Understanding Migraines: A New Era?
Researchers Say Migraines Differ From Normal Headaches; Finding Could Lead to New Treatments
|by Lee Hickling
drkoop.com Health News

Medical science has confirmed what migraine sufferers have always said -- there are headaches, and then there are migraines.

Dr. Michael Welch, vice-chancellor for research at the University of Kansas Medical Center, said in a briefing at the National Institutes of Health Thursday that migraines are touched off by "a very unique event," and sophisticated modern scanning techniques have made it possible to watch that event happening.

Another top expert in the field, Dr. Richard Lipton, a professor of neurology at Albert Einstein College of Medicine, said the World Health Organization ranks severe migraines with the most completely disabling diseases, along with quadriplegia and active psychoses.

The briefing was held during a two-day conference of leading researchers into migraine, sponsored by the National Institute of Neurological Disorders and Stroke.

Lipton said the disorder is more common than is generally realized, even by migraine sufferers, who often blame their headaches on sinus infections or stress, and try to treat them with over-the-counter painkillers.

Eighteen percent of American women and 6 percent of American men get migraines, Lipton said. Many things can trigger an attack, but high on the list is a low level of the hormone estrogen. Women, because they menstruate, become pregnant and use birth control pills, are subject to fluctuations in their estrogen levels, which seem to explain why three times as many women as men suffer from migraines.

The unique event that causes migraine, Welch said, is "neuroelectrical," and involves cells at the back of the brain that, for reasons not yet understood, have become hyper-excitable. These cells, in the brain stem, the most primitive part of the brain, suddenly begin firing electric impulses that travel through the rest of the brain like ripples spreading when a stone is thrown into a pond.

When they reach the cerebral cortex, they race back to the deep brain stem, where the cells that started it all have subsided to a lower level of activity. Their return, however, makes the brain stem start sending out the severe pain messages that characterize migraine.

Lipton said the new knowledge of the mechanism of migraine should lead to new and more effective treatments for the pain, but that is in the future.

Dr. Sheldon B. Silverstein, a professor of neurology and director of the Headache Clinic at Jefferson Medical College in Philadelphia, said the treatments available now fall into two types -- those to treat the pain and those that may reduce the frequency and severity of migraines.

The severity of a patient's pain should dictate the treatment chosen, he said. Doctors tend to start with pain relievers such as aspirin, which might be enough for a mild attack. If not, they may prescribe a narcotic pain reliever such as Darvon. Then if necessary they may prescribe one of the drugs for moderate to severe pain, including ergot alkaloids, one of the triptans, or combinations of isometheptene, which narrows the blood vessels in the head, with acetaminophen to relieve pain and dichloralphenazone to help the patient relax. If that doesn't do the job, there are several drugs that can be administered in a doctor's office, such as DHE-45, Demerol, Stadol or various corticosteroids. They are not recommended for more than short-term treatment.

Silverstein said such stratified or escalating therapy is not a good way to handle migraines. Rather, the medication selected should depend on the severity of the pain, and if it is severe, a physician might go straight to one of the higher levels of treatment.

Silverstein said patients often do not get appropriate treatment, and about half the time it's their own fault because they do not see a doctor. Even for the half that does, there may be poor communication between them and their physicians. They may just report that they have a bad headache, but don't make it clear that the pain is so severe that it is affecting their entire lives.

There are indications that repeated migraines can even change the structure or behavior of the cells responsible for starting migraines, making attacks more frequent and more severe, until a patient may suffer nearly all the time.

Prophylactic therapy, to prevent future attacks rather than cure one going on at the present, mainly uses drugs that "modulate" or dampen down the excitability of cells in the affected area of the brain. Beta-blockers, antidepressants, calcium channel blockers, serotonin antagonists and anticonvulsants are often tried, and may be effective.

Dr. Gerald Fishbach, director of the NINDS, said the recent discoveries about what causes migraines have opened up very exciting new avenues of research. "There is a list of specific and testable hypotheses that are new," he said, and medical science is suddenly "on the threshold of great change" in the discovery of more effective treatment for migraine and ways to prevent it, or at least to reduce its frequency and severity.