The Treatment Of Migraine Headaches

Migraine is a very common type of headache, and is about three times more common in women than in men. This preponderance of women sufferers is thought to be due to the cycling of estrogen, a female sex hormone, that occurs during a woman’s menstrual cycle. Some women have regular attacks of migraine at the time of their periods. Birth control pills, which also involve cycling levels of estrogen, may also stimulate migraine headaches.

Migraine headaches are usually described as moderate to severely painful, one sided, becoming worse with exertion, and may be accompanied by nausea, vomiting, or sensitivity to light, sounds or smells. There is no test that specifically diagnoses migraine. The diagnosis must be made based on a careful history taken by the doctor. Tests that may be done, such as scans of the brain, are ordered to exclude other causes of headache, but cannot themselves diagnose migraines.

The cause of migraines is not known. Variations in the blood flow to the brain have been seen, and may play a role in the production of the pain. The migraine aura, usually described as flashing or sparkling lights which precede the actual headache by a few minutes, are now known to be present in a minority of people with migraine. This type of the headache is known as classical migraine. Migraines may occur frequently, but the daily headaches for a period of a year described by our first writer is unusual in my experience. Since neither of our writers has described the actual symptoms she gets with her headaches, I couldn’t say that they do or don’t have migraine, but I would urge our first writer to have her diagnosis confirmed by a doctor experienced with headaches, since I agree that her frequent use of ergonovine may cause serious side effects, and her care needs to be better managed.

Some migraines are mild enough to respond to anti-inflammatories like ibuprofen (Motrin, Advil), or naproxen (Naprosyn, Alleve). Both are available over the counter (OTC) without a prescription. Two or three pills of the OTC formulations may be necessary to get relief.

If anti-inflammatories do not bring about relief, then the next drugs to try would be one of the ergot preparations like ergotamine, which is available in pill form, in suppositories for rectal administration, or as a nasal spray. Or try one of the triptans, of which sumatriptan (Imitrex), mentioned by our second writer, was the first to appear on the market in the U.S. My references do not list ergonovine as available in the U.S. but the side effects of all the ergot preparations are similar. A form commonly prescribed here with which I am familiar is Cafergot, and it is recommended that no more than six tablets be taken in one day, or 10 tablets in one week to avoid side effects. Our first writer appears to be taking substantially more than that.

Both the ergot preparations and the triptans cause constriction of blood vessels. Therefore, they should not be taken by people with coronary heart disease, disease of other arteries, or uncontrolled hypertension. Ergot preparations have a side effect that the triptans do not have — the development of a syndrome known as ergotism when an overdose is taken, or they are taken too often and too long. In ergotism the small blood vessels become very constricted, leading to cold hands and feet, pain, nausea, vomiting, weakness and even gangrene of the fingers or toes. Ergotism is more of a danger in someone with arterial disease in the arms or legs, or Raynaud’s syndrome.

Although I prescribed Cafergot for years when it was about the only option, I have been very impressed with the effectiveness of sumatriptan. The injectable form acts quickly, and is packaged in a syringe for self-administration at home when the headache first starts. It will often stop a headache even after it has been present for a couple of hours, something the ergot preparations seldom did. The newer triptans, zolmitriptan (Zomig), and rizatriptan (Maxalt) are said to have fewer side effects than sumatriptan.

Someone having more than one migraine per week may want to consider preventive treatment. The classical drug used for this is propanolol (Inderal), but other beta blockers are also effective, as are often the drugs called calcium channel blockers. Both types of drug are used to treat hypertension, and may be particularly helpful in a migraine sufferer who has uncontrolled hypertension, for whom the triptans and the ergots are contraindicated.

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