The New York Times

Giving Migraine Treatments the Best Chance

If you’ve never had a migraine, I have two things to say to you: 1) You’re damn lucky. 2) You can’t begin to imagine how awful they are. I had migraines — three times a month, each lasting three days — starting from age 11 and finally ending at menopause. Although my migraines were not nearly as bad as those that afflict many other people, they took a toll on my work, family life and recreation. Atypically, they were not accompanied by nausea or neck pain, nor did I always have to retreat to a dark, soundless room and lie motionless until they abated. But Despite being the seventh leading cause of time spent disabled worldwide, migraine “has received relatively little attention as a major public health issue,” Dr. Andrew Charles, a California neurologist, wrote recently in The New England Journal of Medicine. It can begin in childhood, becoming more common in adolescence and peaking in prevalence at ages 35 to 39. It afflicts two to three times more women than men, and one woman in 25 has chronic migraines on more than 15 days a month. But while the focus has long been on head pain, migraines are not just pains in the head. They are a body-wide disorder that recent research has shown results from “an abnormal state of the nervous system involving multiple parts of the brain,” said Charles, of the UCLA Goldberg Migraine Program at the David Geffen School of Medicine in Los Angeles. He told me he hoped the journal article would educate practicing physicians, who learn little about migraines in medical school. Before it was possible to study brain function through a functional MRI or PET scan, migraines were thought to be caused by swollen, throbbing blood vessels in the scalp, usually — though not always — affecting one side of the head. This classic migraine symptom prompted the use of medications that narrow blood vessels, drugs that help only some patients and are not safe for people with underlying heart disease. Furthermore, traditional remedies help only a minority of sufferers. They range from over-the-counter acetaminophen and NSAIDs like ibuprofen and naproxen to prescribed triptans like Imitrex, inappropriately prescribed opioids, and ergots used as a nasal spray. All have side effects that limit how much can be used and how often. Neurologists who specialize in migraine research and treatment (“there are not nearly enough of them, given how common the affliction is,” Charles said) now approach migraine as a brain-based disorder, with symptoms and signs that can start a day or more before the onset of head pain and persist for hours or days after the pain subsides. Based on the new understanding, there are now potent and less disruptive treatments already available or awaiting approval, though cost will certainly limit their usefulness. To be most effective, the new therapies may require patients to recognize and respond to the warning signs of a migraine in its prodromal phase — when symptoms like yawning, irritability, fatigue, food cravings and sensitivity to light and sound occur a day or two before the headache. Even with current remedies, people typically wait until they have a full-blown headache to start treatment, which limits its effectiveness, Charles said. His advice to patients: Learn to recognize your early, or prodromal, symptoms signaling the onset of an attack and start treatment right away before the pain sets in. “It’s possible that a lot of therapies might be effective, including meditative breathing and relaxation techniques, that don’t help once the train is out of the station,” he said.

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