Migraine: Managing Migraine Misery (cont.)

Diamond: We know that patients with more severe, harder to treat headaches, migraine specifically, get something called central sensitization. That means that the whole brain has become involved in the migraine process. These headaches are harder to break or stop and can last for days at a time. It is important for your doctor to plan an effective intervention to turn off your headaches as quickly as possible. There are many ways to approach this but there are other options to use to prevent this from happening. Sometimes adding a preventative medication may be helpful as well.

Member: I have started having sharp stabbing pains on the right side of my head for the last 24 hours and I called my doctor and he said not to worry, it was probably nothing. Could this have something to do with my migraines?

Diamond: Yes. Many migraine patients get "stab jab headaches." These are commonly seen in migraine patients, but if they persist and become more frequent you should see your doctor to be checked.

Member: What is the most effective treatment for menstrual migraines? Will migraines stop after menopause? If you take HRT after menopause, will migraines return?

Diamond: Seventy percent of women who suffer from migraine can predict that they will have at least some of their attacks around the menstrual cycle. These headaches respond, oftentimes, to traditional migraine therapies like triptans (for example, Imitrex). For patients with more difficult to manage migraine, combining a nonsteroidal anti-inflammatory drug with their triptans during the menstrual cycle may be helpful. For women taking oral contraceptives, taking continuous pill packs (skipping your placebo days and going to the next pack and having a period once every three to four months instead of every month) may be helpful. However, some women who have migraine can have them worsened by oral contraceptives. So it is important to keep track with your headache history diary (your calendar) to make sure this does not worsen your headaches. When women with menstrual migraine go through menopause, many of them will have remission of their headaches or will not have them as much or as severely. We used to tell women who had migraine never to use HRT; however, some of our patients tolerate it well and it is an individual choice given the controversy regarding its benefits. Again, this is a good time if you start hormones to keep track of your headache diary to make sure the medicine isn't making your migraines worse. It is important to remember that any change in characteristic of your headaches after the age of 50 should prompt a visit to the doctor for a good exam, to make sure nothing else is going on.

Member: I have never seen a migraine specialist for my allergy-related headaches. Would you recommend that I see one? I live in Chicago, not too far from your clinic.

Diamond: I think if you are having recurrent headaches that are impacting your ability to function, you should see somebody.

Member: Just curious, are you a migraine "survivor?"

Diamond: I am a survivor! And a treater. Good migraine therapy means the ability to live with your migraine, and this doesn't mean you have to suffer. We don't have cures right now, but there are excellent treatments available, and we know a lot more than we used to.

Member: Are there any migraine relief medications that are safe for a pregnant or nursing mother to take? I was given contradicting advice by my ob-gyn (take Midrin) and my internist (do not take Midrin).

Diamond: Many women who have migraines will do well during pregnancy. About one-third of patients will not have any headache at all. About a third will have a few (especially in first trimester, in week one through 14) and shortly after delivery. And a small percentage will get worse. When anticipating pregnancy or planning pregnancy, it's important to do all the natural things you can do to improve headache frequency.

Member: What are some effective treatment and prevention techniques for migraines that do not involve medication?

Diamond: Eating regularly, not skipping meals, regular exercise, good sleep hygiene are all important. In saying that, there are still some women who will need medications during pregnancy. Drugs are rated A, B, C, D, and X [for use in pregnancy]. With A being the safest, and X being really bad. There are very few A drugs. A few B drugs. Most drugs we use are listed as category C, which means they are not necessarily harmful, but we don't know for sure they are safe. The safest treatment for a woman with migraine who is pregnant would be Tylenol or Tylenol with codeine. If nausea is present, then a drug called Reglan is also very safe. If the headaches are very frequent, some preventative drugs are safe to use. Midrin is listed as a category C drug. Many moms and babies have been exposed to Midrin and there is not sufficient data to say it's a problem. But there is also not sufficient data to say it's not. In my own experience, it is not my favorite drug to use in pregnancy. There are certain drugs you should avoid when pregnant, including Depakote, Lithium, and Fiorinol.

If you have very frequent difficulty managing migraines and you feel you may need medication during pregnancy, it's important to talk to your ob-gyn and also a genetic pharmacologist. These are healthcare professionals who specialize in determining if there is sufficient data (enough data) to say if a drug is okay to use or not. Most university hospitals will have a genetic pharmacologist on staff in their obstetrics department, and a consultation can often be done by phone or through your primary care doctor.

Lactation (breast feeding) is a little bit easier. Because many of the medications we use don't stay in your system for long, and if your doctor tells you how long it will last in your system, you can pump your breasts and dump that milk, and then resume breastfeeding the next time. A drug like Imitrex, which isn't very concentrated in breast milk, is gone very quickly from the system. Other medications may last longer. Again, if this is an issue, talking to the genetic pharmacologist will be helpful.



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