Interview: Living with Migraines Means Combination of Treatment and Prevention

Without a Cure, Symptom Management Is Key

Alexander Mauskop, M.D., is the director of the New York Headache Center in New York City and an associate professor of clinical neurology at SUNY-Downstate at Brooklyn. He is also a fellow of the American Academy of Neurology and chairman of the board of the Eastern Pain Association. Dr. Mauskop's main research interests are the role of magnesium in migraines and the efficacy of nondrug therapies in the treatment headaches. He has conducted many trials of drugs for the treatment of headaches and other conditions and is the author of "What Your Doctor May Not Tell You About Migraines" (Warner Books, 2001).

Q. Why are migraines so frequently misdiagnosed or underdiagnosed?

A. For many years, we didn't have any fixed treatment for migraines. So there was no big need for a precise diagnosis until we could get better therapies. Now we have the triptans, the newest class of prescription drugs specifically designed for migraine treatment [see box, page 3]. So doctors and patients are much more concerned about making and receiving the correct diagnosis. But many physicians don't pay attention to headaches. As long as they do a scan of the brain and there's nothing wrong with the scan, they think there's nothing wrong. So people go on suffering, and that's very unfortunate.

Q. Is there a test for migraines?

A. No. It's a descriptive disease, so it's called diagnosis by exclusion - making sure there's nothing else going on. Migraines are often misdiagnosed as sinus headaches because the pain is often in the front of the head in the area of sinuses. But sinus headache almost exclusively occurs only if you have other symptoms of sinus disease such as congestion and nasal discharge.

Q. Why do so many people with migraines not seek treatment?

A. I encounter people who have had severe, disabling headaches for a long time but they've never seen a physician because they think there's nothing you can do about it. Today we have very effective treatment, so you don't have to suffer.

Q. How do migraines affect a person's life?

A. The headaches cause disability that limit work, physical and social activities not only because of the pain, but also the nausea, vomiting and other symptoms associated with it. Even after the pain is gone, many people feel "washed out" for as much as 24 hours afterwards. And the fear of an attack prevents some people from making social plans.

Q. How do you differentiate a migraine from another kind of headache?

A. Sinus headache is usually accompanied by yellow or green nasal discharge and sharp pain in one part of the head. Tension headaches don't interfere with your life; they're pressure-like, you can live with them, take over-the-counter drugs and they go away. Cluster headaches are extremely severe headaches that are often mistaken for migraines or sinus headaches. They are always one-sided, occur daily for an hour or two and are accompanied by clear nasal discharge, tearing and agitation.

Q. Do migraines occur on just one side of the head?

A. Migraine headaches can be at the front, the back, one side or the entire head. In fact, the location of pain is not very useful in diagnosing where the pain comes from because one nerve provides the sensation to the entire head. So if you have pain in the back of the head, or even in the neck, it may be perceived as pain in the front of the head. Some doctors and patients also think you have to have visual disturbances or aura to qualify it as a migraine. But just 15 percent of migraine sufferers have the aura.

Q. What do you recommend when people come to you with migraines?

A. I give my patients a list of things to do. First, try to eliminate triggers, stress being the biggest trigger. But I never tell my patients that their headaches are caused by stress because they're not. They're caused by a genetic predisposition. Hearing that is very reassuring for patients because they've been told their headaches are all their fault, all caused by stress, and that if they learned how to relax and not take things so seriously, the headaches would get better.

Q. What are some other triggers?

A. An excessive amount of caffeine is a major problem. In one double-blind, placebo-controlled study, (5) where the average consumption was two and a half cups of coffee a day, more than half of those who were withdrawn from caffeine developed a headache as the primary sign of withdrawal. And these were not headache sufferers. If you're not a headache sufferer, you can drink six cups and never get a headache. But if you're prone to headaches, just two cups a day is definitely enough to make headaches worse. And not just coffee, but Coke, Pepsi, tea, even over-the-counter medications such as Excedrin and Excedrin-Migraine, contain caffeine.

Q. What role do physical activity, relaxation and other mind-body approaches play in migraine treatment?

A. Aerobic exercise relieves the effect of stress on your body, while improving circulation in your brain and releasing endorphins, which are natural pain killing substances in the brain. You don't have to do a lot of exercise-20 to 30 minutes four to five days a week is often sufficient.(6,7)

Next on the list is biofeedback. Also, yoga, meditation and any other form of relaxation works as long as you do it on a regular basis. (8)

Q. What is the connection between magnesium and headaches?

A. Studies find that half of all patients with severe headaches don't have enough magnesium. (10) Magnesium is a vital element involved in the regulation of a variety of activities in the brain. For instance, serotonin, a chemical in the brain called a neurotransmitter, is involved in headaches. And serotonin receptors are regulated by magnesium. If you're low in magnesium, they don't work as well. Studies also find that patients with low magnesium levels don't have as much success with sumatriptan (a common medication for headaches). But after researchers gave patients magnesium supplements, the sumatriptan worked better. Magnesium also regulates NMDA receptors in the brain, which are very important in the pain process. Magnesium is also a vasodilator, relaxing blood vessels. In fact, there may also be a connection between stress and magnesium because studies find that stress depletes magnesium, which may trigger the migraine.

Q. How about riboflavin and feverfew?

A. Riboflavin is vitamin B2, which has long been suspected to help migraines. In one double blind trial conducted in Belgium, participants headaches improved from an average of four headaches a month to two a month after three months of taking daily 400 mg of riboflavin. (11) I do not recommend this high a dose for pregnant women. In another study, 72 volunteers received either feverfew or a placebo. Those receiving the herb found the severity and frequency of their migraines reduced. (12) Feverfew, like all other herbal supplements, should not be taken by pregnant women or those taking blood thinners, such as Coumadin.

Q. Why do more women get migraines than men?

A. In childhood, there is no difference in the number of migraines between boys and girls. The difference appears at puberty, when migraine becomes three times more common in women then in men. After menopause, the incidence is the same. So hormones obviously play a role, although no one knows exactly what it is. We do know that a drop in estrogen before menstruation triggers migraine, while during pregnancy and after menopause migraines usually stop.

Q. Is there a connection between migraine and psychiatric disorders?

A. Yes. Large studies confirm that if you have migraine, you are two to three times more likely to become depressed, anxious and have panic attacks. (13) But it works in both directions. If you're depressed, you're three times more likely to get migraines.

Q. What other therapies are available for migraine sufferers?

A. Acupuncture helps some people. (14) Botox injections also may help. Botox is the deadliest toxin known to man. But used in very small amounts, it's extremely effective for a variety of conditions, including movement disorders. It's used for cosmetic treatments, and through that use we've discovered that it helps migraines. (15) In my experience, 70 percent of patients with intermittent migraines found relief.

Migraine Headache Defined

Symptoms of migraine occur in various combinations and include pain, extreme sensitivity to light and sound, nausea and vomiting. The pain of migraine is often described as an intense pulsing or throbbing pain in one area of the head, but it can be pain on both sides of the head with no throbbing. About 15 percent of those who get migraines can predict the onset with tell-tale signs that include visual disturbances. This is called a migraine "aura." (16)

For many years, scientists believed migraines were linked to the dilation and constriction of blood vessels in the head. They now believe migraine is caused by inherited abnormalities in certain cells in the brain. People with migraine have an enduring predisposition to attacks triggered by a range of factors. Specific abnormal genes have been identified for some forms of migraine.

Using new imaging technologies, scientists can see changes in the brain during migraine attacks. Scientists believe that there is a migraine pain center located in the brain stem, a region at the base of the brain. As neurons fire, surrounding blood vessels dilate and become inflamed, causing the characteristic pain of a migraine. To keep this process in check, prompt treatment is critical.

Migraines can be triggered - not caused - by lack of food or sleep, exposure to light or hormonal irregularities in women. That's why doctors advise those with migraines, called migraineurs, to follow a regular schedule of eating and sleeping. (16)

Medications may be taken on a daily basis to prevent attacks. Some medications developed for epilepsy, depression and high blood pressure are taken daily to prevent migraines. Medicines also are used to relieve pain and restore function during attacks. The most promising of these are drugs called triptans. For some women suffering from migraines, hormone therapy may help because there is a connection between hormones and migraine. Stress management strategies, such as exercise, relaxation, biofeedback and other therapies to help limit discomfort, also have a place in migraine treatment and prevention. (9)

Interview #2: : Nondrug Approaches Supplement Migraine Treatment

Donald B. Penzien, Ph.D., is a clinical psychologist who specializes in assessment and treatment of recurrent headache. He is associate professor of psychiatry and director of the Head Pain Center at the University of Mississippi Medical Center. Dr. Penzien has published numerous research articles and chapters, received research grants from NIH and other agencies and is a fellow of the American Headache Society. He served as chair of the Nonpharmacologic Therapies Review Group for the Headache Treatment Guidelines Project funded by the Agency for Healthcare Research and Quality, and he serves on the executive committee of the U.S. Headache Consortium.

Q. Where do behavior-based interventions fall on the migraine treatment spectrum?

A. Behavioral treatments are not considered by everyone to be mainstream. After all, everyone uses medication for headache, and most of us do just fine with nonprescription treatments. Others do great with prescription drugs. So many people, even physicians, don't recognize there is a role for nondrug treatments, either alternatively or in addition to drug therapies. Today, there's enough scientific literature about what works and doesn't work to include nondrug therapies in national treatment guidelines.

Q. What are nondrug therapies?

A. Most of what I end up talking about has to do with behavioral therapies, which I break into three major categories: relaxation training, biofeedback and cognitive behavioral therapy, and stress management therapy.

Q. What do you mean when you talk about relaxation training?

A. There are many different varieties under that heading, but basically it's teaching people to learn how to identify when they're becoming physiologically aroused or uptight and then what to do about it. It usually means going through a series of relaxation exercises to reduce the overall level of arousal and stress reaction.

Q. And what about biofeedback?

A. While there are several types of biofeedback, the two that seem to work best and are well validated and most commonly used for headaches are electromyographic (EMG) biofeedback and warming, or temperature biofeedback. (17)

Q. What is the difference between the two?

A. EMG biofeedback is used to help patients learn to better control their muscular tension, because muscular involvement is often an important contributor to migraines. So it helps people learn when their muscles are reacting and how to reduce that muscular tension. We usually focus on the head and neck muscles.

Temperature biofeedback is based on the notion that as you become more anxious and uptight, your fingertip temperature falls. The blood vessels in the fingertips are responsive to the sympathetic nervous system activation. So the more aroused you get, the cooler your hands get. We put a temperature biofeedback device on the fingertips and teach people through the feedback they get that if they can learn to warm their hands, they can learn how to reduce that level of arousal and relax.

Q. How long does it take to learn this?

A. With biofeedback, some people are just naturals at it. They're almost like star athletes and they have it right away. For most, it takes eight to 12 sessions to learn biofeedback. But once you've got the skills, it's like learning to ride a bike. It tends to stay with you and you don't need a lot of additional workups or booster sessions to keep your skills sharp. It's the same with relaxation training.

Q. How does cognitive behavioral therapy help?

A. In cognitive behavioral therapy, we work hard to identify what's going on in the person's life and environment that may be triggering their headaches. The most common headache triggers are stressful activities - the same kinds of everyday stressors that bug anyone else. But people with migraines tend to react more to what's going on in their daily lives so it affects them more. Thus, stress management training helps you to recognize the behavioral trigger factors that bring on headaches.

Q. Can you give an example?

A. Say there's a woman who has a poor relationship at work, she's not getting along with her boss and dreads going to work. We have her do some self-monitoring and she recognizes that she's more likely to have headaches on work days than on weekends. That's not an uncommon pattern. So we look at the factors causing this: is it trouble sleeping or stress levels at work? We find out she begins to gets a headache on the drive to work because she knows she has to confront her boss, who is going to be unhappy that her work is not up to date. So we help her figure out what to do about this. But instead of focusing on just solving this one problem, we try to teach her techniques that can be used to handle other stressors, as well.

Q. How would you do that?

A. We might have her consider how realistic is her perception that her boss is really hassling her. Or have a more realistic assessment of her own abilities. Or teach her how to sit down and talk to her boss about this in a nonconfrontational way. Even if it's a chronic, daily stressor that she can't do anything about, we'd teach her to learn to accept it and just get on with her day.

Q. How long does this take?

A. Most times, stress management training takes a couple of months to get through a course. It's most typical for these treatments to be done in weekly sessions with a professional who sits down and works with you. But we are working to develop minimal contact treatments where you use the same kinds of techniques but learn them at home on your own rather than having to come into the office. These are not cures by any stretch, but empirical evidence shows these techniques can provide between 35 percent to 55 percent reductions in headache activity.

Q. When would you try behavioral therapy with migraines?

A. When the patient is trying to treat the headaches with medication but can't tolerate the medications or there are contraindications. For instance, someone who is trying to get pregnant, is pregnant or is nursing.

There's also a large subgroup that doesn't respond well to medications. And then there are patients who just don't like using medications.

We've also discovered over the last 15 years that if you use many different medications frequently you can get rebound headaches. This is particularly a problem for people with the worst headache problems. So they may have migraines six or seven times a week; they really shouldn't be taking medications that often. These are people where nondrug alternatives, even used with medications, can help prevent rebound headaches. Finally, we also often see people in the clinic who are just clearly overwhelmed. They have stress-coping deficits, just a very difficult time coping with life. So they come see us even if they are doing well with prescription medications.

Q. How do you know if you're a person for whom these approaches will work?

A. There's not a lot of great science that tells us who responds best. But we do know that kids tend to do great with behavioral treatments, while elderly people tend not to do as well. But in a few labs, where they've designed treatments specifically for the elderly - providing more time in sessions, and less homework, making more of an effort to ensure the rationale is clear - the older person does just as well as the younger folks.

Q. For whom do behavioral therapies not work?

A. If you're having headaches every day, it's tough for either drug or nondrug treatments to work because it's tough for people to learn to relax if they have a severe headache every day. It's like learning to swim in a pool versus an ocean; if you never have a calm day, it's hard to learn to swim. So we work with the physicians to first break the severe pain cycle with drugs, then try nondrug treatments.

Q. What's coming in the future with behavioral therapies for migraines?

A. Making the treatments more accessible to patients. Eighty-five percent of my patients are women, most of them working outside the home. They don't have time to come and sit here for an hour a week. Plus, there's still some stigma associated with headache and with seeing a psychologist. So we need to find ways to repackage the training for these therapies so they can be made available to patients in their primary care doctor's office. That's where most people go to get headache treatment, and that's where the treatments need to be initiated.

Communicating with Physician Critical for Diagnosis and Treatment

The first national survey of migraine prevalence in 1989 turned up the surprising information that just 41 percent of American women and 29 percent of men who had migraines had received a specific medical diagnosis of migraine. (19)

Ten years later, when the study was conducted again, those percentages had risen only 4 percent, despite the introduction in the intervening decade of the first medications specifically developed to treat migraines (the triptans) and a growing body of scientific evidence proving the effectiveness of both drug and nondrug preventive methods.

This is despite that fact that many more people had visited their doctor and talked about their headaches (48 percent in 1999 compared to 16 percent in 1989). (19)

These figures lead study author Richard Lipton, M.D., professor of neurology, epidemiology and social medicine at Albert Einstein College of Medicine in New York, to conclude that barriers to effective diagnosis and treatment of migraine exist on two levels: most people don't go to the doctor about their headaches, and even when they do, the medical consultation is ineffective.

Given that migraine is misdiagnosed as tension (a catch-all phrase) or sinus headache (a relatively rare condition) almost as frequently as it is correctly diagnosed, it is critical for the migraine sufferers to find a better way to communicate with their physicians.

"The communication barriers are very clear," says Dr. Lipton, who has reviewed numerous transcripts of patient visits to their primary care physicians for headaches. Very often the patient wants to know what's causing the headaches and is looking for a diagnosis and strategy for managing the pain, while doctors think their job is to reassure the patient that the headache doesn't have a life-threatening cause, such as a tumor.

Instead of focusing on the pain, Dr. Lipton suggests patients describe how the migraines interfere with their daily lives: how much work they miss, how many days they can't work effectively, how it affects their family life. When patients do that, he says, doctors are more likely to diagnose migraine and provide appropriate treatment than if they just focus on pain.

Migraine sufferers might also consider finding a doctor who suffers from migraines - a relatively easy thing to do if they're looking for a neurologist. In a survey of 576 male and female doctors, researchers found the rate of migraines among migraine specialists is 60 percent to 70 percent, compared with 12 percent in the general population. (4) "There are two possibilities," says Lipton, who co-authored the study (but who does not suffer from migraines himself).

One is that migraine itself produces a set of interesting neurologic phenomena that draws those who suffer from it to the field; the other is that neurologists who specialize in migraines are simply more attuned to the symptoms of migraine and thus more likely to diagnose their own headaches as migraine.

Preventing Migraines

Today, there are numerous ways to treat and prevent migraines, ranging from tricyclic antidepressants, anticonvulsants and beta blockers for prevention, to the triptans and nondrug therapies for prevention and treatment. (20)

Finding a combination that works best is often a hit-or-miss exercise, with physicians prescribing one thing after another before arriving at the best mix - or before the patient gives up in frustration. Kenneth Holroyd, Ph.D., a professor of clinical psychology at Ohio University, is conducting the first study to try to identify which combination of multiple treatments works best to prevent and treat frequent and severe migraines.

He's particularly interested in learning if behavioral therapy, such as stress reduction, and preventive medications, such as propranolol, can improve the effectiveness of acute medication therapies such as triptans or analgesics. "It's really what needs to be asked these days," he says, "because most people with severe migraines are on triptans. So the real question about preventive medications and behavioral therapies is 'do they add anything to that?'"

Neither he nor other researchers doubt the effectiveness of various behavioral therapies in preventing migraines - even though the mechanism by which they work isn't always understood. For instance, no one knows for sure how thermal biofeedback, in which individuals are taught to use their mind to warm their hands, works, yet five trials of the therapy found an average 37 percent improvement in headache activity. (20)

One theory builds from the fact that warming the hands dilates capillaries close to the skin and increases blood flow. That, in turn, affects blood flow to the brain. But exactly how this relates to migraines is unknown.

Another theory suggests it plays a role in the brain's neuronal firing. Scientists know that people with migraines have a lower threshold for triggering neuronal firing in certain areas of the brain, such as the visual cortex or motor cortex. So it takes less stimulation to instigate the neuronal firing and thus cause migraines. It may be, Dr. Holroyd says, that handwarming raises the neuronal threshold, thus also raising the threshold for those triggers - stress, light, lack of sleep - that, in turn, cause headaches.

As for food's role in migraine, that's overrated, says Richard Lipton, M.D., professor of neurology, epidemiology and social medicine at Albert Einstein College of Medicine in New York. Most adults know by the time they see a doctor whether certain food or drink triggers their migraine. Children, however, are usually unaware of the connection and might benefit from an elimination diet, cutting out such things as aged cheeses, processed and cured meats and MSG-containing foods.

The Research

1. National Headache Foundation. American Migraine Study II-A Ten-Year Report Card on the State of Migraine. www.headaches.org

2. Hu, X.H., Markson, L.E., Lipton, R.B., Stewart, W.F. & Berger ML. (1999) Burden of migraine in the United States: Disability and economic costs. Archives of Internal Medicine 159(8), 813-818.

3. Lipton, R.B., Diamond, S., Reed, M., Diamond, M.L. & Stewart, W.F. (2001) Migraine diagnosis and treatment: Results from the American Migraine Study 2, Headache 41(7), 638-645

4. Evans, R.W. & Lipton, R.B. (2001) Topics in migraine management: A survey of headache specialists highlights some controversies. Neurologic Clinics 19(1), 1-21.

5. Silverman, K., Evans, S.M., Strain, E.C. & Griffiths, R.R. (1992) Withdrawal syndrome after the double-blind cessation of caffeine consumption. New England Journal of Medicine 327(16), 1109-1114.

6. Lockett, D.M. & Campbell, J.F. (1992) The effects of aerobic exercise on migraine. Headache 32(1), 50-54.

7. Darling, M. (1991) Exercise and migraine: A critical review. The Journal of Sports Medicine and Physical Fitness. 31(2), 294-302.

8. Reid, G.J. & McGrath, P.J. (1996) Psychological treatment of migraine. Biomedicine & Pharmacotherapy 50(2), 58-63.

9. Mauskop, A. (2001) Alternative therapies in headache: Is there a role? Medical Clinics of North America 85(4), 1077-1084.

10. Mauskop, A. & Altura, B.M. (1998) Role of magnesium in the pathogenesis and treatment of migraines. Clinical Neuroscience 5(1), 24-27.

11. Schoenen, J., Jacquy, J., & Lenaerts, M. (1998) Effectiveness of high-dose riboflavin in migraine prophylaxis: A randomized controlled trial. Neurology 50(2), 466-470.

12. Murphy, J.J., Heptinstall, S., Mitchell, J.R. (1988) Randomised double-blind placebo-controlled trial of feverfew in migraine prevention. Lancet 2(8604), 189-192.

13. Merikangas, K.R. & Stevens, D.E. (1997) Comorbidity of migraine and psychiatric disorders. Neurology Clinic 15(1), 115-123.

14. Manias, P., Tagaris, G. & Karageorgiou, K. (2000) Acupuncture in headache: A critical review. The Clinical Journal of Pain 16(4), 334-339.

15. Binder, W.J., Brin, M.F., Blitzer, A. & Pogoda, J.M. (2001) Botulinum toxin type A (BOTOX) for treatment of migraine. Seminars in Cutaneous Medical Surgery 20(2), 93-100.

16. National Institute of Neurological Disorders and Stroke. Migraine Update. www.ninds.nih.gov

17. Chapman, S.L. (1986) A review and clinical perspective on the use of EMG and thermal biofeedback for chronic headaches. Pain 27(1), 1-43.

18. Gauthier, J.G. & Carrier, S. (1991) Long-term effects of biofeedback on migraine headache: A prospective follow-up study. Headache 31(9), 605-612.

19. Lipton, R.B. & Stewart, W.F. (1993) Migraine in the United States: A review of epidemiology and health care use. Neurology 43(6 Suppl. 3), S6-10.

20. The US Headache Consortium. Evidence-based Guidelines for Migraine Headache in the Primary Care Setting. Academy of Neurology, April 25, 2000.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

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