The Dark Truth about Migraine Treatments

Meet Jane. Most days she is like any other 37-year-old professional woman. Busy with her career and 8-year-old, she is always running off to some important meeting or soccer game. Some days, however, she is a migraine sufferer. She is among the 17% of women who suffer from migraines each year 1.  She suffers the typical symptoms: severe throbbing headache, nausea and vomiting, intolerance to light and sound, and pain. These symptoms stop Jane from living her life for the 24 hours she is a migraine sufferer. These debilitating migraine symptoms affect a surprising number of Americans 2. How do they deal with it?

  According to a survey on CureTogether*, for 5,678 migraine sufferers, going to a dark and quiet room was the most popular treatment. Free, easy and effortless, it comes with no surprise that such a treatment won in popularity. Interestingly, the same group of migraine sufferers found it to be the most effective treatment, beating out popular over the counter drugs (ibuprofen and acetaminophen) as well as the more expensive prescription drug, Imitrex. With migraine sufferers making up 3 percent of the visits to the emergency department in the United States resulting in $11 billion in health care costs 3, can something so simple as a dark, quiet room bring this cost down?

Neurobiology 101: Neurons talk to each other using chemicals

Our brain is extremely complex. This complexity, while daunting, can be understood by thinking about the brain in terms of its parts. Our brain is made up of neurons. Neurons pick up sensory information (sight, hearing, touch, smell, taste) from our environment. This information travels to the brain and ultimately acts on muscles, blood vessels and glands to cause a reaction. When tapped on a shoulder, the reaction is to turn ones head. Neurons pick up the sensory information (tap) and translate it into an action (turn head). How does this information travel? Neurons talk to each other using chemical signals. When a neuron picks up sensory information, it becomes activated and releases chemicals. These chemicals act on nearby neuron to either activate or inactivate it. If the next neuron in line is not activated, communication is lost.

Teamwork: the neurons and blood vessels work together to cause migraines

There are two main players involved during a migraine attack. Neurons of the trigeminal nerve and blood vessels. The trigeminal nerve, one on each side of the face,  provides sensation to the face (eyes, nose and mouth). Messages communicated along the complex assembly line of neurons of the trigeminal nerve trigger the sensation of pain. This route of communication exists to protect us from dangerous sensory information-toxic smells, strong lights, spoiled food. When the trigeminal nerve continues to be activated, the pain persists. Blood vessels of the brain also become inflamed and expand. A migraine attack can result 4.

The expansion of the blood vessels in the brain was once thought to awaken the trigeminal nerve and cause pain. Now scientists believe that the primary event occurring during a migraine involves the nervous system (neurons) and not the vascular system (blood vessels) 5. The current thinking is that activated neurons of the trigeminal nerve release chemicals that may act on the blood vessels to cause them to expand and become inflamed 6. While the details are still not ironed out, it is becoming clear that both players contribute to the pain felt during migraines.

DNA and the environment

The DNA of the mother and father determines the potential that their child will develop migraines 7. That potential then dictates the threshold that needs to be reached to trigger a migraine attack. Those triggers come from the environment. Some of these include: stress, hormones, odor, not eating, weather, alcohol, smoke, lack of sleep, neck pain, food, heat, exercise 8. Some affect the nervous system directly through the sensory organs. For example, sensory neurons will pick up an odor in the air and communicate that information (bad smell) to the brain. Others act on the blood vessels. Alcohol consumption leads to dehydration and expansion of blood vessels. But not everyone develops a migraine in the presence of obnoxious odor or after a night of cocktails, even if their DNA says they should. A unique combination of DNA and environmental factors determines if  and when a person will experience migraines.

Seeking darkness

Sensory information often exacerbates migraine pain. Bright lights, bad smells, loud music, and strong flavors tend to make people feel worse during a migraine. As the pain gets more and more debilitating, the natural instinct is to escape to a dark, quiet room. Why does sensory deprivation reduce the pain during a migraine?  Scientists have found that light activates the trigeminal nerve that causes pain. If light activates the neurons that allow us to perceive pain, eliminating the light should reduce the pain. The scientists found exactly that. People who are blind do not experience more pain during a migraine when in the presence of light as do seeing people 9. But they still experience migraines. While the onset of migraines is still not fully understood, it is becoming more clear that reducing sensory information during a migraine helps manage that pain. This may be because during a migraine the pain pathway is even more sensitive and easy to excite than in the absence of a migraine. Reducing additional sensory information helps prevent the pain from escalating.

The migraine’s future

Migraines do not have to be debilitating. While medicine does not have a way to prevent them, they can be managed. Taking the time to learn about ones family history and paying attention to patterns will help identify ones sensitivity to certain environmental triggers. Migraines can be frightening experiences especially for those that experience them for the first time. It is no surprise that 3 percent of the visits to the emergency room come from migraine sufferers, driving health care costs up. All migraines are not created equal. And every migraine sufferer does not have the same threshold for pain. A trip to the emergency room during a migraine attack is sometimes necessary. Yet, that visit to the hospital is not always more productive than seeking quiet solitude in a dark room. Exposure to sensory information during migraines makes them worse. The time spent getting to and waiting in the emergency room is time during which the already activated pain pathway is being provoked. Limiting that exposure is an effective method for managing the pain. And eliminating unnecessary visits will bring health care costs down.

Educating oneself about migraines is the first step in managing them. A primary care appointment can provide sufferers with the tools to prevent future visits to the emergency room. Being prepared for these visits requires listening to ones body and identifying patterns of potential environmental triggers. Since not everyone experiences the same triggers it is difficult to predict migraines. Understanding ones lifestyle will also help in identifying the more effective treatment. Not everyone can interrupt their day and escape to a dark room during a migraine. The best-kept secret about migraines is that there are really good drugs that work. Imitrex, a popular and effective drug, narrows the expanded blood vessels in the brain. A lifestyle that cannot afford to spend a day in bed away from light and sound may benefit from Imitrex. But like any prescription drug, there are side effects and will not work for everyone.

The migraine sufferer’s to do list

1. Ask family members about experiencing migraines.

2. Keep a diary to track when the migraines occur. Note the weather, stress levels, specific foods eaten, alcohol consumed, stage of menstrual cycle (women).

3. Try spending time in a dark, quiet room during a migraine if possible.

4. Assess lifestyle and decide if taking medication may be a better option.

5. Discuss findings with your physician.

*= CureTogether=Looking for support from a community of fellow migraine sufferers? Consider checking out CureTogether and joining the discussion.

This post is checked by the following science articles:

(1): Stewart WF, Shechter A, Rasmussen BK. Migraine prevalence. A review of population-based studies. Neurology. 1994;44(6 Suppl 4):S17.

(2): Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States. Relation to age, income, race, and other sociodemographic factors. JAMA. 1992;267(1):64-9.

(3): Hawkins K, Wang S, Rupnow M. Direct cost burden among insured US employees with migraine. Headache. 2008;48(4):553-63.

(4): Goadsby PJ, Lipton RB, Ferrari MD. Migraine-Current Understanding and Treatment. N Engl J Med. 2002; 346(4):257.

(5): May A, Goadsby PJ. The Trigeminovascular System in Humans: Pathophysiologic Implications for Primary Headache Syndromes of the Neural Influences on the Cerebral Circulation. J Cereb Blood Flow Metab. 1999; 19:115-27.

(6): Goadsby PJ, Edvinsson L, Ekman R. Release of vasoactive peptides in the extracerebral circulation of humans and the cat during activation of the trigeminovascular system. Ann Neurol. 1988;23(2):193.

(7): Anttila V, Stefansson H, Kallela M et al., Genome-wide association study of migraine implicates a common susceptibility variant on 8q22.1.Nat Genet. 2010;42(10):869.

(8):Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia. 2007;27(5):394.

(9): Noseda R, Kainz V, Jakubowski M, Gooley J, Saper C, Digre K, Burstein R. A neural mechanism for exacerbation of headache by light. Nature neuroscience. 2010; 13(2):239.

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