visual field, a blind spot in their visual field oftentimes occurs. Occasionally, we will find patients experience a pins-and-needle sensation inside their face or up into the ear, numbness or tingling around their lips or their nose, or even sometimes discomfort or odd taste associated with the tongue and nose. After a migraine is complete, for about 24 hours after the attack, typically the patient feel very drained and very tried. They do sometimes still experience a low-grade type of headache and still remain very sensitive to light and sound. 

How are migraines diagnosed?

Migraines typically are diagnosed when any of the above listed symptoms that I just talked about are present.  Migraines typically begin in the childhood or early adulthood ages. There typically is a family history of migraine which predisposes migraine sufferers, so that would indicate some type of genetic predisposition for migraine. A complete physical and history performed by your physician may also include blood testing, brain scanning which either includes a CAT scan or MRI or possibly even a spinal tap. 

How migraines are typically treated?

Typical treatments can either be non-medication or medication approaches. Therapy for migraine that does not include medication can provide symptomatic and preventative type therapy. Using ice, biofeedback, a variety of different relaxation techniques may help in stopping attack once it is started. Sometimes sleep is very, very beneficial. 

There are also other trigger mechanisms that are important to identify and our patients are coached in focusing on what they have done activity wise, what foods they have ingested, if there have been any odors or smells or anything they have been exposed to prior to the onset of the migraine because these oftentimes are trigger mechanisms.  We also find that people that smoke oftentimes have migraine headache.  We find that patients that indulgence in certain foods, especially foods that are high in tyramine such as sharp cheddar cheeses or foods containing sulfites like wine or nitrate which are found in nuts and processed meat also oftentimes trigger migraine headache.  We have also found in our clinic that patients that indulge in wheat products, MSG, also are often triggers for migraine headache.  Lifestyle change, good nutrition, adequate water intake, getting enough rest, exercise is also helpful ways to prevent the onset of migraine headache. We have in our experience used acupuncture as well to treat patients with migraine headache.

There are several natural substances also that helps in the prevention and treatment of migraine headache. Two herbs in particular have recently been studied and had been shown to be very beneficial in the treatment and prevention of migraine headache.  They will include feverfew and Butterbur.  Riboflavin has also been shown to be very effective in the treatment of migraine headache.  Clinical studies have shown similar benefits through different mechanisms for feverfew and high amounts of riboflavin in positively, affecting inflammatory processes, particularly in the brain.  There are several medications that have been used for the treatment of migraine, some are over-the-counter and some are prescription only.  For some patients, this has been effective in treatment and control of migraine headache.  For others, it has not helped at all. 

For this discussion, I would like to speak in a bit more detail concerning ways to prevent migraine headache.  There are basically two factors or two ways to prevent these headaches from occurring.

     1)  By avoiding the trigger factors that we have discussed earlier.
   2) By preventing headaches with medications or prophylactic medications or utilizing the herbal preparations that we have previously discussed. None of these strategies are 100% effective but it certainly should be tried because they have been effective in a great number of our patients. 

What are the migraine triggers?

We have previously discussed some of the trigger mechanisms, but basically the trigger is any factor that causes a headache in individuals who are prone to develop headaches. Only a small portion of migraine sufferers, however, clearly can identify the triggers.  It takes a great deal of discipline; time, effort, and energy to actually isolate these trigger mechanisms. Again, a list of trigger mechanisms would include stress, sleep disturbances, fasting, and hormone imbalances oftentimes we find are trigger mechanisms for migraine headache which is why we find many females first starting to experience migraine headache during the period of pubescence or puberty. Bright flickering lights oftentimes are triggers.  Odors, cigarette smoke firsthand or secondhand oftentimes are migraine triggers.  Alcohol:  Some patients are completely and very, very sensitive to use of alcohol. Aged cheeses should be very, very limited in intake.  Chocolate, monosodium glutamate, as we previously discussed. Nitrates, aspartame, and caffeine all can be triggers for migraine headache.  For some women, the decline of blood level estrogen during the onset of menstruation is a trigger for migraine headache. The interval between exposure to a trigger and the onset of headache varies from hours to days. Exposure to a trigger does not always lead to headache.  Conversely, avoidance of triggers cannot completely prevent the headaches. Different migraine sufferers respond to different triggers and any one trigger will not induce a headache in every person who has migraine headache.

Disturbances such as sleep deprivation or too much sleep, poor quality of sleep, and frequently awaking at night are associated with both migraine and tension headaches, whereas improved sleep habits have been shown to reduce the frequency of migraine headache. Sleep also has been reported to shorten the duration of the headache.

Fasting may precipitate migraine headaches by causing the release of stress-related hormones and lowering blood sugar levels. Therefore, migraine sufferers should avoid prolonged fasting. Bright lights and other high intensity visual stimuli can cause headaches in healthy subjects as well as patients with migraine headache. The migraine patients seem to have a lower than normal threshold for light-induced pain.  Sunlight, television, flash lights, strobe lights all have been reported to precipitate migraine headache.

Caffeine is contained in many food products:  Colas, teas, chocolates, coffee, and over-the-counter analgesics. 

Caffeine in low doses can increase alertness and energy but caffeine in high doses can cause insomnia, irritability, anxiety, and headache. The overuse of caffeine containing analgesics can cause rebound headaches. Individuals who consume high levels of caffeine regularly are more prone to develop withdrawal headaches when caffeine is stopped abruptly. 

Chocolate has been reported to cause migraine headache, but scientific studies have failed to directly link that chocolate consumption and headache correlation. Red wine, however, has been shown to cause migraine headache in some sufferers. It is not clear whether white wine also will cause migraine headache. Tyramine, a chemical found in cheese, wine, beer, dry sausage and sour crab can be a trigger mechanism for migraine headache, but there is no evidence that consuming a low-tyramine diet can reduce migraine frequency. These are studies that have not yet been performed.

Monosodium glutamate or MSG has been reported to cause headache, facial flushing, sweating, and palpitations, especially when consuming high doses on an empty stomach. This phenomenon has been called Chinese restaurant syndrome.

Nitrates and nitrides which are commonly found in hot dogs, ham, Frankfurters, bacon, and sausage has been reported to cause migraine headache.

Aspartame, a sugar substitute sweetener found in diet drinks and snacks has been reported to trigger headaches when used in high doses for prolonged periods. 

Some women who suffer from migraine headache experience more headaches around the time of their menstrual periods. Other women experience migraine headache only during the menstrual period. The term menstrual migraine is used mainly to describe migraines that occur in women. They have almost all of their headaches from two days before to one day after their menstrual period. The declining levels of estrogen at the onset of menses are likely to be the cause of the menstrual headache. Decreasing levels of estrogen may also be the cause of migraine headache that develop among users who use birth control pills, especially during the week that estrogens are not taken. 

Another possible cause for migraine headache which we have seen clinically is the cervicogenic migraine.  Oftentimes, a vertebral subluxation or misalignment of vertebra in the upper part of the cervical spine can trigger a cervicogenic migraine which involves altered blood vascular flow and extreme pain. 

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