Microsoft word - against the migraine

Against the Migraine
The Sunday Washington Times Journals Newspapers, Sunday, March 7, 1999
By Susanne Lazanov
Patients battle disease

Thirty years. Three decades. That is about how long Ellen Blau has suffered fromheadaches.
Blau, now 46 and support group coordinator for the National Headache Foundation,recalls being 16 when the headaches began.
"At first they were only a nuisance that coincided with my menstrual periods," shesaid. "But by the time I was in my twenties they had become debilitating." Like many other migraine sufferers, Blau consulted a host of physicians in hersearch for pain relief. She tried the various medications they prescribed and foundmos When she became pregnant at age 25, the headaches stopped completely. But theyreturned, with a vengeance, after the birth of her son, Jason.
According to MAGNUM, a migraine awareness group based in Alexandria,approximately 65 percent of female migraine suffers complain of headaches before,during, or immediately after their menstrual periods, while more than three-quartersof migraines reported a complete eradication of headaches during pregnancy.
By the time Blau was in her thirties, she was so sick that she would spend abouthalf of every week in bed suffering from migraine pain. But she had a young childto take care of.
"I would set my alarm clock for 3 p.m. each day. Get up and get dressed beforeJason came home from school," she said recalling that low point in her life. "Iwould pretend to be OK and spend time with him, but as soon as he went off to dohis homework I would crawl back into bed." The day that Blau decided she could either die or get better was a turning point inher life. She spent two weeks as a hospital in-patient learning biofeedback andrelaxation techniques and starting on an MAO-inhibitor, an anti-depressant she callsa drug of last resort.
"Certain foods and medications taken in conjunction with this drug can make yourbl the drug for seven months its effectiveness waned. Blau says that at that point shechanged her attitude and decided not to be sick any more.
She began using the biofeedback and relaxation techniques she had learned, but hadnever put into consistent practice. And she looked for a drug regimen that she couldlive with long term.
For the past ten years, a combination of drugs including an anti-depressant, an anti-inflammatory, and a muscle relaxant combined with psychotherapy and lifestylechanges has reduced her number of attacks to a manageable two to three a month.
When she does get a headache she also takes Imitrex, a drug approved in 1993specifically to treat migraine.
Blau also has carefully identified the triggers that often bring on migraine. "But theillness is a puzzle for migraineurs because some days we can eat a specific triggerfood and not get a headache. So we tend to cheat, especially if it involves eating afavorite food like chocolate. Then the next time we eat the food we get a headache.
Or we get a headache in the absence of any triggers at all," she said frustrationfilling her voice.
importance of paying strict attention to triggers. "Uncontrollable triggers include weather patterns and menstrual cycles, while controllable triggers include brightlight, aspartame (the ingredient in some artificial sweeteners), and alcohol. Theseverity and frequency of migraines for one person depends upon how manytriggers that individual must experience before a migraine is induced, and thecombination is different for each person," he said.
Far Reaching Effects
Migraine is an illness that is devastating. And it extends far beyond the individualsuffers.
person may be afraid to socialize, travel, take vacations," Blau said. [Migrainesuffers] suffer from a lot of anxiety and panic, and their partners may be sick of thewhole situation." Coleman, a migraineur since age six, knows firsthand about that aspect of thedisease.
In the early 80s he was married to a nurse he describes as loving and verysupportive. "But the illness wore her down, and the lack of compassion of herf pain. And that I was faking the pain to get attention tore us apart," he said. "My in-laws used to sa up his job as an art director with the US Navy, a position he had held for six years.
The Now he devotes himself to informing migraineurs and the general public about themyths and reality, the treatment and management of migraine. "We are far from acure let alone a sure-fire treatment for migraine," he said. "But understanding thatmigraine is a real and debilitating disease goes a long way toward improving thequality of life for migraines and their loved ones." Unlike migraineurs like Coleman who see the condition purely as a neurologicaldi experience, combined with the history of other migraineurs, has convinced her thatsome past traumatic event prevents certain suffers from rising above their illness.
"The average person has 50 percent control over his or her headache.
Alternative treatments
Blau firmly believes in support groups and lifestyle changes as adjunct therapies to the medical management of migraine pain.
"People need to learn that they are not alone, and that there is hope," she said. "Andbiofeedback and relaxation techniques are incredible tools for headache sufferers, ifpe veto convince David Barwell that biofeedback plays an important role in treating migraine. The Gaithersburg, Md. man has taught these self-monitoringtechniques to more than 2,000 headache sufferers over the past 22 years.
history to determine if underlying conditions require medical attention he uses physical models to explain how reactions to stress - suchas jaw clenching and teeth grinding - upset the trigeminal nerve and lead toheadache. According to Barwell this nerve goes through the jaw to the frontalsinuses, eyes, forehead and shoulder.
"People have different symptoms with their headaches depending on which branchof the nerve is upset," he said. "But most people are aware that they have headachesat time of tension.
Barwell uses surface electrode to measure muscle tension in the forehead. Hisclients wear earphones that emit clicking noises in proportion to the tensionregistered. While a frown may measure a "90" and result in a rapid set of clicks,relaxing that frown may read "50" and be accompanied by a much slower series ofsounds.
"I teach them to relax certain body parts and do breathing exercises. Then I canmeasure and prove objectively that they are relaxing. The feedback is in their ears,"he said.
Barwell says patients can get results after only six one-hour sessions if they aresufficiently motivated to practice for an hour every day and eliminate habits such aschewing gum and using the shoulder to cradle the phone receiver.
Maureen Lyon, an Alexandria, Va.- based psychologist who works with patients onstress management and pain control, says the relationship between psychologicalfactors and migraine pain has not been proven by research. "But hypnoanalgesia, amethod of using a relaxed hypnotic state to manage pain, is a well-supportedapproach," she said.
When migraineurs use self-hypnosis they still have the same amount of pain,measurable for example by rising blood pressure, but they experience it as beingoutside of themselves and so find it more tolerable.
Lyon also teaches highly suggestible migraineurs other techniques that are designedto give them more control over their condition. "Using visualization people learn to focus on the pain and visualize it getting bigger and then smaller," she said. "Orthey can phone someone with whom they have a particularly satisfying relationshipand use the distraction to help put the pain in the background.
"Seeing a physician first is essential for any migraine sufferer says Lyon, who seesher treatment as an adjunct to medical therapy. "It is important that migraineursunde optimum quality of life under the circumstances," she said.
Other alternative treatments for migraine include acupuncture, which is believed toremove obstructions to the flow of energy, daily doses of Vitamin B2, a possiblepreventative, and feverfew, a herb that may reduce inflammation and give relieffrom nausea and vomiting.
Diagnosis and treatment
Doctors used to think that migraine pain resulted from a widening of the bloodvessels in the membrane surrounding the brain. They also believed that "aura",which may consist of flashing lights, blind spots, slurred speech, or numbness onone side of the body that warns about 10 percent of migraineurs of an impendingattack was caused by reduced blood flow during an initial narrowing of thesevessels.
Unfortunately doctors, who through misinformation tended to always connectmigraine with aura, often failed to recognize migraine in the overwhelmingma "During the aura phase there is a reduction of blood flow, but what initiates that arechemical changes," said Stuart Stark, M.D., an Alexandria-based neurologist with aspecial interest in treating headache sufferers. "But the most common type ofmigraine is migraine without aura, occurring in about 85 percent of migrainuers." Stark also says that about 5 percent of migraine suffers experience only visualsymptoms such as seeing bright, intense lights or sparkles instead of havingheadache pain. And in children and adolescents, vertigo (dizziness) with or withoutnausea is the most common migraine symptom.
Current migraine research indicates that a signal from the brain stimulates the painsensors in the trigeminal nerve system, which runs from near the center of the skullup and over the eyes, and toward the forehead. Certain protein fragments releasedby these pain sensors cause the blood vessels to widen and further irritate the nervesthat control pain, vision, and nausea.
"The symptoms of migraine are felt to be due to an abnormal sensitivity of the brainin response to various triggers," Stark said. "And there is ample evidence thatgenetic factors are important because the vast majority of migraine suffers can identify a first-born relative with similar headaches." The discovery that serotonin, a multi-purpose chemical normally found in the brain,can stop migraine pain by binding to receptors on the trigeminal nerve, 5HT, hasled researchers to develop a new class of drugs called triptans. Triptans are referredto as "abortives," meaning their purpose is to reduce the severity and duration of themigraine symptoms when taken at the first sign of an impending attack.
Sumatriptan, available as Imitrex since 1993, is a selective triptan, meaning itactivates the helpful effects of serotonin while blocking the less desirable ones suchas nausea. Once available only orally or by injection it is now also marketed as anasal spray, insuring rapid delivery to the brain. "Because nausea and vomiting arecharacteristic of many migraine attacks, the nasal spray provides a treatment optionin which the drug is directly absorbed through mucous membrane of the nose, thusbypassing the stomach," said Seymour Diamond, M.D., director of the DiamondHeadache Clinic in Chicago.
According to Diamond DHE, a drug that has been available for decades to haltmigraine attacks, was approved in a new nasal spray form in 1997 under the nameMigranal. In clinical trials it provided relief for up to 70 percent of patients withinfour hours of a single dose, and it remained effective in most patients for 24 hours.
Other drugs to receive recent FDA approval are zolmitriptan (Zomig and Zeneca)and naratriptan (Amerge). These drugs tend to work quickly and provide long relief,a boon for migraine sufferers.
and frequency of migraines interferes significantly with their quality of life maybenefit from preventive drug therapy.
"But we want to avoid preventatives because of their potentially harmful sideeffects," he said, "and we aim to get people off them after six months." Doctors prescribe general pain management using prescription and non-prescriptiona overuse of these drugs can lead to "rebound headaches," adding further pain andsuffering.
In the US alone about 25 million people suffer from migraine. According toMAGNUM, the cost to industry and the health care system due to migraine isthought to be as high as $17 billion a year. And even though most migrainesufferers attempt to continue working through pain that often is incapacitating,many of them find their productivity and income fall over time.
"One of the latest studies on the economic cost of migraine found that theunemployment rate in individuals with severe migraine is 10 to 20 percent, several times that of the general population," Coleman said.
Migraine and medicine
Coleman says that migraine is the top misdiagnosed disease partly because doctorswho were in medical school before 1994 received inaccurate and inappropriatei disabling to the sufferer as the disease itself.
"Many emergency rooms have been known to treat migraneurs poorly, makingt According to neurologist Stark, because blood vessels are involved in migrainepeople can suffer a stroke from the condition.
"Women with migraine with aura are more likely to have a stroke if they are usingbirth control pills and have other risk factors such as smoking," he said. "Butmigraine without other risk factors is itself a low risk factor." The reason many migraine sufferers fail to get a proper diagnosis and treatment is afactor of time Stark says. "With managed care and the state of health care ingeneral, doctors have to see more patients, but the evaluation of a complaint ofheadache requires a lot of time. Many doctors may not take the time to get all theinformation they need and so the patient is treated symptomatically. Also, so muchinformation has changed in the past two decades that the treatment of people withheadaches has been revolutionized. Keeping up with the changes is a specialty inand of itself." Stark also says that a lot of migraine sufferers also have other conditions such aschronic sleep disorder, depression, or obsessive-compulsive disorder, and doctorsneed to unlock their whole history.
"Primary physicians such as general practitioners and even general neurologistsa Migraine and women
of adult migraine sufferers are men (the numbers are roughly equal in childhood)and because migraine can be triggered by hormonal changes that are unique towomen. Some women migraineurs, whose headaches abated or disappeared duringpregnancy, report being told by doctors to keep on having children. Countless otherwomen were subjected to needless hysterectomies as a "cure." into migraine causes and treatments. "With women assuming larger numbers ofmajor roles in the business world it was noticed when they were sidelined withmigraine pain," Coleman said. "When they miss two to three days a month becauseof The flip side of this is that both men and women face discrimination in theworkplace when it becomes known that they have migraine. Migraineurs are oftentold they cannot do a particular job because it is stressful and stress causesmigraine.
migraine and to overcome the myth that migraineurs are unable to handle stress.
The group is also working with Sen. Charles Robb (D-Va.) to get intractablemigraine included in the Code of Federal Regulations Listing of Impairments, PartsA & B, as a neurological impairment similar to epilepsy.
While many people use the term migraine to describe a really bad headache,Coleman says the terms are not interchangeable. "Headache is a symptom, butmigraine is a disease," he said emphatically. "It is disease with a complex naturethat is highly adaptive and unique to the individual who suffers from it." of migraine. "The migraine disorder has seven sub-categories, and no two patientshave exactly the same symptoms," he said. But ending on an optimistic note Starkadded, "Nowadays there are lots of things like medication, dietary changes, andbiofeedback that patients can try and control their lifestyle and reduce their triggersfor migraine."


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