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Migraine FAQs: An interview with a Mayo Clinic specialist
By Mayo Clinic staffA Mayo Clinic specialist answers some common questions about the causes, triggers and treatment of migraines.
Jerry W. Swanson, M.D., chairs the Headache Division in the Neurology Department at Mayo Clinic, Rochester, Minn. He routinely counsels people with migraines about their treatment options. Here he offers his personal insights as he answers frequently asked questions about migraines.
What happens in the brain and nervous system to cause migraine symptoms?
There is increasing evidence that migraine is a neurobiological disorder, meaning that it begins or originates in the brain. Presumably, there is something that turns the migraine switch on. Or alternatively, a mechanism that prevents us all from having headaches somehow fails. In fact, it may be a combination of both — that is, something that essentially switches the migraine on, but also the failure of mechanisms that suppress that. But it does appear that deep within the brain, within what we call the brainstem, are messaging centers where an attack appears to originate.
How are the blood vessels in the brain involved in migraines?
At one point in the past, there was a theory that migraine was primarily a blood vessel problem. The vessels probably play a role, but it's really a passive role, being driven largely by the nervous system. There is evidence that some vessels tend to dilate and that may contribute to the pain, but the headache itself seems to begin in the brain. Blood vessels may play a downstream role in the genesis or the cause of a headache, but they're not the underlying trigger or initiating mechanism.
How do stress and diet affect migraines?
Certainly foods are much talked about as triggers, but they probably play a relatively small role overall. It's been quite hard from a scientific standpoint to actually validate that foods serve as triggers. Nevertheless, if individuals clearly recognize something in their diet that's likely to trigger a headache, of course we would suggest that they try to avoid that, just as we would say to avoid other triggers.
Stress is the most common trigger for migraine attacks that is identified by individuals with migraine.
I think one can summarize triggers in migraines by simply saying that migraine loves change. So changing the wake-sleep cycle, missing meals, being exposed to stress, even following stress — which has sometimes been called a let-down headache — all of these things may perturb the inner steady state in a person who is prone to have migraines. A particular perturbation might mean a lot for one individual and not much for another, but there are patterns.
What's the role of caffeine?
It's clearly a two-edged sword because a number of prescription and over-the-counter medications for treating acute migraine contain caffeine. So caffeine can play a positive role in some individuals. We try to tell people to limit their caffeine since overuse may aggravate headaches. If they typically do get caffeine at a fairly early time in the morning, as many of us do, usually via coffee or some other drink, then try to keep it on the same schedule each day. That might be helpful in reducing the likelihood of a headache.
Who should consider preventive treatment?
Typically we consider preventive treatment if the person has more than a few days of migraine headache per month. Where one draws that line is, in part, related to the individual's preference. For some people who have severe attacks and are quite disabled, even if they occur just a few days a month, we might consider preventive therapy because the acute treatments are not working very well and those individuals are frequently missing work or other activities. Then we try to prevent the attack. We certainly don't like to see people using acute medications more than about two days per week or more than nine days per month.
What's the problem with taking acute medication more than twice a week?
The problem that can arise in individuals with migraine headaches is something we refer to as "medication overuse headaches" or "rebound headaches." Essentially, in this situation, a person's migraine headaches, for whatever reason, increase in frequency and lead to using medications more than a couple of days per week. That can result in withdrawal headaches caused by physical dependence on that medicine. Rebound headaches are difficult to treat until the individual completely stops taking that particular medication.
How do you select medications for preventive treatment?
First, some medications clearly have a good track record based on studies showing that they are effective fairly frequently. We then look at contraindications — that is, sometimes people are on other medications or have other medical conditions in which it would be very poor practice to select a particular medication. In addition, we might look for a medication that would have a therapeutic effect on another medical problem.
An example of that might be to use one of the beta blocking agents, the oldest of which is propranolol, in a person who has asthma. That could make the asthma much worse, so we would want to avoid it. On the other hand, if an individual had high blood pressure and needed to be on medication for that, we might select a beta blocker like propranolol to treat the blood pressure and to treat the migraine headache as well. We refer to that as a therapeutic opportunity. Obviously, the high blood pressure would need to be carefully monitored to be certain that this treatment was effective management for that problem.
In some cases, a number of preventive medicines could be considered, because the individual we are seeing isn't taking any other types of daily medications. In that instance, usually what I will do is review two or three preventive medications that I think would be particularly reasonable to consider. I would also discuss their side effects because I think, for a given individual, one particular side effect or a group of side effects might be less tolerated than another.
When preventive medication works, do occasional migraines still occur?
We seldom completely eliminate all migraine headaches. Certainly someone who is placed on preventive medication also needs to have an acute medication plan or acute rescue plan as well.
Do acute medications sometimes lose their effectiveness over time?
Sometimes acute medication works well for a time and then becomes less effective. In that circumstance, the options depend on the dose. If the person is not taking the maximum dose of the medication, we may just simply increase it. We may switch them to a different medication. There are seven triptan medications, and there isn't a universally best one for all individuals.
There is data, some comparative, for different triptans, but if you boil it down to one person at a time, it's difficult to predict which medication an individual will best respond to. We do find that if an individual isn't pleased with his or her response to one triptan, we may move on to another one with the hope that this will provide better results.
We also may change the route — for instance, go to a nasal spray, which might be sumatriptan or zolmitriptan, or to an injectable. The only injectable triptan is sumatriptan. So changing strategies in that way might be helpful. Or we may add in another medication, for instance the anti-nausea drug metoclopramide, which actually helps the stomach to empty during a migraine attack, thereby getting the medication out of the stomach and into the small intestine, where it can be more effectively absorbed. Or again, we may add a nonsteroidal anti-inflammatory medication, which has a different anti-pain mechanism, along with the triptan.
Things to consider about migraine treatment Emerging treatments for migraine
