Migraine

MIGRAINE no ordinary headache

What causes migraine ?

There is very seldom a single cause for this condition, but more a series of triggering mechanisms in varying degrees affecting a susceptible person usually with a hereditary disposition to migraine.

What are the migraine triggers ?

Hormonal balance tends to be a major aspect especially in females. Migraines tend to occur around period time. It is interesting to note that HRT therapy can often cause or intensify attacks and medically it would be advisable to stop therapy should this be the case.

Food allergy is perhaps the best known of the migraine triggers, but not fully understood. It is not the food as such that causes the problem, but particular compounds common to certain food groups. Citrus fruits, red wine, chocolate, cheese, all contain the enzyme Tyramine, but the list is more extensive. Other compounds such as Phenylisothiocynate found in pulses and beans, as well as foods high in the amino acid Serotonin, ie banana or avocado could also become triggers. Low blood sugar or what may be called functional hypoglycaemia is another common trigger where the attack is triggered after a period of irregular eating or missing out meals.

Low blood pressure, which at face value may be a great asset, tends to be a common finding in migraine sufferers. When considering the neurovascular aspect of migraine "blood vessel headaches", low blood pressure becomes an understandable trigger.

Platelet stickiness, migraine and coronary risk.

Articles in the general and medical press suggest that the incidence of migraine headache and/or abdominal migraine is increasing. The initiating event may involve a specific chemical such as tyramine from cheese or chocolate, a food or chemical sensitivity or a stress sufficient to trigger inappropriate adrenaline release. The severity of what follows frequently hinges on the willingness of the platelets to adhere (clump together). This is an equally important issue in cardiac and other vascular-risk situations. For many years, Biolab has assessed platelet aggregation by examining the effect of three different levels of ADP on a suspension of the patient’s platelets in their saline-diluted plasma. That test continues to be available. Pyridoxine (B6), vitamin C and ginger are among the most powerful substances for reducing platelet stickiness. However, they do not all work for any one patient. Using a new microscopic technique employing laser technology, Biolab can now assess the effects of each of these anti-aggregation measures in-vitro, request platelet protection studies. It is hoped that this will enable doctors to better advise on protective and preventative measures. The same technique can explore substance-specific platelet aggregation and a panel will include tyramine, gliadin (wheat protein) and casein (milk protein), request platelet sensitivities. The three tests together are offered as a Migraine profile although it may also be of use in some other vascular investigations such as stroke risk.

Hormones & Migraine

Epidemiologic studies have shown us that women are three times more commonly afflicted with migraine than their male counterparts.
As women with migraine are acutely aware, migraine is frequently affected by hormonal fluctuations, including menarche, menstruation, pregnancy, menopause and during times of oral contraceptive use or hormone replacement therapy.
It is unlikely that hormones explain the entire epidemiological variation seen in the gender differences in migraine, but considerable evidence does exist to suggest that there is a link between migraine and the female hormone estrogen.
The biological basis, however, is not completely understood.

Why is migraine more prevalent in women?

The female hormone estrogen likely plays a critical role in explaining the difference in prevalence between men and women, however, it is unlikely the only factor. Genetics, biology, and reporting habits are important contributiors. The drop in estrogen, occurring just before the onset of menstrual bleeding, is believed to be the trigger for migraine.

At what age does migraine usually start?

Prior to puberty migraine is slightly more common in boys than in girls, but after puberty, we begin to see an emerging female predominance. Many women recall first experiencing their migraines around menarche, that is, when they first begin menstruating. It's important to remember that young girls can be afflicted with migraine and if not managed properly, it could lead to school absenteeism or social isolation.

What is Menstrual Migraine (MM)?

Up to 60% of women experience MM, that is migraine that is associated with their period, and occurs at other times of the month as well. Typically, the migraine is experienced a day or two before menses begins or during the first few days of menstrual flow. True menstrual migraine, which occurs only during menstruation, is experienced by only 10 to 14 per cent of women.

What can you do for Menstrual Migraine (MM)?

It's important to remember that if you are menstruating, there is always the possibility of pregnancy. You and your doctor should keep this in mind when choosing medications. For many women, treatment of MM can be very difficult and often the 'standard' anti-migraine medications are insufficient.

The first and in many cases most important step is to keep a headache diary for 3 months. You should record the days on which headache was experienced, timing of menstrual flow and the presence of triggers, if any. This will help determine the association, if any, between your migraine attacks and the timing of your menstrual cycle, as well helping to eliminate recall bias. Non-pharmacological treatments should also be stressed, including avoidance of known triggers, sleep hygiene and biofeedback. In the majority of cases, however, pharmacological intervention is necessary.

Medications include those for acute relief of migraine, those for symptomatic relief of associated symptoms such as nausea and preventive medications. There are many very effective medications now available on the market. Recently some of the medications have been shown to be highly effective for both acute treatment and prevention of MM.

Will the birth control pill affect your migraine?

Most women notice no change in their migraines when starting the pill, however, there is a chance that your migraine pattern may be affected. Some women notice a worsening of their migraines after starting an oral contraceptive pill(OCP). A three month trial is usually recommended, as the migraines may settle down after time. If your headaches continue to get worse, and you want to remain on the OCP, talk to your doctor about switching to a lower estrogen dose pill or to a monphasic pill. For those women with irregular cycles, the OCP may actually help regulate estrogen levels and improve migraine.

Generally speaking, women with migraine may safely use oral contraceptive pills. However, if your migraines change after going on the pill or you develop new associated symptoms or complicated aura, you should discontinue the pill. Women with migraine who smoke, have diabetes, high blood pressure or other risk factors for heart disease are not good candidates for the birth control pill.

What happens if you get pregnant?

The good news is that women often notice improvement in their migraine during pregnancy, particularly by the second trimesters. This is especially true for women who experience migraine without aura and in women with a history of MM. A smaller number of women notice no change in their migraine pattern and up to 10 per cent of women may experience their first migraine attack during pregnancy. Thus, during pregnancy, a woman's migraine may improve or worsen or stay the same.
The greatest concern regarding treatment of migraine during pregnancy relates to drug safety. Generally speaking, migraine drugs should not be administrated to pregnant patients or to women who are actively attempting to conceive.

Reassurance, rest, ice packs and biofeedback are often beneficial and may help women who are pregnant get through the first trimester, after which migraine may improve. For women who have severe, intractable migraine (often accompanied by nausea, vomiting and dehydration), medical therapy may be indicated, since this could pose a risk to the developing fetus greater than the risk of medication. You need to talk to your obstetrician and headache doctor about medications, if you require them while pregnant. Remember that even some over-the-counter medicines can be harmful to the unborn child.

Will your migraines go away at menopause?

The quickest answer is maybe. The changes in hormone levels occurring with menopause lead to a variable effect on migraine. Since estrogen production falls off, MM may improve. However, hormone replacement therapy often prescribed for symptoms of menopause, may worsen migraine. The type of menopause may also affect migraine. In one study, 2/3 of women experiencing physiological menopause noted an improvement in migraine, while 2/3 of women undergoing surgical menopause noted a worsening of their migraine. Hysterectomy is never recommended for treatment of migraine.

It can be difficult for women who require hormone replacement therapy, but for whom such treatment worsens migraine. If estrogen replacement therapy is felt to be necessary and your headaches get worse, try a low dose estrogen in an uninterrupted manner. A number of other strategies may be helpful, including:

1. reducing the dose of estrogen
2. changing the type of estrogen preparation (synthetic to natural or vice versa)
3. employing continuous administration instead of cyclical (especially if headaches are associated with estrogen withdrawal)
4. using estrogens which provide more uniform levels - like the patch
   Overall, the management of hormonally migraine can be difficult and frustrating, but perseverance on the part of both you and your doctor usually leads to success. The vast majority of women can control their migraines and enjoy life to the fullest.