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Migraine; Treatment.

Health care professionals say that many women don't express the true extent of the pain they feel with migraine, perhaps because they're worried about "complaining" too much. One problem may be that many people with migraines think there is nothing that can be done. They may have watched their mother or grandmother suffer from migraines, and think they simply have to suffer, too, or resort to the often-ineffective treatments their older relatives used to cope with their migraines, despite significant advances in medication and treatment options available today.

Patients commonly deal with a migraine by taking some kind of pain relief medication, lying in bed, struggling with nausea and vomiting, and trying to minimize lights, noises and smells that can either trigger a migraine attack or make it worse.

Unfortunately, many migraine sufferers put off seeking treatment despite the very effective treatments available today.

If you have migraines, it is important to develop a good relationship with your health care professional because the condition is recurrent and there is no cure. You can build an active partnership first by finding a health care professional with experience in treating migraine who understands that migraine is a biological disease.

Headache specialists also recommend looking for a health care professional who is willing to consider a variety of options for treatment, including over-the-counter and prescription medications, as well as lifestyle changes.

Communicating treatment needs can be difficult for migraine sufferers for a variety of reasons, but communication is key to effective treatment. One study showed that only about half of people who met the criteria for migraines had been properly diagnosed by their health care professionals--a statistic that may be improved with proper communication.

A number of communication and treatment aides can help open a dialogue with a health care professional about migraine pain and treatment. Many migraine sufferers find that keeping a headache calendar is a first step in gaining some control over their headaches. This tool is especially helpful as you begin designing a treatment program with your health care professional.

A headache calendar should include:

when your headaches occur

severity and duration of the headache

possible triggers, including dietary, stress, environmental, etc.

dates of your menstrual periods

interventions attempted

View an example of a headache calendar at the American Council for Headache Education's Web site at www.achenet.org.

Another headache management technique is to make a checklist of your symptoms and treatment responses then rank the effectiveness of your current treatment program. Use descriptors ranging from very satisfied to very dissatisfied with several categories between to determine how satisfied you are with your current treatment program. Evaluate if the treatment:

is fast acting

has minimal side effects

is non-sedating

relieves sensitivity to bright light and/or sound

is easy to use

relieves head pain

requires only one dose per week

is available in an injection

is available in a nasal spray

is available in a tablet

has a proven track record

is available in several forms

Also rank these attributes in terms of how important they are for you; use the descriptors, very important to not important, to prioritize and personalize the components of any treatment program.

Next, list those activities you feel your migraines most often disrupt. Be sure to include work, family interactions, personal time, sleep, exercise, social opportunities or other activities you've canceled one or more times because of migraine attacks.

In fact, recording and communicating your migraine-related disruptions/disabilities with your health care professional may be the key to you receiving the most comprehensive treatment course. Health care providers are more likely to manage patients' treatment more effectively and aggressively when they receive detailed information on symptoms. Unfortunately, headache-related disability information is often overlooked during consultations. That's why there are tools designed to improve communication about headache-related disability, such as the Migraine Disability Assessment questionnaire or the The Migraine Disability Assessment Test, to improve migraine management.

Next, make an appointment with a health care professional to discuss your migraine experiences. Bring your checklists with you. Ask for a treatment plan that incorporates those components you feel are most important to your headache treatment and lifestyle. Before leaving the professional's office, arrange a follow-up appointment to discuss the treatment's success or failure.

Finally, once you begin a treatment program, keep a diary of the frequency and severity of your headaches and how your treatment plan is working. Share the diary with your health care professional on your next visit, and be willing to modify your treatment plan if necessary. It can take patience and several changes to find the individualized treatment program that works for you.

In their most recent clinical practice guidelines, the U.S. Headache Consortium has identified both short-term and long-term goals that are important in establishing an effective acute migraine treatment plan. Here are the short-term goals:

treat attacks rapidly and consistently without recurrence

restore the patient's ability to function

minimize the use of back-up and rescue medications

optimize self-care and reduce subsequent use of resources

be cost-effective for overall management

have minimal or no adverse events

Here are the long-term goals:

reduce attack frequency and severity

reduce disability

improve quality of life

prevent headache

avoid increasing headache medication to prevent medication-induced headache or rebound headaches

educate and enable patients to manage their disease

Medication-Based Treatment

In general, health care professionals develop a migraine treatment plan depending on the frequency of migraine headaches. Infrequent headaches, which come once or twice a month, are usually treated with a fast-acting, acute-type medication that responds to the occurrence of a headache and relieves head pain, nausea and sensitivity to bright light and/or sound. Women who have migraines more frequently need a different strategy; a preventive medication is often recommended.

For frequent headaches--three or more times a month--you may need to take a daily medication aimed at preventing the migraine in the first place.

Drugs to treat or shorten the duration of migraines:

One of the most commonly used class of drugs for migraines are serotonin receptor agonists, also known as triptans. Scientists are not sure exactly how they work, but the drugs reduce the pain of migraines, and limit symptoms such as auras. Specific triptans include naratriptan (Amerge), rizatriptan (Maxalt), sumatriptan (Imitrex), zolmitriptan (Zomig), almotriptan (Axert), frovatriptan (Frova) and eletriptan (Relpax). They can be administrated in a variety of ways: orally, nasally through a spray, and by injection. The fastest acting and most effective form is the injectable form.

Medications used for emergency relief of severe migraine pain include:

dihydroergotamine (DHE 45)

opioids, narcotics that include meperidine and butorphanol

corticosteroids, including hydrocortisone and dexamethasone

Because ergotamine tartrate and dihydroergotamine (DHE 45) can cause nausea and vomiting, they may be combined with anti-nausea drugs. Experts caution that ergotamine should not be taken in excess or by people who have angina pectoris; severe hypertension; vascular, liver or kidney disease. Same with DHE; also, pregnant women should not use this drug.

Drugs to treat/prevent frequent migraines

Beta-blockers: These drugs stop blood vessel dilation prescribed. They include propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor), nadolol (Corgard) and timolol (Blocadren). Note: Health care providers recommend that people taking beta blockers, especially people with a history of heart problems, do not suddenly stop taking these drugs.

Calcium channel blockers usually work slowly, taking from two to eight weeks before you see any improvement. Studies are mixed on their effectiveness. Common calcium channel blockers include: verapamil (Calan, Isoptin), nifedipine (Procardia, Adalat) and diltiazem (Cardizem).

Divalproex sodium (Depakote) and topiramate (Topamax) are anticonvulsants

Amitriptylines (Elavil, Endep), one in a class of antidepressants that include doxepin (Adapin), nortriptyline (Aventyl) and protriptyline (Triptil).

Selective serotonin reuptake inhibitors, or SSRIs, another class of antidepressants that includes fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft).

Atypical antidepressants, such as venlafaxine (Effexor) and mirtazapine (Remeron), may also help by enabling certain brain chemicals such as serotonin, norepinephrine and dopamine to remain in the brain longer.

Note: Antidepressants carry a black box warning concerning the increased suicide risk in adolescents and children. Anyone taking antidepressants should be carefully watched for any signs of suicidal behavior.

Non-medication Treatment

Drug therapy for migraine is often combined with biofeedback, cognitive behavioral therapy and/or relaxation training.

Biofeedback is a technique used to gain control over a function that is normally automatic (such as blood pressure or pulse rate). The function is monitored and relaxation techniques are used to change it. Biofeedback uses electronic or electromechanical instruments to monitor, measure, process and feed back information about blood pressure, muscle tension, heart rate, brain waves and other physiologic functions.

There are several types of biofeedback:

Thermal biofeedback allows you to consciously raise your hand temperature, which, one theory suggests, may increase blood flow to the brain and may reduce the number and intensity of migraines. When learning thermal biofeedback you wear a device that transmits the temperature of an index finger or hand to a monitor. As you try to warm your hands, the monitor provides feedback either on a gauge that shows the temperature reading or by emitting a sound or beep that increases in intensity as the temperature increases. You're not told how to raise your hand temperature, but are given suggestions such as, "Imagine that your hands feel very warm and heavy."

Electromyographic training, or EMG training, is a type of biofeedback that detects and records electric activity in the muscles and helps you learn to control muscle tension in your face, neck and shoulders.

Biofeedback can be practiced at home with a portable monitor. But the ultimate goal of treatment is to wean you from the machine so you can use it anywhere at the first sign of a headache.

Relaxation training involves learning to counteract muscle tension by relaxing your mind and body through methods such as yoga, meditation, progressive relaxation and guided imagery. Relaxation techniques may be used alone or in combination with biofeedback.

Cognitive-Behavioral Therapy

This therapy helps you identify areas in your life and environment that may be triggering your headaches. People with migraine have the same sorts of stressors most people grapple with, but for migraine patients, the stress can trigger migraine episodes. Thus, stress management training helps you to recognize the thoughts, feelings and behaviors that bring on headaches and work to handle them without triggering a headache.

Dietary Treatment

Some migraine sufferers benefit from a treatment program focused solely on eliminating headache-provoking foods and beverages. That's why it is so important to keep a migraine diary to identify your unique triggers.

A diet that prevents low-blood sugar (hypoglycemia), which can cause dilation of the blood vessels in the head, may help some migraine sufferers. This condition can occur after a period without food: overnight, for example, or if you skip a meal. Those who wake up in the morning with a headache may be reacting to the low-blood sugar caused by the lack of food overnight.

Treatment for headaches caused by low-blood sugar consists of scheduling smaller, more frequent meals. A special diet designed to stabilize your body's sugar-regulating system may be recommended. For the same reason, many specialists also recommend that migraine patients avoid oversleeping on weekends. Sleeping late can change the body's normal blood sugar level and lead to a headache.

References

R.B. Lipton, D. Dodick, R. Sadovsky, et al. " A Self-Administered Screener for Migraine in Primary Care." Neurology 2003 Vol. 61. (pages 375-382) http://www.healthfinder.gov.

National Institute of Nuerological Disorders and Stroke, National Institutes of Health. NINDS Migraine Information Page. September 5, 2003. http://www.nih.gov.

American Council for Headache Education. http://www.achenet.org. Accessed June 4, 2004.

"Headache Consortium Guidelines" American Headache Society. http://ahsnet.org. Published April 2000. Accessed June 4, 2004.

W.F. Holmes, E.A. MacGregor, J.P.C. Sawyer, R.B. Lipton. "Information About Migraine Disability Influences Physicians' Perceptions of Illness Severity and Treatment Needs." Headache, The Journal of Head and Face Pain. Vol. 41, No. 4, April 2001. http://ahsnet.org

National Headache Foundation. Chicago, IL. http://www.headaches.org. Accessed June 4, 2004.

"Migraine Headaches." National Women's Health Information Center. Office of Women's Health. U.S. Department of Health and Human Services. 1998. http://www.4woman.gov. Accessed June 4, 2004.

"Women and Migraines: Take Charge of the Pain." National Women's Health Resource Center Health Report. Vol. 20, No. 1. February 1998.

"Migraine Medications" Jewish Hospital HealthCare Services. Updated March 2002. http://jhhs.org. Accessed June 4, 2004.

"Guidelines for Treatment of Migraine Headaches" No. A-650-600. Geisinger Health System. Revised: May 1999. http://www.geisinger.org. Accessed June 4, 2004.

American Migraine Prevalence and Prevention (AMPP) Study Fact Sheet." National Headache Foundation. http://headaches.org. Accessed July 7, 2006.

Keywords: Asymptomatic shedding,Benzodiazepines,Post-exertional malaise,Salpingo-oophorectomy,Systemic sclerosis,Healthcare proxy
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Date:Dec 11, 2006
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