Newer Theories on Headache
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 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. 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 B 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.