Expert Advice on Migraine Triggers and Symptoms How to Avoid and Treat Migraine Pain

It’s not just a headache. When symptoms of a migraine come on, many sufferers want to run for the hills. Or into a dark, quiet room where they can sleep. Our migraine expert shares how to prevent and reduce migraine triggers, and, should you get a headache, how to manage migraine pain... More than 28 million Americans suffer from migraine pain – and women are three times more prone to experience symptoms of a migraine than men, says Janine Good, M.D., associate professor of neurology and medical director of ambulatory services at the University of Maryland Medical Center. Women are more prone to migraines, possibly because symptoms of a migraine can be triggered by hormonal fluctuations. Certain foods, environmental factors, even too little caffeine or too much sleep can also be migraine triggers. In this interview, Good tells us how migraine sufferers – called “migraineurs” – can better understand their condition, lessen the length and number of symptoms of a migraine and, most importantly, manage pain. How is a migraine different from a regular headache? A migraine includes a constellation of symptoms, including a throbbing, intermittent headache usually affecting only one side of the head, as well as nausea and extreme sensitivity to light and noise. A migraine is far more disabling than a typical headache. How do you know it's a migraine and not something more serious, like a brain tumor? Migraines are recurrent, but between episodes you feel perfectly normal. In more serious conditions the pain stays steady or gets worse. If you can sleep off the headache, that’s a good sign it’s a migraine. Are certain foods migraine triggers? Not all patients note dietary migraine triggers, but among those who do, cheese, alcohol, caffeine, MSG, citrus fruit and soy sauce are typical offenders. Chemicals that end in the letters “amine,” such as tyramine, found in aged meats, red wine, and especially cheese, are often problematic, so check labels. Chocolate is controversial. For some time it was considered a trigger, but now the theory is that perhaps chocolate is only a pre-headache craving, and not one of the migraine triggers. Speaking of chocolate and cravings, are women more apt to experience symptoms of a migraine at certain points in their menstrual cycle? Women who keep headache diaries often note they get migraines at a certain time each month. For some, it’s a week before their period; for others, it’s ovulation. There’s also a subcategory called the “menstrual migraine,” which starts anywhere from two days before the flow to two days after. Women in perimenopause sometimes see a spike in migraines, but after menopause is over, many patients report they get fewer migraines and some women stop having migraine pain altogether. You mentioned a headache diary. Should all migraine sufferers keep one and, if so, what should it contain? As soon as I see a new patient, I urge them to start a diary, which can just be notes on a basic calendar, and to keep it for a minimum of three months. When they have a headache, they should note where they are in their menstrual cycle, any food or drink they’ve had, and also things like the weather and where they are. Environmental factors like heat, exposure to certain chemicals, smoke, changes in barometric pressure or even odors can also be migraine triggers. They should rate the pain on a scale of 1 to 10, and note if they took any medication, and whether it worked. What patterns emerge from these diaries? One patient realized she only had migraine pain on Saturdays. We figured out that she drank coffee at work, but not on weekends. So it wasn’t caffeine that was triggering her, but rather caffeine withdrawal. Migraines also are related to sleep patterns. Too little or too much sleep can be migraine triggers, as can any change in your normal cycle. For example, night-shift workers often get headaches on weekends when they try to catch up on sleep. Should you treat migraines with over-the-counter (OTC) medication? If headaches are infrequent and relatively mild, over-the-counter medication may be enough. But some patients get such frequent and intense migraines that OTC medication can’t help. Also, some OTC medicines can damage the stomach or liver over time, while others, like Excedrin, have caffeine, which often makes migraines worse. Finally, OTC drugs can cause rebound headaches. Follow the rule of moderation: If you only use OTC medicines once or twice a week, that’s probably fine. But if you’re using them five or more days a week, that’s too much. What’s a rebound headache? It’s a chronic daily headache resulting from overuse of medication, whether OTC or prescription. Anything you take more than twice a week can put you at risk for a rebound. I tell patients, if you need that much medicine just to function, take a look at your lifestyle. Do stress and anxiety act as migraine triggers? A lot of migraineurs have Type A personalities. They tend to be very organized, classic perfectionists. Along with migraines, you often see depression, anxiety and irritable bowel syndrome. Depression and anxiety don’t cause migraine pain, but the conditions are often seen together. People who get migraines tend to be sensitive to changes in routine, so it’s important they create regular rituals in their daily lives. Can medicines you take for other conditions be migraine triggers? Blood pressure medicine, birth control pills, hormonal treatments and certain antidepressants can be problematic, so talk to your doctor if you take any of these drugs and find your headaches getting more frequent or worse. Even OTC treatments for acid reflux and heartburn can be migraine triggers. Is there a genetic component to migraines? It’s not clear. About 60% of people with migraines say they have a first-degree relative with migraine, which seems too high to be accidental, so there seems to be a genetic piece to the puzzle. But a lot of migraine sufferers don’t have anyone else in the family with the condition. At what age do people start getting migraines? Migraines peak between the ages of 25-55. If boys are going to have them, they usually start in pre-adolescence, while girls usually get them around puberty. After the age of 55, they often begin to fade. What prescription medicines are commonly prescribed for migraine pain? Do they have side effects? The most common class of medicines used to treat migraines are tripans, drugs such as Imitrex, which reduce inflammation of blood vessels in the brain, and thus reduce sensitivity. Side effects are pretty mild – nausea, throat fullness, slight fatigue or flushing of the face. Sometimes there’s a mild escalation of the headache before the drug begins to work. Do natural remedies such as vitamins and herbs help combat migraine triggers? Butterbur and feverfew are sometimes mentioned, but I don’t see evidence they help. St. John’s Wort, which is sometimes used as a natural antidepressant, is currently in studies. So far, the most promising evidence points to supplementing with Vitamin B2 and magnesium. Are all the medicines used to treat existing pain? Is there any way to stop migraine triggers? There are two categories of migraine drugs. Abortive treatments, which are designed to stop the pain once it’s started, are where there’s the most growth. Seven new tripans have come on the market in the last 10 years, along with new ways to administer them. Right now, we have pills, needles and nasal spray, but they’re looking at patches and powders as well. The second category is in preventative drugs, and there’s been less advancement in those. Only four have been approved over the last few years, and no one seems able to find a definitive way to raise the threshold that keeps migraine triggers from breaking through. In other words, there’s no cure so far. We’re getting better ways to manage migraine pain once it happens, but we are lagging behind in finding ways to prevent them altogether. What about Botox? Botox has just been FDA-approved for people with chronic migraines – which is defined as people who have headaches more than 15 times a month, with eight of these headaches intense enough to be categorized as full migraines. The protocol is injections on the forehead, temples, back of the skull and down the neck. The temples and forehead? How can they make sure people aren’t faking headaches to get the Botox for cosmetic reasons? You only get FDA approval to use it for the worst cases, which means people who have been under the care of their doctor for a long time. Since it’s just been approved, it’s too soon to say how successful it will be, but Botox may rise on the list of common treatments once we get more data. When, if ever, should you go to the emergency room with a migraine? Go to the emergency room if you have any of these symptoms of a migraine: alteration of consciousness, disorientation or confusion, fever over 101, weakness or numbness in your arms or legs, nausea that won’t stop, speech changes, or severe vertigo. People who have had migraines over time get familiar with their migraine triggers, what they feel like, how they start, where the pain localizes and how long they last. So if you’re having a new kind of headache or it’s the worst pain of your life, you’re going to know that this isn’t your typical experience and you need to get it checked out immediately. Can lifestyle measures help prevent migraines? Anything that makes you feel good is also good for preventing migraine triggers: a healthy diet, good sleep hygiene, regular exercise, avoiding smoke and alcohol. Find ways to manage stress, unwind and relax. It can be biofeedback or meditation or a hobby — some sort of escape mechanism. But if these commonsense steps don’t stop your migraines, seek help. Treatments are improving all the time, and there’s no need to let migraines control your life. What Do You Know About Migraines? In the U.S. alone, 30 million people suffer from migraine headaches, and the condition is three times more common in women than in men. However, surveys show that fewer than half of sufferers have received a diagnosis from their health-care providers.