Not Your Usual Headache (cont.)

Professional and Personal Costs

Even normal physical activity tends to intensify the pain of migraine. "Migraines are unlike tension headaches in that they often interfere with people's activities to the extent of forcing them to stop what they're doing and lie down," says Randy Levin, M.D., a medical officer in the Food and Drug Administration's division of neuropharmacological drug products. Only 8 percent of migraine sufferers report that the headaches don't significantly interfere with their ability to function, says Fred Sheftell, M.D., the founder and director of the New England Center for Headache.

"A migraine is a hell of an enemy," Coleman says, "and you don't know when your next one's going to come. But you still have to pay the bills. You can be in an incredible amount of pain and put on a happy face, and then when people leave the room, you literally fall on the floor."

Coleman fears generalizations arising from the "Super Bowl migraine." Davis didn't win the Super Bowl with a migraine, he points out, but rather was lucky enough to have a relatively mild migraine that responded to early treatment and allowed him to play to his potential.

Coleman says that his own migraines interfered with every aspect of his life. As his migraines grew worse in the early- to mid-1980s, he gave up his job as an art director with the U.S. Navy, which he'd held for six years. He opened his own art studio, thinking that the hours would be more flexible. But he lost his studio, too, which he calls his "life's work," because he was unable to work enough hours each week.

And Coleman says his migraines also took their toll on his personal life, leading to a break-up of his seven-year marriage. Coleman's wife, a nurse, was "very supportive," he says, "but it wore her down."

Modern Medicine

The over-the-counter and prescription medications that are used to treat migraine pain fall into two general categories: those for use during an attack and those that help prevent attacks. A sufferer may need to take different medications to address distinct symptoms. For example, some drugs can help relieve the nausea and vomiting, while others may ease the head pain.

"It's important to have as many drug options as possible for migraine," says FDA's Levin, "because different people respond differently to medications, and what works for one patient may not help the next."

An over-the-counter drug may help some migraine sufferers with mild to moderate pain. In January 1998, a version of extra-strength Excedrin called "Excedrin Migraine" became the first over-the-counter medicine specifically approved by FDA for migraine.

People who want to use an over-the-counter migraine medication should see their doctor anyway, Levin says, to rule out more serious conditions.

For many years, Coleman struggled with his pain without professional medical help, treating himself with over-the-counter drugs. But as he kept upping the dosage in search of relief, he noticed his headaches were getting worse instead of better.

Like Coleman, many patients who take headache medicine more than a couple of days a week experience "rebound headaches," where the pain reappears as each dose of medicine wears off, leading patients to take even more medicine.

Coleman now treats his migraines with prescription drugs, including sumatriptan (Imitrex), a popular migraine drug since its approval by FDA in 1993. "It's night and day," Coleman says of his pain before and after Imitrex.

Other prescription drugs approved specifically for migraine include ergotamine tartrate (Cafergot, Wigraine, Ergostat), isometheptene mucate combinations (Midrin, Isocom), and dihydroergotamine (DHE-45). Some of the newest anti-migraine medicines are zolmitriptan (Zomig), naratriptan (Amerge), and a nasal spray form of dihydroergotamine (Migranol), which was reportedly used by Davis during the Super Bowl. At press time, companies were developing additional anti-migraine drugs.

Drugs to prevent migraine are sometimes recommended for those whose migraines are especially frequent or debilitating. Two of the many drugs that are tried for migraine prevention are approved by FDA for this use: Inderal (propranolol) and Depakote (divalproex sodium).

While a medical professional can help a patient choose the right treatment for his or her particular symptoms, patients themselves also play a critical role in controlling pain by observing what triggers their migraines and avoiding those things when possible.

Individual Triggers

Many scientists think migraine is a vascular disorder caused by a tightening (constriction) and sudden opening (dilation) of the blood vessels in the head, neck or scalp.

Others believe that the throbbing pain of migraine is caused by an abnormal release of neurochemicals in the brain, such as serotonin or noradrenaline.

Migraine sufferers may be born with a hypersensitive nervous system that makes them prone to the headaches. Then, a lifestyle or environmental "trigger," such as a hormonal change or a certain food or chemical, can provoke an attack.

A simple change in lifestyle to avoid personal triggers may minimize the frequency of migraines in some patients.

Potential dietary triggers include:

alcoholic drinks (especially red wine)
foods containing a chemical called "tyramine" (for example, aged cheeses, sour cream, and yogurt)
chocolate
dairy products
foods with additives such as nitrites, MSG, or aspartame.
A change in caffeine intake, either up or down, can also trigger migraine.
Other lifestyle factors, such as change in sleep habits and even overuse of headache medicines, may sometimes provoke migraines, as can environmental factors, such as:

change in weather (often the approach of a low-pressure weather front) or temperature
high altitudes
bright or fluorescent lights or sunlight
loud noises
strong odors.
The role of hormones in provoking migraine helps explain why three times as many women as men suffer from this type of headache. "Hormones seem to play the most important role in this women-men differential," Sheftell says. Because of the impact of hormones, women who are pregnant, using birth control pills, or going through menopause often experience an increase or decrease in the frequency of headaches.
Migraines can also be triggered by emotional factors, including not only negative feelings like frustration, anxiety or depression, but also by relaxation and positive feelings such as excitement. "Someone can go through a very stressful time--no headache--and then the weekend or holiday comes and they can finally relax, and the headache comes on," Levin says.

For Coleman, weather is a key trigger. But things that trigger migraine in one person might not affect another, even someone else in the same family. For this reason, experts say that keeping a personal "headache diary" may help in determining the best treatment approach. The diary should include characteristics of each attack, including triggers as well as the date and length of the attack, preheadache symptoms, level of pain (on a scale of 1 to 4, for example), sensitivities during the headache, medicine taken within 48 hours before the attack started, and other observations.

Stress as Aggravator

The fact that stress can play a role in migraine, experts say, doesn't mean that migraine is a psychological disorder. "Does stress or worry ever provoke a headache? Of course," says Neil Raskin, M.D., a neurologist at the University of California at San Francisco. "But it's simplistic to think that someone is having a headache solely because of stress. That would be extraordinarily unusual."

The role of psychological stress on migraines, Sheftell explains, is like the role of psychological factors on epilepsy, asthma, hypertension, and heart disease. "Stress is not the cause of migraines, but psychological issues can worsen migraines as they can these other medical conditions."

Like someone with high blood pressure or heart disease, people with migraines should maintain a healthy lifestyle, including regular sleep patterns, a healthy diet, and exercise. Beyond those traditional healthy habits, some people report benefiting from behavioral treatments even though these have not been scientifically proven effective. These treatments include relaxation therapy, yoga, or biofeedback, which teaches people to reduce their muscle tension.

Despite the biological cause of migraine, Coleman says the myth persists that the pain is imagined or rooted in a psychological problem. "My in-laws used to say, 'Michael, are you still pretending to have those little headaches to get attention?'"

Many doctors, too, lack knowledge about migraines, which Sheftell says may account at least in part for the high rate of undiagnosed migraine cases--an estimated 60 percent of women sufferers and 70 percent of men.

Sheftell recommends forming a partnership with your health-care professional to ensure the most effective treatment. Seek a knowledgeable and interested doctor who will work with you, he says, and get information yourself from headache organizations.

"There's a great deal more that can be done for migraine today than 20 years ago," Sheftell says. "Don't accept 'You have to live with it.'"