Managing Migraine Misery: Merle Diamond, MD

By Merle Diamond
WebMD Live Events Transcript

Migraine sufferers -- the doctor is in! In recognition of National Headache Awareness Week, join us for migraine prevention and treatment tips from Merle Diamond, MD, associate director of the Diamond Headache Clinic.

The opinions expressed in this transcript are those of the health professional and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician.

Moderator: Hello, Dr. Diamond and welcome to WebMD Live. We have so many questions from our members, let's get right to them.

Member: I have been having headaches for a few months now. How can I learn if they are migraines?

Diamond: The question is how can you diagnose migraines or self diagnose. Migraine is typically a sick headache. It's associated with:

  • Nausea
  • Occasional vomiting
  • Light and noise sensitivity
  • The pain is usually throbbing
  • Sometimes it's one-sided
  • It typically lasts four to 24 hours
  • The patient is usually pain-free between episodes

Member: Is it possible for another type of headache, such as a sinus headache, to "turn into" a migraine?

Diamond: That's a great question. Many people believe that their sinus headaches are migraines. And many people with migraines believe they have sinus headaches because they get the pain when the barometric pressure changes and these symptoms are often seen with a runny nose or pressure in the face. This can be confusing for patients as well as doctors. So what many people call sinus headache may actually be migraine. The nerve that's involved in migraine also has branches that go to the sinuses. So it is likely that migraine in the face is often called sinus headache.

Member: Even though I stay away from chocolate, cheese, and alcohol I still have such pain. Just days ago I had to go the emergency room because it hurt so bad! How do I recognize the oncoming symptoms before the migraine begins? Once I took Imitrex too soon -- I didn't know it would turn out to be just a regular headache, and I was nauseous all day.

Diamond: Some patients, almost 60% who have migraine, have something called prodrome. These premonitions of migraine can be yawning, carbohydrate craving, light sensitivity, neck pain, irritability, and lethargy (tiredness). Recognizing this occurs with your migraine may help you to get your treatment as early as possible.

Member: This may seem like an odd question, but can rain or change in weather cause migraines? It seems that whenever my allergies act up I get crippling headaches. Some mornings I will wake up with my eyes swollen shut. I am currently taking Zyrtec to act as a preemptive measure but it does not always work. At times the headaches are so bad I am unable to get out of bed, let alone go to work. Any suggestions?

Diamond: It sounds like migraine, and barometric pressure changes are common triggers for migraine patients. Forty percent of migraine patients get their headaches between 4 a.m. and 9 a.m. And once the migraine is in place, it is very hard to treat. For these kinds of headache, having a medication to treat your migraine in an injectable (shot) form or suppository can be helpful. When migraine is severe when you catch it, the patient's stomach sometimes does not absorb medicine well, and that's why having another avenue to get medication in like with the suppository or shot can be useful in those situations.

Member: I never go a day without headaches or migraines. I have been to doctors and neurologists and all they do is give me pain medicine like Darvocet, which I do not want to take. I do yoga to help with stress and circulation but this does not always help me headaches. Any suggestions? I just want my life to be pain free.

Diamond: Chronic migraine or chronic daily headaches is a very common problem seen in a neurologist's or headache specialist's office. There are many treatments available, some of which include drugs and some of which are behavioral. Some simple things to address include caffeine consumption, over-the-counter medications, decongestants, and prescription pain medicine. These can all lead to rebounds. Having a healthcare provider who is interested in managing your treatment over a long period of time is important. The National Headache Foundation may be able to give you appropriate resources in your area.

Member: I recently had a migraine that lasted over 10 days (no medication helped. I took Excedrin on top of Amerge and Tylenol with codeine) and ended up going to the ER for relief and a CT scan (normal results). I don't get migraines often, but when I do, they have lasted up to two weeks. Why?

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.

Member: When I recently went to the ER for a migraine with nausea, I was given Nubain and Phenergan. This seemed to work better than the original Demerol and Phenergan recipe -- why?

Diamond: Well, different medications have a different effect in patients. Nubain has a longer half life, which means it hangs around in the system a bit longer, and because migraine is a longer headache, it may be helpful because of that.

Member: Is there anything I can do to treat a migraine besides prescription medicine? My insurance company won't pay for Imitrex, which works for me really well.

Diamond: First of all, I would have both your physician and yourself write a letter of appeal to your insurance company. It seems cruel to not allow a patient to have effective therapy, and sometimes a letter from your doctor can help get a medication approved. Other nondrug therapies include biofeedback, meditation, hot or cold packs, and lying in a dark room. But clearly, having an effective medication is your best weapon. Most of the companies that make the triptans have prescription programs for patients who don't have medication benefits. You would probably have to fill out paperwork, but it's likely you could get some medication from the companies in this manner.

Member: I have been a migraine patient all of my life. My concern is for my children. Are they hereditary? Also, I recently read that a child that gets car sick usually develops migraine headaches later in life. Do you have any knowledge of that statement? Thanks for your help!

Diamond: Motion sickness is probably an early migraine forerunner. Migraine is a genetic disorder and if you have one parent with it, you have a 50% likelihood of getting it. If both of your parents have it, you have an 80% chance of getting it. In saying that, migraine in a family will vary so that one person may have very severe attacks and other patients within the same family may not have as severe or as many attacks.

Member: Most of the time, during migraine attacks, I don't want to take any medicine, I just let it pass naturally, by taking a long sleep. Am I doing the right thing?

Diamond: No. The treatment for migraine with sleep is an old one and we've been using it for years. But the problem is are you sleeping much of the week or is it an infrequent occurrence? If it's once in a blue moon, no big deal, but if you are missing important occasions like work, school, and time with family, having an effective medication might be useful, too.

Member: I hear a lot of migraine sufferers have CT scans to see if the pain is caused by a tumor or other condition. Would you recommend that all migraine sufferers get a CT scan as a precaution?

Diamond: Good question. I don't think you need a CAT scan or MRI to diagnose migraine, but if your pattern is atypical (symptoms don't necessarily fit) or you have a changing pattern of headache, or neurologic symptoms, then a scan is very much in order. Most patients who have migraine will probably end up getting a scan at some point. But it isn't absolutely necessary. Some patients will want it for reassurance purposes.

Member: How do you treat adolescent (girl) migraines that are chronic and possibly related to sleep pattern (serotonin or melatonin?)?

Diamond: There are many treatments, depending on the patient. Melatonin has received some attention because of its usefulness in some patients with sleep disorders. There isn't enough evidence yet to show whether it is helpful in migraines.

Member: Can you explain what is actually happening, vascularly, when a migraine headache occurs?

Diamond: That's an area of controversy, but we do know that the migraine generator or control center is located in the brain stem. Which is the area just above the spinal cord, but below the cortex. That generator sends signals to the blood vessels that line the brain, causing them to dilate, or get bigger, get swollen, stretch, and send pain signals back to that control center. Our migraine abortive drugs, the triptans, DHE45, and even Midrin to some extent, help to prevent that from happening.

Member: But are there safe medications for adolescents to take who suffer from severe, chronic migraines that interfere with their daily living?

Diamond: Absolutely yes, but you need to see somebody who is interested in treating kids with chronic migraine who can put together not only the headaches but other contributing factors.

Member: I am 63 and have suffered from migraine for the last 25 years. The earliest attacks used to impair my sight. Now I control my suffering by taking Valium and Ponstel as soon as I get the inkling of the oncoming attack. Does chronic migraine and its medication cause any other serious ailments, such as strokes or cancer?

Diamond: Stroke is more common in patients with migraine. The increased risk is very small but is present. So it's very important for migraine patients to control other cardiovascular risk factors. Good control of blood pressure, cholesterol, diet, and smoking cessation are all helpful in limiting those risk factors. There is no data that migraine patients are at greater risk for cancer. We do know that migraine is often associated with depression and anxiety. There is also some greater risk of epilepsy or seizures.

Member: I read about the NTI dental device in USA Today. Do you have any more information about this?

Diamond: I am not a dentist. And when I have a patient with TMJ I send them to the dentist because that's a dental disorder. However, poorly managed TMJ may lead to more tension headaches. The NTI is a type of dental night guard. Traditional night guards for people who grind or have TMJ cover their front and back teeth. Many patients take them out while they are sleeping or find them difficult to sleep with. The NTI is a device that prevents grinding by preventing the occlusion (coming together) of the front four upper and lower teeth. The dentist who makes this device says that it cures migraines. I have been doing headache work for 14 years and I've seen lots of devices come and go as well as cures. While I'm sure the device might be helpful for some, there is not enough evidence, in my mind, to say people should run to get it. Not all migraine sufferers grind and have TMJ. Patients with migraines that are hard to control will often try anything and I'm concerned when people say they have a cure. That can do damage, too.

Member: My husband gets auras -- flashing lights, etc. -- just before getting a cluster headache. He takes Excedrin Migraine, but, being a migraineur myself, do you think that the OTC drugs may eventually 'rebound'? And, should I take him in for an appointment to my neurologist?

Diamond: Yes, I think taking an OTC on a regular basis can lead to rebounds. A good rule of thumb is two treatment days per week. If he needs more than that or the treatment is not effective, he should see the doctor.

Member: My fiancé is a migraine sufferer. He has been to many, many neurologists. None have really helped any. His current neurologist has sent him to pain management. All they do is give him methadone and morphine. How do we proceed? Do we go to a big hospital like Johns Hopkins?

Diamond: I would take him to see a headache specialist. Sometimes in very severe cases, long acting opioids like methadone can be used. But you are really masking the pain, not preventing it. There are many good headache specialists who deal with this every day. It might be helpful for him to see one.

Member: How do you find a headache specialist? His neurologist specializes in headaches.

Diamond: Most of them will have headache after their name -- like our clinic, as an example. A good resource is the National Headache Foundation. It's important to ask the questions "how many headache patients do you see?" and "is your practice mostly headaches?" You may want to go to a place that just does headaches. The National Headache Foundation is an excellent resource and I would recommend using them.

Member: A few years ago, I was diagnosed with chronic daily headaches. I kept a journal for six months with everything I ate and all the activities I did during that time. The physician's diagnosis was that I had cluster headaches and there was nothing they could really do for them. The physician also ordered a CAT scan, which was negative. I have headaches that last for months with no relief, sometimes becoming migraines (on average about twice a week, sometimes more, sometimes less). Have there been enough significant advances in this field that it would be worth my time and energy to go back to a physician regarding my headaches?

Diamond: Absolutely. We know a lot more than we used to. There are many new treatments available. The most important thing is to find a doctor who cares. With a motivated doctor or healthcare provider and a motivated patient, a lot of good things can be accomplished.

Member: Dr. Diamond, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Diamond: Thank you very much for chatting with me and having me on. The questions were great. What I would tell those who suffer with chronic headache and chronic migraine and cluster headaches, is to get an effective treatment, communicate with your doctor if treatment isn't working. Get a therapy that will allow you to have a normal life. That's a reasonable goal.

Moderator: We are out of time. Our thanks to Merle Diamond, MD, and thank you, members, for joining us today. For more information about the Diamond Headache Clinic, visit their website at www.diamondheadache.com. For more information about the National Headache Foundation, please visit their website at www.headaches.org, or call 1-888-NHF-5552. Please check out our news stories, features, and archived interviews with experts for more information about migraines -- visit our Migraines/Headache Center. Also, visit our Migraine Message Board to talk with other members and have your questions answered by Gary Vogin, MD.



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Last Editorial Review: 10/23/2003