Newer Theories on Headache
Headache, or migraine is the most common neurologic problem of human beings. Many migraine sufferers do not know that what they have is migraine. Anyone with normal brain anatomy who has a headache spontaneously without a blow to the head is having “migraine”. So, migraine is not only a severe, unilateral, throbbing headache with nausea, sensitivity to bright light and visual symptoms. Migraine can also be a small “sinus headache” in the face or just a feeling of neck tension. The pain that accompanies migraine can be severe, but it can also be mild. It can be episodic, lasting for hours, or it can be there daily, year after year. The pain may be in the head, the face, or in the neck. Frequently daily neck pain patients visit the chiropractor’s office. The face pain patients visit the allergist. They can’t understand why their pain syndrome doesn’t get better. They don’t have “sinus headache”, or “a pinched nerve”, they really have migraine. Migraine can cause dizziness or vertigo, visual disturbances, numbness, even difficulty concentrating or getting words out. Only a small percentage of migraine sufferers have these extra symptoms, most just have headaches.
Everything in this handout applies only to a person who has had a CT scan of the head that shows that the brain is normal. There is no difference between the head pain caused by a brain tumor and a headache from a migraine gene. Everyone with severe or frequent headaches must have a CT scan of the head before assuming that their headaches are “migraine”.
The concept of migraine as a hyper excitability of the head pain system is not widely recognized. Most physicians have a very narrow view of migraine. They tend to call our less severe headaches “tension headaches”, or “stress headaches”. They were taught that pent-up anxiety or tension causes contraction of the muscles in the neck and scalp, which makes our head hurt. In reality these headaches are also migraine, just mild migraine.
What do we know about how migraine occurs? The early theories about migraine called it a “vascular” headache. That is because the early medicines that helped migraine constricted the blood vessels. Recently we’ve learned that the blood vessel constriction is really a side issue, and migraine is really a hyper excitability of the head pain system. Once the brain stem “pain center” is turned “on” messages go out to several other parts of the brain producing a general feeling of “not able to think right”, light sensitivity and nausea, as well as pain in the head or neck. Headache location and severity varies from headache to headache. Sometimes it is triggered just a little and a mild, generalized headache occurs, sometimes all the symptoms occur together causing severe disability. Most people who have not experienced a full-blown migraine do not understand the disabling nature of this syndrome, it is not just pain. During a migraine most of our brain cells are not able to function normally.
What should you do once you recognize you have migraine? All the treatments for migraine change the chemistry of the brain, whether that treatment is a medication, a daily exercise program, or a vitamin to improve your sleep. The medications fall generally into two categories: episodic medications, taken only at the time of the headache, and preventative medications that are taken daily. The type of treatment you should use depends on the severity and the frequency of your headaches. Three factors determine migraine frequency; sleep disorders, hormones, MSG (a flavor enhancer). If many ”trigger factors” happen at once the migraine center switches on and you’ll experience a migraine. Most people who have a headache every single day on awakening have a sleep disorder. The most common cause of this sleep problem is vitamin D deficiency.
What about sleep? Most people who have daily headache have a sleep disorder that is causing the headaches to appear daily. Not sleeping properly prevents the body and the brain from properly repairing at night. Without nightly repair and regeneration of the chemicals we need to feel good, the head pain system is “on” every morning when we wake up. The daily prevention medications we use can make these headaches better but the best fix of all is to fix the sleep and the headaches will go away by themselves. Most people who have sleep disorders have either vitamin D or B12 deficiency or sometimes both, causing their sleep to be interrupted or not restorative, i.e. they sleep but still feel tired. Patients with vitamin D deficiency often have body pain in addition to daily headache.
How can you prevent your migraines? If you have not had your vitamin D level checked ask your doctor to check your Vitamin D25OH level and your Vitamin B12 level. Don’t let them tell you they are “normal”, ask for the number. We make vitamin D from sun exposure so your level in the fall should be 70– 80 ng/ml, your level at the end of winter should never fall below 50. For questions about Vitamin D deficiency and doses go to www.vitamindcouncil.org. Many young healthy people have both vitamin D and B12 deficiency. The B12 deficiency comes from the vitamin D deficiency. Your B12 should be >500. If it is not, in addition to vitamin D take 1000 mcg vitamin B12 pill per day. The shots of B12 are not better than the pills. All of these are over the counter supplements. Once you hit the right dose of vitamin D and/ or B12 your sleep will start to be normal and you will wake rested, when that happens your headaches will start to be better. It’s the sleep that fixes the headaches, it doesn’t happen rapidly, it happens slowly over weeks to months. If you’re still not sleeping after months check your levels again and try a sleep medicine. Unfortunately some people do these things and still have headaches; they’re the ones who will benefit from a preventive medication.
Most preventative medications were first used for other reasons, such as blood pressure control or seizure control. Most have been found to be effective for migraine by accident. Most of the medications work on “channels” that allow ions to move in and out of the brain cells. Some of the preventive medications that are commonly used include verapamil, zonisamide, valproate, topiramate, propranolol and atenolol.
What about foods? MSG is very common in prepared foods, even canned soup and bouillon cubes. It is often in foods that are labelled “smokey” or barbeque or “Cajun”, usually salty foods, not sweet foods. Look for MSG in any food that you have had in the 6 hours before your bad headaches.
Why are migraines worse around the menstrual cycle or menopause in women? The ovaries produce estrogen and progesterone, the hormones responsible for the menstrual cycle. The brain tells the ovaries to make these hormones. It does this using “releasing hormone”, a chemical that is released from the brain into the blood to talk to the ovaries. Releasing hormone is also a neurotransmitter; it affects brain cells as well ovary cells. High releasing hormone levels make the migraine center more hyper excitable, often leading to sleep interruption as well. This can lead to monthly headaches in young women and daily headache in women going through menopause.
What do I use if I have a headache once a week or once a month? The over the counter headache medications work for most people. If they are not working then talk to your doctor about something stronger. Usually that will be a medication called a “triptan”, (zolmatriptan, naratriptan, eletriptan, sumatriptan, almotriptan, frovatriptan, rizatriptan) one of 7 medications that are specific migraine medicines. They work on serotonin receptors, they are not pain relievers, they are much more effective for the treatment of all types of headaches than the OTC medications.
How to use the triptans: All of the “triptans” are medicines that act migraine “pain center” to make the brain chemistry go back to normal. They work better if taken at the beginning of the headache, and a bigger dose will be needed if the headache is already pretty bad. If the triptans don’t work for you it usually means that either you took it too late or your brain chemistry is so out of kilter that a daily preventative medication will be needed before the triptans will work for you.
SGominak 10/2011