Multifactoral Approach to Migraine
"One pill makes you smaller, one pill makes you larger, the pills mother gives you do nothing at all," observed the Cheshire-Cat. Over one hundred years ago, a fine art photographer took us on a wonderful journey through the eyes of Alice. The photographer-turned-writer drew from his personal experience with the disease he so suffered from, that of Migraine. His name was Lewis Carroll. And one may argue that if it were not for his constant Migraine attacks, he may not have been inspired to give us these gifts of fantasy by writing Alice's Adventures in Wonderland and Through the Looking-Glass and What Alice Found There.
Finally, advanced technology and the age of information have begun to give us the knowledge we need to understand this debilitating condition. Migraine disease is a serious health and disability problem that affects approximately 23-26 million Americans . There is no known cure for Migraine disease, only treatments for its symptoms. Furthermore, such treatments are not yet wholly effective. People with migraines may show a diminished tolerance to a variety of medications, treatments, and pain management regimens. Therefore, it is important for Migraine suffers to take a MULTIFACTORIAL approach to treating this illness.
Migraine can induce a host of serious physical conditions: strokes, aneurysms, permanent visual loss, severe dental problems, coma, and even death. Furthermore, Migraine can lead to ischemic stroke, and stroke can be aggravated by, or associated with, the development of Migraine. Twenty-seven percent of all strokes suffered by persons under the age of 45 are caused by Migraine, which is why seeking a Migraine medical specialist and exploring all the possible treatment options now available is the most prudent action a Migraineur can take today.
In the past, Migraine tended to be managed in a way that either prescribed drugs that helped prevent attacks OR prescribed drugs that treated pain during an attack, but not both. However, the best approach to Migraine management is what MAGNUM calls a MULTIFACTORIAL approach, which involves addressing all four aspects of Migraine health care: preventive treatment, trigger management, abortive treatment, and general pain management.
First, prophylactic, medications are prescribed to prevent or reduce the number of attacks in patients who experience frequent Migraines, typically two or more per month. In general, these medications act over time to prevent blood-vessel swelling; however, they do not treat the Migraine-associated symptoms and are non-selective. Many sufferers using preventive treatments will still have to take attack-aborting medications to relieve pain and other symptoms. Examples of conventional preventive therapy include: beta-blockers, antidepressants (for their effect on serotonin, not depression), calcium channel blockers, methysergide (potential serious side-effects), and Divalproex Sodium. Examples of non-pharmacological preventive therapy include: vitamin B2 and magnesium supplements, Tanacetum Parthenium (Feverfew Leaf), and Petasites Hybridus (Butterbur root)(For more information on Petasites Hybridus, refer to interview on page 46).
MANAGING MIGRAINE TRIGGERS
Second, trigger management is important in preventing Migraine attacks. Triggering factors can cause Migraine, and if recognized and/or avoided, impeding attacks may be aborted. Triggers vary from person to person. They include changes in weather or air-pressure, bright sunlight, glare, fluorescent lights, chemical fumes, menstrual cycles, untreated lactose intolerance, and certain foods such as processed meats, red wine (tyramine), beer, dried fish, broad beans, fermented cheeses, aspartame, and MSG. Addressing allergies is prudent. In addition, not confusing Migraine induced sinus pain with allergy triggering the actual Migraine attack is import to bear in mind. Migraine triggers DO NOT include lifestyle, stress, anxiety, worry, emotion, excitement, depression, and caffeine. Caffeine, which constricts blood vessels, is not a trigger, and, in fact, may help relieve mild Migraine pain caused by vasodilatation.
ABORTING MIGRAINE ATTACKS
Third, attack-aborting medications are used to relieve the severity and/or duration of Migraine and associated symptoms. In general, most attack-aborting medication should be taken as early as possible in an attack. Certain cerebral vasoconstrictor abortive agents are designed specifically for Migraine. They may be administered by subcutaneous, oral, rectal, or intramuscular means. These medications include ergotamine tartrate, dihydroergotamine, sumatriptan, naratriptan, rizatriptan, zolmitripan, electriptan, and isometheptene mucate. An excellent non-vasoconstrictive abortive agent is butorphanol tartrate offered in a patient-administered injection and now a nasal spray. In an ER (Emergency Room) environment, narcotic injections, usually taken with promenthazine or hydroxyzine for nausea, can offer a non-cerebral vasoconstrictive option if all the above fail or are contraindicated. An off-label use of lidocaine had had some recent success too. A non-drug abortive approach has been the use of 1g magnesium sulfate through a slow intravenous push during an acute migraine with 85% effectiveness.
Fourth and last, general pain management may include the prescription of narcotic analgesics which act on the central nervous system and alter the patient's perception of pain. These drugs generally relieve pain. However, because they are narcotic, they may be addictive, and such usage should be done in an appropriate manner to return a reasonable quality of life for the intractable Migraine sufferer. Non-steroidal anti-inflammatory drugs (NSAIDs) act by inhibiting blood vessel inflammation. These medications include naproxen, ibuprofen and ketorolac. Simple analgesics, available over-the-counter (OTC), are generally used for mild pain. They relieve pain by acting on peripheral pain receptors. (Some analgesics also have anti-inflammatory effects). Though readily available, they are generally not strong enough to relieve Migraine pain and overuse may cause rebound headaches. These medications include acetaminophen and aspirin, and include a newly-released medication, which is the same exact medication as extra strength version of said OTC drug, but with a new package and new name. Botox (Botulism toxin) is currently being investigated as an alternative treatment for long-term (three to six months) head pain.
We are far from a cure, let alone a sure-fire treatment, for Migraine. But understanding that Migraine is a real and debilitating disease goes a long way toward improving the quality of life for Migraineurs and their loved ones. Remember: Migraine is an "invisible" disorder. "Well! I've often seen a cat without a grin," thought Alice; "But a grin without a cat! It's the most curious thing I ever saw in all my life!" Like Alice's Cheshire-Cat who sat in a tree revealing himself only to Alice, he nonetheless had great impact on her daily travels, as Migraines do on individuals who suffer from them. For more Migraine information on Migraine, visit MAGNUM¹s web site at http://www.migraines.org, or ACHE¹s web site at http://www.achenet.org.
1 Smith, TB: Migraine Prevention Need No Longer Be a Headache. Hospital Medicine 34(10):13-14, 19-21, 25, 1998 2 Woods RP, Iacoboni M, Mazziotta JC: Brief Report: Bilateral Spreading Cerebral Hypoperfusion During Sponteous Migraine Headache. The New England Journal of Medicine 331(25): p. 1689-1692; 1994. 3 Gaby, A. & Wright, J. "Nutrition Update," AANP 10th Annual Convention, Snowmass, Colo., Oct. 11-15, 1995. 4 Facchinetti, F., et al. "Magnesium Prophylaxis of Menstrual Migraine: Effects on Intracellular Magnesium", Headache, 31: 298-301, 1991. 5 Grossman, W., Migraine Prophylaxis With a Phytopharmaceutical Remedy: The Results of a Randomized, Placedo-controlled, Double-blind Clinical Study With Petadolex, Der Freie Arzt, Nr3-05-05 1996. 6 Mauskop, A. "Intravenous Magnesium Sulfate Relieves Migraine Attacks in Patients with Low Serum Ionized Magnesium Levels: A Pilot Study," Clinical Science, 89: 633-636, 1995.
Michael John Coleman is the Founder and Executive Director of MAGNUM (Migraine Awareness Group: a National Understanding for Migraineurs), a non-profit health care organization. Coleman is a nationally recognized award winning artist, leader in alternative process photography. Coleman's artwork has been featured in national magazines, books, major exhibitions and events. He has suffered from intractable Migraines since the age of six, and has experienced the life-altering effects of the disease. MAGNUM's use of art and media in its Public Awareness efforts allows Coleman to focus full time on Migraine disease awareness advocacy, without abandoning his fine art career. Michael formerly served as an Art Director with Naval Sea Systems Command, was as a Head Coach of a woman's division national soccer team, was juried into the nation's oldest and largest art center, The Torpedo Factory, and served on the Board of directors of Washington D.C.'s Art League, Inc.
Terri Miller Burchfield is the Co-Founder and Legislative Director of MAGNUM, Inc., which is also known as The National Migraine Association. She obtained her Industrial Engineering degree from Stanford University and her MBA from Georgetown University. She currently works for the U.S. Congress for the Committee on Banking and Financial Services in the U.S. House of Representatives, specializing in the area of financial derivatives and working on other banking issues such as the Congressional Whitewater investigation.area of banking and finance. Terri formerly worked for the Pentagon (where she meet Coleman, an art director at the time) and subsequently for the investment banking firm of Goldman Sachs in its two-year analyst program on Wall Street.
© 1998 IJIM