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Migraines affect as many as 36 million Americans

Pittsburgh Post-Gazette

07-02-12

July 02--Imagine having a terrible, throbbing headache, maybe so bad you're nauseated or even vomiting, perhaps unable to tolerate the touch of a comb to your head or a bright light or noise. Now imagine that happening not just once in a while, but regularly, maybe even 15 or more times per month.

That's what life can be like for someone who gets migraine heachaches, a regularly occurring, frequently inherited and incurable brain disturbance that affects as many as 36 million Americans, including children.

"Simply, it is characterized by headaches that at some times become disabling," said Robert G. Kaniecki, a neurologist who serves as director of The Headache Center at UPMC. "We're dealing with the three 'S's': Severity, Sickness -- nausea or vomiting, Sensitivities, mainly to light or noise. Typically they last between four hours and three days untreated and possess one or all three of those attributes."

Migraine headaches differ from tension headaches, which aren't severe, do not make one sick and do not leave the sufferer sensitive to light or noise. They also differ from sinus headaches, which Dr. Kaniecki said are rare. "Ninety percent of the time it is [instead] a form of migraine," he said. "It turns out a sinus infection can cause a sinus headache. There's no pattern to that, whereas migraine is characterized by multiple episodes."

Less than half of all migraine sufferers have been diagnosed with migraine by their healthcare provider, according to the Migraine Research Center. "About half the time, they go to see a physician and get a non-migraine diagnosis, and almost always it's [diagnosed as] tension or sinus," Dr. Kaniecki said.

What causes migraine?

"It's a mixture of things," said neurologist Lara Kunschner Ronan of Allegheny General Hospital. "Most migraines have environmental triggers. It varies from person to person. About half have family history. There are families that have very strong generational predisposition, probably multiple genes."

"Migraine results from a biological disturbance in the brain," Dr. Kaniecki said. "Often individuals will have a first-degree relative, a parent or sibling or a child with similar headaches. A common thread is a heredity of a nervous system that is more sensitive.

"They're much more likely to have motion sensitivity -- car sickness, more likely to have temperature sensitivity -- ice cream headaches. That brain sensitivity is relatively persistent: flashing light, bright light, noise, strong odors."

The brain pushed past a threshold of tolerance, different for each patient, will respond with a brain storm, a chemical disturbance in the brain, he said.

Serotonin is released; nerve endings on the surface of the brain emit chemicals that are irritating and inflammatory to the brain and blood vessels start to swell, resulting in throbbing pain, he added.

Triggers -- or things that set off migraines -- include stress, the menstrual cycle, sleep deprivation, meal irregularities, weather change, overstimulation, light, noise, odor, certain foods like red wine, smoked cheese and aged and fermented products of any kind, caffeine and food additives such as MSG.

There are many treatments.

At UPMC's Headache Clinic, the initial approach is natural, or "anything to keep the nervous system in balance. It's like driving a very sophisticated vehicle versus a simple car. It needs more maintenance," Dr. Kaniecki said. The clinic stresses a regular schedule for sleep patterns, meal patterns, exercise patterns, patterns of hydration, and school or work attendance because the brain is very sensitive to change.

"The menstrual cycle, the weather, common triggers for migraine, there are a number of things we can't control, but those we can control, we try to," he said.

Next, patients are encouraged to avoid the common triggers listed above. The clinic then uses "a whole host of supplements," including magnesium and the root of the butterbur plant.

"There are vitamins that have shown benefits," Dr. Kunschner Ronan said.

Many migraine sufferers take over-the-counter medications, she added. The Food and Drug Administration has approved three products for migraine: Excedrin Migraine, Advil Migraine and Motrin Migraine Pain, according to the Migraine Research Foundation.

"Most doctors see those who don't get relief from over-the-counter [products]," Dr. Kunschner Ronan said.

"If [the migraines are] frequent, we'll prescribe daily medications, and that's 25 to 35 percent who require medications daily, and then the majority will require something for attacks when they come -- [there are] multiple products over the counter and multiple prescription products for when they strike," Dr. Kaniecki said.

For preventive use, there are well over 20 medications to choose from, and for when they occur, well over 30, he added. One family of drugs designed to treat migraine attacks is triptans, which include Maxalt (rizatriptan), Axert (almotriptan), Amerge (naratriptan), Zomig (zolmitriptan), Frova (frovatriptan) and Relpax (eletriptan). Preventive medications include Inderal (propranolol), Blocadren (timolol), Topamax (topiramate) and Depakote (divalproex sodium).

Medications usually work, Dr. Kaniecki said.

When they don't, there are alternative methods to try, including biofeedback, which is poorly covered by insurance; acupuncture, which is still under study; special diets, surgery and Botox, which was just approved by the Food and Drug Administration within the past year for people who have a minimum of 15 migraines a month and who have failed more traditional options. There also are trials of nerve stimulator devices in progress.

It is not known exactly how Botox works, but Dr. Kunschner Ronan said it has helped more than two-thirds of her patients treated with the injections.

"What it does, it settles the nerve endings down, the ones that let go of chemicals," Dr. Kaniecki said. "It intervenes in that stage of the migraine attack."

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Pohla Smith: psmith@post-gazette.com or 412-263-1228.

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