Generally, the lay person thinks of a migraine as a very severe headache. So, when they get a “bad” headache, they usually refer to it as a “migraine”, but this is not the case at all. There are many types of headaches which are severe enough to ruin one’s day.It wasn’t until the 20th century that the specialty of neurology was born and a way to evaluate headaches scientifically was put into place.
We run around dehydrated, drinking coffee, stare at LCD screens, and on top of that, process more information in a day than our great grandparents did in their lifetime. That’s right! No wonder we run around stressed out. Most of us manifest our stress physically, usually as headaches. In America, particularly, two types of headaches are seen in this regard, muscle tension, and migraine types. Here’s “the quick and dirty” on both.
Muscle tension headaches tend to come on as the day progresses, while the stressors one is dealing with are ongoing and building. So by the end of the day, your headache progressively worsens, your neck and scalp muscles increase their tone and now you have a full blown “knocker” at the end of the day. Migraines on the other hand are vascular in nature, brought on by chemical changes reacting to stress and dietary triggers. You awaken with the headache as they come on after the stress is gone. The following day, after the stressful event is over, you’re in pain. It is the classic euphoric phase of “the general alarm reaction to stress”. So you wake up with a “banger” which is hugely painful and stays with you all day. This is also why a migraineur (pronounced, “mi-gren-urr”) tends to have his headache on Saturday mornings, or say, the day after that big speech.
A test I have many patients, as well as friends and family try, is the “Beer Test”. It’s not one hundred percent, but if you want to know if that headache you’ve had all day is a migraine or tension headache, when you get home, drink a beer. If the headache goes away, it’s a tension headache, if it gets worse, it’s a migraine.
Tension headaches are a direct result of stress insult, like someone turning up the volume on your neck muscles throughout the day. This type of headache is obviously exacerbated by posture, compensatory gait changes, arthritis, chronic musculoskeletal conditions, and of course stress load, and the amount of rest a person gets.
Migrainers suffer because the headache waits, then sneaks up on them when they’re resting. The other thing to remember is that in all these headache types, physical examination, metabolic workups, and imaging, are always negative for “lesion” or organic pathology. “Migraine”, is a diagnosis of exclusion.
“Migraine”, is a very old term derived from the Greek, meaning “semi-cranium” or “half skull”. Yes, a migraine headache is usually, but not always, unilateral, affecting one side of the head. The problem is they come in so many different manifestations. After World War II, neurologists in America started to find consistencies which allowed us an ability to observe, diagnose, and treat with a standard of care. It also allowed doctors to communicate the type of headache a patient was experiencing.
This classification remained in place for nearly sixty years, but in 1995, The National Headache Foundation along with The American Academy of Neurology, published guidelines that have allowed all physicians to more easily navigate the presentation of headache patients, diagnosis them accurately, and treat them appropriately and effectively. The “traditional classification” which is still used by many older doctors, uses excellent descriptors and relies on 5 major presentations, and thus, the patient is labeled as such. They are: Classical Migraine; Common Migraine; Complex Migraine; Mixed Headache; and Migraine Equivalent (also known as Retinal Migraine). I don’t need to remind you that there are many variations on each one of these.
Classical Migraines are the brittle ones you hear about, and the type that causes a great many to present to the emergency department of their local hospital. Here’s a typical presentation. Usually a woman, as 75% of migraineurs are women, she awoke with a one sided throbbing headache that wouldn’t respond to any medication. It started with a visual aura of sparkles in the upper left visual field (what we in medicine call a stratified visual scotoma). She can’t stand to have any light in the room, noises make the pain worse, and she’s nauseous and vomiting, in addition, just moving around makes it much worse. The patient generally requires narcotic pain management and neurovascular control with a triptan drug (see below). It is this sufferer, who insurance statistical experts and The U.S. Department of Labor have stated, “costs our nation nearly 95 billion dollars in lost man hours a year! That’s not including the tab to her health insurance company, or if she’s on Medicaid, your tax dollars. Wow!
Common Migraines, are much less intense and disabling, they still throb, are usually one sided, the patient can have nausea, but generally no vomiting. The lights and sounds are still bothersome but not as overwhelming. Most apparent in their history, is no aura or scotoma. These are self limited, usually responding to aspirin, Tylenol and caffeine in combination, and of course, rest.
Complex Migraines can be terrifying. Also referred to as Hemiplegic Migraines, they will generally have features of either a classical or common type, but in addition, present with neurologic deficit. Many are mistaken for Cerebral Vascular Accidents (stroke), or Transient Ischemic Attack, and require hospital observation and treatment. Ancillary studies are usually negative, and the event resolves spontaneously. Obviously, this patient requires an exhaustive evaluation before being given this diagnosis.
Mixed Type is just that. Usually a common migraine with muscle tension overlay or muscle tension headache with migraine overlay. Again, aspirin, Tylenol, and caffeine are helpful; also mild muscle relaxants are effective. Usually if one component is treated, the other falls away.
Migraine Equivalent types are very interesting. Generally seen in college aged “type A” personalities, their hallmark is the scintillating visual scotoma, but there is no pain. That’s right! There is no headache. These patients are obviously afraid they have something serious when they first see their doctors, but after a negative work up and reassurance they do fine. Also interesting is the phenomenon of “dissipation with this migraine. The scotoma starts generally as a “dot”, slowly enlarges, becomes a crescent with a large visual field cut known as a superior quadrantanopsia, (say that 3 times, real fast), sweeps laterally, then vanishes. These types of migraines usually resolve as a condition by the time the individual reaches their thirties.
The newer guidelines have made diagnosis more accurate and streamlined for therapy using two sets: “Migraine with Aura”, and “Migraine without Aura”. Both have their specific subsets, criteria, and recommended therapies.
What we know about migraines now, started in the 1980s, subsequently producing new knowledge and new therapies. When Sumatriptan hit the shelves as migraine weaponry in 1991, much changed in the approach to headaches, including migraine classing. Since its introduction, our understanding of the migraineur’s display of symptoms has been revolutionary, and produced a paradigm shift in treatment. We now know that the “migraine” is actually a cascade of events.
We always knew that there was an underlying driver and that migraines were vascular, hence, the pre-triptan therapies, which were designed to do two things, lyse an acute headache and get the patient to sleep. The other, was to approach chronically, preventing the migraine from evolving. We assumed that they were vascular from the beginning of migraine research history, because they generally throb and respond in kind to vasoconstricting agents. Subsequent research revealed that they occurred in 2 phases. First the blood vessels of the brain would constrict during stress or dietary trigger attack. Then, rather than come back to their original caliber, the vessels would overshoot, engorge, ultimately causing the painful phase.
Our older therapies were designed to keep the constricting phase from manifesting, and therefore, no overshoot and no pain. This is why we continue to see migraineurs treated with blood pressure lowering medications like verapamil and propranolol, which prevent tightening of vessels. In addition to these agents, antidepressants like amitriptyline are added which help control chronic pain. For many patients these drugs work. That’s why they are still used in many who suffer severe and ongoing disabling attacks.
Sumatriptan lead to more compounds in the “triptan class”, which are the mainstay of therapy today, because the research which produced these drugs revealed that deep inside the brain of a migraineur is a “migraine motor”. It is tied to an area in the midbrain called the Trigeminal Nucleus Caudalis. When stimulated by stress loads, sleep changes, medications, or food triggers, it sends pain signals along the Trigeminal Nerve (The Fifth Cranial Nerve), and the vascular bed which surrounds it.
The two Trigeminal Nerves (left and right) are sensory nerves innervating the scalp, forehead, face and periosteal bone of the skull. When the migraine motor is stimulated, blood vessels along the nerves are irritated, inflamed, and dilate, causing severe pain. Sumatriptan counters this directly. Similar to serotonin (5HT), and a 5-HT_agonist, the specific receptor subtypes it activates are present on the cranial arteries and veins. Acting as an agonist at these receptors, sumatriptan reduces the vascular inflammation and dilatation associated with migraine at its source. Even in a disabling attack, sumatriptan injection can lyse the pain of migraine within minutes, without the side effects and sedation of narcotics and anti-emetics.
You’ve probably been asking yourselves, what are these food triggers? Migraine triggers are all over the web. A good place to start for a thorough list is at The National Headache Foundation website: www.headaches.org.
The real mechanism of migraine motor stimulation is not fully understood, but may involve several neurotransmitters, hormones, and different food antigens. However, the triggers are well known and they themselves give us a clue.
Certainly there are known direct vasodilator foods such as Monosodium Glutamate (MSG), caffeine, kava based, and ephedra based herbs, and chocolate. Of course MSG is in all of our salted snacks and most of our “prepared” foods in the freezer section. Not surprisingly, many of my migraine patients when asked to keep a food diary, find they consumed large amounts of MSG the night before an attack, usually a potato chip, Doritos, or Frito binge. Citrus such as orange juice; wine, particularly the reds; hard aged cheeses; meats cured in nitrates; pickles; peanuts; and mint, to name only a few, are well known culprits.
The non-food triggers are classic: too much or not enough sleep; the computer screen you’re looking at right now; stressful life styles; drugs of all kinds; and lastly, medicinal hormones such as progesterone, yeah, your birth control pills. This is one of the reasons why women are more prone to migraine.
Because headaches are so prevalent, they can become a huge topic in conversation with any doctor. Perhaps one needs to write a book on the subject to produce a concise literary treatment which the chronic headache sufferer can utilize. Or should I say, “Another book”. That’s right. There have been many, written by doctors and non-doctors alike. Hopefully this article will help you choose the right one. In the mean time, watch those foods, try some way to lower your stress, don’t forget to drink plenty of water, and if you are a true migraineur, or a chronic headache sufferer, you should see your doctor right away and don’t forget to check out The National Headache Foundation.
Dr. Counce
Author Resource:-
Dr. Charles Counce is a professor of Human Anatomy and Physiology, as well as Cardiopulmonary Medicine, Molecular Biology, Clinical Biochemistry, and Hematology. In addition, he teaches American History.
Dr. Counce's blog, "The Searchlight Messenger", can be seen and commented on at http://www.venture17.com
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