What is a migraine headache?
Migraine can be defined as a limiting headache — a headache that stops you from functioning. The pain is not a mild, insignificant thing you can ignore; you must actively decide what to do about it. Nausea is also a common symptom.
More and more it seems like migraine is a separate illness. In the future, it's likely that we'll be able to define migraine by its distinct genetic pattern.
Where does the pain come from?
We think that migraine "lives" in the brain. The brain doesn't have pain receptors, but it processes pain signals from other parts of the body. It's the pain processing networks, or centers, in the brain that are overly reactive or dysfunctional in migraine.
Isn't there a theory that the pain comes from the dilation — widening — of blood vessels in the brain?
That was the dominant theory in the '60s. But much of the evidence now is that blood vessel constriction and dilation is an epiphenomenon — something that accompanies the pain from migraine but doesn't cause it.
The notion of triggers is central to the diagnosis of migraine. We look for patterns of reactivity and for events or circumstances that set off individual headaches. The problem is that even when you identify triggers, there's frequently not a lot you can do about them. You can't control weather changes, for example.
I think triggers have often been overemphasized in some of the self-help approaches to migraine. Advice on managing triggers can suggest a sense of personal control over migraines that often isn't there.
And dietary triggers?
They exist, but I also think that people can drive themselves crazy trying to identify them. We frequently hear patients report that when they are adequately treated, chocolate, alcohol, and other dietary triggers disappear.
Have drugs like Imitrex made a big difference?
Imitrex [sumatriptan] is one of the triptan drugs. The triptans have revolutionized treatment of migraine headaches once they start to occur — what we call abortive treatment. They allow people to take a specific medicine to target a specific condition and often get back to having a fairly normal day.
People also take medication on an ongoing basis to keep the headaches from occurring, don't they?
Yes, we have three major groups of preventive medications that we prescribe: antiseizure medications, blood pressure drugs, and the older tricyclic antidepressants. It is a diverse set of agents, and why they work is not entirely clear, but they seem to reduce headache reactivity — the triggers may still be there, but they fail to set off the migraine event. Botulinum toxin — Botox — injections into various places the head seem to help reduce headache reactivity in some people.
Is there one that you prescribe more than the others?
I have found amitriptyline [Elavil, Endep, others], one of the older tricyclics, to be particularly effective, often at a low dose: 10 milligrams a day compared with the 100- to 150-milligram dose that was used for depression. Sedation and weight gain are side effects. Amitriptyline is long-acting, so I usually recommend that people take it around dinnertime so they don't sleep too late.
Are there any alternative approaches that work?
Complementary and alternative therapies are usually not strong enough to treat a tough migraine problem alone, but they might be helpful for a mild one. And a lot of these treatments are very hard to study in a double-blind fashion.
The technique for which there is the most evidence is biofeedback, but the problem is that biofeedback is not widely available and often isn't covered by insurance. My own personal favorite for patients is yoga, because it is so widely available and affordable, and it probably has other health benefits.
What about supplements?
Headache specialists seem to love to argue about them. Everybody has their favorite combinations. I suppose the ones I like are melatonin, the sleep hormone; coenzyme Q10; and magnesium.