Headache & Migraine

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Headache, or migraine is the most com­mon neu­ro­logic prob­lem of human beings. Many headache suf­fer­ers do not know that what they have is migraine. I believe that 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. But 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”.

Migraine is a hyper excitabil­ity of the head pain sys­tem.The early the­o­ries about migraine called it a “vas­cu­lar” headache. That is because the early med­i­cines that helped migraine also con­stricted the blood ves­sels. Recently we’ve learned that the blood ves­sel con­stric­tion is really a side issue. The head pain sys­tem is a small stripe at the back of the low­est por­tion of the brain called the “brain stem”. (See below to learn more about the spe­cific anatomy and the genes that pro­duce migraine.) That stripe is sup­posed to switch “on” only when we get hit in the head. Migraine suf­fer­ers have a genetic dis­or­der that makes the head pain cen­ter turn “on” too eas­ily, it turns on with­out a blow to the head. Often, when the brain stem “pain cen­ter” is turned “on” other nearby groups of cells turn on also pro­duc­ing light sen­si­tiv­ity, nau­sea, dizzi­ness and confusion.

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.

Migraine comes in many forms. The headache loca­tion and sever­ity can vary, some­times it is a mild, gen­er­al­ized headache, other times it is pierc­ing and behind one eye. Some­times all the symp­toms of migraine 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 severe 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.

There are fac­tors that deter­mine migraine fre­quency such as sleep dis­or­ders and men­strual hor­mone fluc­tu­a­tions. There are also com­mon “trig­gers”; storms that cause baro­met­ric pres­sure changes, monosodium glu­ta­mate (a fla­vor enhancer), exer­cise, espe­cially in teenagers, and some med­ica­tions. If sev­eral ”trig­ger fac­tors” hap­pen at once, the migraine cen­ter switches on and a migraine results. Most peo­ple who have a headache every 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 their headaches to appear daily. Sleep­ing is not sim­ply lying down and becom­ing uncon­scious. There are spe­cific phases of sleep that we must achieve in order to repair. With­out nightly repair and regen­er­a­tion of the chem­i­cals we need to feel good, the head pain sys­tem can be “on” every morn­ing when we wake up. The daily pre­ven­ta­tive med­ica­tions attempt to dupli­cate the chem­i­cals we are lack­ing, and we can use them to make the headaches bet­ter, but the best fix of all is to improve the sleep so we make our own chem­i­cals. Most peo­ple who have sleep dis­or­ders have vit­a­min D and sec­ondary B vit­a­min defi­cien­cies that cause their sleep to be inter­rupted or not restora­tive, i.e. they sleep but still feel tired. Patients with vit­a­min D and B defi­cien­cies 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 7080 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. Most daily headache suf­fer­ers have both vit­a­min D and sec­ondary B defi­cien­cies. 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. Usu­ally a large dose B com­plex such as 50 is needed for 3 months to regen­er­ate the nor­mal intesti­nal bac­te­ria that usu­ally make our B vit­a­mins. (See vit­a­min D sec­tion or sleep sec­tion for details.) All of these are over the counter sup­ple­ments. Once you hit the right vit­a­min D level and your brain has all the vit­a­mins it needs your sleep will start to nor­mal­ize you will wake rested and your headaches will improve. It is not vit­a­min pills that fix the headaches, it is nor­mal sleep that fixes the headaches and because repair takes time it hap­pens slowly over weeks to months. If you’re still not sleep­ing after 1 month check your D level 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 charged ions such as Cal­cium, Ca+ or Sodium, Na+, 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 that trig­ger migraine? MSG, monosodium glu­ta­mate 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 with mild headaches. 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  on the 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 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 10/2013

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