Why migraine headaches

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Banquets and beer drinking were part of the lives of the people of one of the world's first cities in Urik, Mesopotamia about 5,000 years ago. So were migraine headaches. Described in ancient writings, migraines were thought to be caused by evil spirits or ghosts. The treatments for most diseases then were extractions from plants, animals and minerals mixed with magical incantations and administered by the Babylonian priests. For migraine headaches, the treatment was to mix the ashes of burnt human bones into cedar oil and to then anoint the sufferer with the substance.

Migraines are still with us. Their cure and cause still evade modern medicine, but they can be minimized, even prevented, to some extent in most people. What the Babylonian priest failed to understand was how the neurological system is involved in migraine and how often migraines mimic other problems. Migraine headaches are so common they are often mistaken for other diseases. Patients are often convinced that their headaches must be caused by sinus infections, allergies or poor eyesight, but such problems do not cause severe, chronic recurrent headaches. Although headaches in general may be symptoms of many pathologies, only a small number are the result of serious or life threatening causes.

Migraines affect an estimated 10 to 20 million people. As many as 16 percent of women and nine percent of men suffer from the disorder. Migraine headaches usually begin between the ages of 10 and 30, and decrease as one ages. Rarely do we see first time migraine attacks in patients older than 55 years.

Patients usually describe migraine pain as throbbing or pulsating, often localized to one side of the head. The suffering may be aggravated by light and noise, so patients usually seek refuge in a dark, quiet room. The attacks are often accompanied by nausea and vomiting, which for many patients is more distressful than the headache.

More than half of migraine patients can tell that an attack is imminent because of vague symptoms that may occur hours to days before the attack. These symptoms include fluid retention, changes in mood, increased thirst and urination, and a craving for sweets.

About 10 percent of migraines are characterized by a beginning phase called an aura. The symptoms of the aura reflect abnormal function of a particular part of the brain where the attack is initiated. Most common are visual symptoms characterized by bright sparkles or zig zag lines, with or without regions of visual dimming.

The next most common aura symptom is numbness and tingling involving the face, hand and arm on one side of the body. Sometimes the tingling is accompanied by a weakness or heaviness of the arm. These symptoms typically last about a half an hour and are then followed by the headache. At times, aura symptoms may occur without a subsequent headache, and may therefore be confused with other more serious neurological conditions such as stroke or seizure.

Migraine headaches may be triggered by any number of factors, including food chocolate, wine, nuts, seafood and cheeses, food additives (such as monosodium glutamate and sodium nitrite), hormones (fluctuating estrogen levels during the menstrual cycle or from birth control pills), infections, traveling, loss of sleep, a skipped meal, minor head traumas a change in weather or emotional stress. How these triggers precipitate a migraine attack remains unknown, but they may interact with or change important pain regulating brain chemicals.

There are a number of hypotheses about how migraine attacks arise. For many years, it was thought that during a migraine attack, there was first constriction and then dilation of cerebral arteries. Thus, it was thought that migraine was primarily a disorder of cerebral blood vessels. As more was learned about brain chemicals, called neurotransmitters, the hypothesis emerged that certain neurotransmitters systems, important in regulating pain, might somehow become abnormal during migraine. Modern models of migraine incorporate elements from both of these hypotheses. Attacks involve nerve cells in certain pain-regulating parts of the brain. These nerve cells release chemicals that affect blood vessels and other brain cells.

Important in understanding the cause of migraines is the observation that most types of migraine are inherited. The headache unit of the neurology department at the Emory University School of Medicine is presently conducting research on the genetic mechanisms of migraines. The diagnosis of a migraine is made by first elimi-nating the diagnosis of any serious diseases of the brain, head or neck and then by classifying the headache on the basis of its characteristics. This is done by taking the patients headache and neurological history, by performing a neurological examination and sometimes by obtaining special diagnostic studies such as an MRI or CT scan of the brain.

Treatment of migraine headaches includes involvement of the patient in managing his or her lifestyle to eliminate triggering factors as much as possible. Further treatment includes the use of medicines to regulate abnormal neurotransmitter levels. There are two groups of drugs used to treat headaches: one group is used to prevent them and the other is used to stop or abort those that have started.

The preventive drugs include betablockers such as Inderal or Corgard; anti-depressants such as Elavil or Pamelor; calcium-channel blockers such as Calan or Dynacirc; ergotamines such as Sansert or Ergotrate; and anticonvulsants such as Depakote. If headaches do occur despite these preventive medicines, they can be treated with abortive medicines including ergotamines such as Cafergot or Ergostat, anti-inflammatory agents such as Naprosyn or Anaprox.

Severe headaches that do not respond to these drugs can be treated with such medicines as DHE-45, Compazine, Tordol, or the soon-to be released Sumatriptin. Migraine patients should avoid pain medicines such as Percocet, Fiorinal, Darvon or even aspirin-containing compounds. These analgesics only temporarily cover up headaches, and often lead to increasingly frequent and severe rebound headaches.

If one is concerned about headaches of any kind, the first person to see is a primary care physician who can diagnose and treat some headaches or refer the patient to a neurologist for more specialized care.

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by Joseph E. Freschi, M.D.

Dr. Joseph E. Freschi, M.D. is Associate Professor of Neurology, Emory University, School of Medicine.

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