About five percent of people suffer from a strange group of symptoms called migraine. Why do more women than men suffer from it? Does it affect only highly intelligent people? A British consultant neurologist with a special interest in migraine answers questions about this frightening and common illness.
What is meant by migraine?
It has recently become fashionable to call any headache migraine, partly because of the suggestion that migraine affects only highly intelligent people. But this is a myth. Migraine affects people in all walks of life and of differing abilities, although conscientious people do tend to be more susceptible.
How then can migraine be defined? There can be no rigorous definition because there are no objective measurable phenomena associated with it. A rough definition is that migraine is a paroxysmal disorder, characterized by recurrent attacks of headache usually associated with visual or gastrointestinal disturbances.
Attacks occur with or without warning and consist of headaches that last at least some hours, often for the remainder of the day. Head pains of a few minutes’ duration, or continuous over weeks, are not migrainous. Migraine headaches may occur regularly, or in clusters, or without any apparent pattern, but they are always interspersed with periods of complete freedom.
The pain may be confined to one side of the head or affect both and may wander from place to place in the head, even during a single attack. It is best described as a deep-seated ache or a sensation of boring and may throb at intervals like the hammering of the pulse.
A person can often continue at work during a mild attack, but if the headache is severe he, or more commonly she, may have to lie or skin a darkened room because exposure to light is painful.
Noise may accentuate the pain, and so may coughing, sneezing, or movement. The patient may lose the desire for food, feel nauseated or even vomit, and constipation is also common dining attacks.
The appearance is naturally affected during an attack; the victim looks haggard, with bags under the eyes; the face appears pale, white, greenish, or, occasionally, red. The hands and feet usually feel cold during a severe seizure and the quiet, dark bedroom is the only refuge. After a good sleep, or in some cases after vomiting, the pain is relieved and life is once again worth living, although many patients remain washed out for hours or even for a day or two after an attack has passed.
What are the warning signs?
The classic warning consists of seeing bright flashing lights or various sparkling shapes like a flash of lightning, or stars, or bizarre patterns resembling the outline of a castle wall. Other visual disturbances include blind patches that bisect the field of vision, either vertically or horizontally or a central blind spot.
Other migraine victims note that vision is blurred, as though through a windowpane obscured by rain. Some patients may feel particularly well, in fact, too well, before a bout, while others feel excessively tired. A less common warning is a sensation of numbness down one side of the body or a speech impediment.
These warning symptoms (called the aura from the Greek word for a breeze) last from a matter of minutes up to half an hour, after which the headache ensues. But many migraines come unheralded, and the sufferer is woken by pain during the night or wakens at his usual time with a headache fully established. Attacks may also begin gradually, with an awareness in the head which becomes increasingly severe.
How do you know when you have the real thing? Are there different kinds of migraine headaches?
Pain can be produced by almost every organ or tissue in the head. Migraine, however, is believed to be due to an overexcitability of blood vessels, and the headaches occur at intervals as described in the answer to the first question. If your headaches fit this description, you probably have migraine, but if in doubt consult your family doctor.
However, some migraines differ from the usual patterns. For instance, in hemiplegic migraine, the aura consists of a weakness or numbness in the limbs on one side of the body, and if the right side is involved the person is usually bereft of speech at the same time. These alarming symptoms may be quite prolonged, and the headache is the least distressing feature. This type usually runs in families. Another rarity is ophthalmoplegic migraine, where paralysis of the eye muscles results in double vision or drooping of an eyelid.
A more common variation is migrainous neuralgia or cluster headaches. These attacks last 30 minutes to an hour, the patient often being woken in the early hours of the morning by severe pain behind one eye. The affected eye may become red, puffy, or watery, and the nostril on the same side is usually blocked. The headaches occur nightly for six or eight weeks, followed by months or years of freedom.
A lot of people complain of having a migraine. Is it really as common as it seems?
The incidence of migraine varies with the population sampled, the methods employed, and probably the bias of the investigators. A recent survey in the Rhondda Valley in Wales showed that one in every five women suffered from migraine. Other surveys have revealed an incidence of nine percent in a group of young American men, 5.4 percent in a group of medical students and nurses, and 3.3 percent in a house-to-house survey in one city in the North of England. A fair average would seem to be five percent.
The figures indicate the size of the problem and its importance, as the number of working days lost each year must be considerable.
What sort of things bring on an attack?
Several factors can trigger off a migraine attack. Alcohol is one good example, hence many migraine sufferers never touch a drop. In other patients, a number of factors operate, making it difficult to separate one from another. The difficulty is increased by the fact that a migraine does not invariably follow, let us say, a glass of sherry, but it may do so.
The other factors include certain foods, such as cheese and chocolate, missed meals and fasting. Some patients have told me that even eating a raw apple, strawberries, or an ice-cream can bring on an attack.
In other sufferers, fluid retention, particularly noticeable in women in the premenstrual week or in those taking contraceptive pills, is a potent factor.
As 80 percent of women lose then migraine completely in pregnancy, hormonal factors also appear to be at work. This is more likely to account for the greater incidence of migraine in women than the suggestion that they are more neurotic than men!
Temperature can also be a contributory factor and an attack may follow exposure to cold winds or excessive heat in a stuffy room or sitting under a hair-dryer.
Other physical factors include intense light or excessive noise; sleeping an hour or two longer than usual or taking an afternoon nap; local pain arising from a bad tooth, infected sinus, or muscular pam in the neck; and respiratory infections like the common cold or influenza.
Stress is commonly blamed, but, surprisingly, attacks tend to occur after, and not during, excessive work or strain.
It is often said that particularly intelligent people are more susceptible than others. Is there any evidence for this?
No. There is, however, evidence that migraine is often associated with traits of over/conscientiousness, recognizable in people who are more punctual, tidy, and ambitious than the average. Hence, with the same degree of intelligence, this kind of person may get further in life than the more happy-go-lucky and so seem superficially more clever.
Is migraine affected by age?
Bilious attacks, cyclical vomiting, and travel sickness are common in childhood and may be replaced by migraine in the teens, but children can have typical migraine headaches as early as five or six years of age, and possibly earlier. In both sexes, however, puberty is the most frequent time for the onset of migraine.
It used to be thought that migraine in women grew worse during menopause and that they frequently lost their migraines when they had completed the change. However, a recent follow-up study of 92 patients has shown that one-third lost their migraine spontaneously at various ages.
In the remaining victims, some improvement was found as they grew older. In some, the aura disappeared and only the headaches remained; others lost the headaches but retained the aura.
A surprising finding was that 18 women noted no change in the frequency or severity of their migraines during menopause. In six others migraine was worse, and only four showed some improvement during this phase of their life.
With most men and women, migraine seems to die out during their fifties and sixties, but attacks occasionally continue into the seventies.
Are there any particular times when attacks are worse?
Attacks may be more frequent at the weekend, the start of a holiday, the end of a very busy day, or after a period of stress. Some women find attacks occur more frequently when menstruating, during the menopause, or while taking contraceptive pills; and attacks are more frequent in the winter for some, in the summer for others. Some Moslems have more attacks during the Fast of Ramadhan, presumably because of the prolonged low level of blood sugar caused by not eating during the daytime, and Jews, fasting for 25 hours, may suffer an attack on the Day of Atonement.
Is migraine inherited?
With an incidence of five percent in the population as a whole, it is of course likely that another member of the family will suffer from the same complaint. But migraine in the same family seems to occur more often than the random chance of one in 20, and there are families where as many as four generations are affected.
These family trees prove that migraine is not sex-linked but inherited as a dominant trait. Of course, similar conditions of stress may occur in a family situation, or an item of food shared by the whole family might be involved. Nevertheless, stress is pant of everybody’s life and grown-up children leave home and eat different foods – yet attacks continue.
Is migraine usually so bad that one should consult a doctor?
Family doctors would have no time to treat any other illnesses if all migraine sufferers consulted them about their headaches. Many people are not troubled to the extent of seeking medical advice at all; others have their own remedy, coping with their headaches by going to bed and perhaps taking a couple of aspirins, and consult their doctor only when attacks become unduly frequent or severe.
But a few patients have to be referred to hospital specialists because the standard remedies do not help, or because they become depressed, or fear they have a brain tumor. Some victims fear that their attacks may become continuous and hence unbearable, and a severe attack may make the sufferer fear the oncome of a stroke or insanity. All these are normal fears but are none the less groundless.
My wife seems to get more headaches since she switched over to the Pill. Is this a coincidence?
The Pill cannot cause migraine, but it may bring it on in a woman who has an inherited tendency to attacks. More commonly, it produces an increase in the number and severity of attacks and about ten percent of women stop taking the Pill because of headaches. The Pill contains two synthetic hormones, an estrogen and a progestogen, and certain proportions of these two hormones can make migraine more severe. It was known long before the discovery of the Pill that migraine may start in women soon after the birth of a child, which is further evidence that a hormonal factor may be involved.
What can be done to prevent an attack?
It is clear that we do not know all the factors that precipitate attacks, and many migraine victims are affected by more than one factor. But this does not mean that we cannot act within our present limited knowledge.
If alcohol, cheese, or chocolate seems to bring on your migraine, try to avoid each for a period of two to three months. If the frequency of your headache is diminished, then you have begun to detect the triggers that fire off your attacks. But do not expect a simple pattern of cause and effect. Alcohol may not invariably give rise to migraine, but this does not mean that it is not a factor.
If missing a meal, sleeping too long on Saturday or Sunday morning, or taking an afternoon nap brings on a headache, avoid it. If doing the housework and shopping on a Saturday morning, as well as cooking your husband’s lunch, starts an attack, then plan the week’s shopping, or Saturday’s meals, differently.
The overconscientious person who knows that he or she can do a task more efficiently than anyone else must learn to delegate or seek co-operation. Trying to do too much in too short a rime is also a potent precipitant of migraine.
We have already mentioned the effect of the contraceptive Pill. Here a different preparation or an alternative method of contraception may be tried. The taking of tablets to increase fluid output in women who retain fluids premenstrually sometimes helps. In others, muscle relaxation may also diminish attacks. If sitting too near the cinema screen or driving too far is a cause, then you may have to choose the more expensive seats farther back, or restrict the distance you drive.
Where stress response is the main factor, sedatives can help, but they should not be dependa! upon for any length of time. Finally, a useful precaution is to carry the appropriate tablets in one’s pocket and take these as soon as an attack threatens.
What causes migraine?
The cause of migraine is not yet known, although much research is being carried out. However, it is thought that blood vessels probably play a major role, as the pain is often of a throbbing nature, and that the warning symptoms are caused by a temporary constriction of the arteries supplying localized areas of the brain, which leads to visual disturbances or molar and sensory symptoms.
These preliminary symptoms are followed by dilatation of the blood vessels on the surface of the head, between the scalp and the skin, which gives rise to the throbbing headache.
The evidence for this curious behaviour of the blood vessels rests on the fact that, during the aura, observers have occasionally seen constrictions of vessels at the back of the eye; and drugs that dilate vessels can cause warning symptoms, such as a blindspot, to diminish.
During an attack, the headaches may be diminished by pressing on the carotid artery in the neck, or the artery that runs just in front of the ear. Further evidence is supplied by instruments measuring the pulse waves produced by the superficial blood vessels of the head; they have recorded increased pulsation in these vessels during migraine attacks. There are also tiny blood vessels overlying the whites of the eye and, seen through a microscope, these have usually shown dilatation during the headache phase. More recently, blood flow measurements made by using radioactive gases have again indicated increased blood circulation during headaches.
A pathologist has discovered a link, in a number of women on the Pill, between headaches and an abnormally large number of blood vessels lining the womb. This association depends on the ratio of the hormones contained in the Pill. If migraine is due to a disturbance of blood vessels, this kind of study could prove rewarding in elucidating its bask cause, and possibly its control.
What is being done to find a cure?
There are two necessary elements of research: first, scientists with ideas; second, money to support them. In Britain, financial help comes from the Migraine Trust, formed four years ago to support and co-ordinate scientific research. The Medical Research Council is supporting some research work, and money is also provided by the Migraine Association – a group of patients who raise funds to help find the cure for their own affliction.
The problem is being tackled at the physical, chemical, psychological, and epidemiological levels. On the physical side, the brain waves of migraine patients are being studied to see if these suggest any physical abnormality in the brain, and whether any objective changes occur in the pattern of the waves during the attack. Further research may show whether or not such changes could help to assess the effects of treatment, and whether or not they could provide a lead to the basic cause of the migraine.
Brain wave records are used for the same purpose with children suffering from recurrent headaches and cyclical vomiting. Another group of investigators is injecting the radioactive gas Xenon into blood vessels supplying the head, and checking the resultant radioactivity with a geiger counter to measure the regional blood flow in different parts of the brain.
The chemical approach concentrates on the natural ammonia-containing substances in the body, called amines. The drug reserpine both liberates amines and sometimes precipitates migraine. So it is possible that there is a metabolic disturbance in migraine victims which makes them unable to handle certain amines.
Another drug, methysergide (Deseril), which is antagonistic to an amine called serotonin, also has anti-migraine properties. So, to see if migraine is caused by the inability of victims to cope with amines, the urine of migraine subjects has been examined for the excretion of serotonin and other amines. Results so far, however, are conflicting.
Another line of approach stems from the fact that cheese and chocolate may precipitate attacks. These foods contain a high quantity of an amine called tyramine. A group of volunteers who associated either chocolate or cheese with the onset of attacks was given capsules containing either tyramine or a dummy substance, lactose. There was a clear relationship between taking tyramine capsules and developing a headache, though at varying intervals. The lactose capsule did not give rise to a headache. This seems a particularly promising approach and the work continues.
Epidemiology, the study of the environmental and personal aspects of disease, has already provided important leads in establishing the cause of lung cancer and coronary thrombosis.
The Rhondda Valley was chosen for a survey of migraine sufferers because it is a comparatively stable community. But the results (20 percent) probably indicate an unusually high incidence in the population there. A trial is now in progress to assess the effects of the migraine palliative, ergotamine tartrate.
How can attacks be cut short?
- Study the precipitating factors and avoid them completely if you can, or try to reduce them to a minimum. Keeping a diary or just watching yourself may help you to pinpoint the triggers.
- Take heed of warning symptoms, whether they develop into an attack or not.
- Study the measures that relieve your attacks and use them as soon as possible; don’t wait until an attack, has become fully developed, because tablets are then frequently useless.
Many patients can stop an attack by taking two ordinary or soluble aspirins, two tablets of codeine or paracetamol, or some other simple pain killer. If these are effective in your case, carry them around with you.
Tablets should be taken before a meal on an empty stomach. If you wait until the end of the meal, the tablets will not be absorbed until the stomach has emptied, and that may be up to two hours after the meal. Having taken your tablets, try to relax for 20 to 30 minutes until they have produced some effect.
What is the present situation about treatment?
Continuous treatment with mild sedatives like phenobarbitone or Stemetil is advocated by some practitioners, but it has its limitations. Prophylactic treatment with ergotamine preparation is particularly useful in nugrainous neuralgia, and at times is useful in migraine, too. Finally, Deseril has been extensively used all over the world since its discovery. This drug is often very effective in preventing attacks, but has dangerous side effects if used continuously and it is advisable not to take it longer than six months at a stretch. Ergotamine or the tranquilliser chlorpromazine Largactil is occasionally given in a suppository, because nausea or vomiting may stop the absorption of tablets by mouth.
Most patients know that a good sleep is one of the best ways to end an attack. A warm, dark room and sniping a hot sweet drink can also help. If simple measures fail, doctors sometimes prescribe a course of preventive tablets containing ergotamine, or ergot-plus-a-sedative, or a sedative alone.
Is there a way of permanently preventing attacks?
At present, no. If there were, all research would be unnecessary. Attacks do cease spontaneously in a percentage of people, and another illness such as jaundice may occasionally intervene, and its onset will mark the end of them. But so far we know of no certain way to stop attacks completely.
Is migraine dangerous?
Migraine is not dangerous, nor does it herald anything sinister. Even in hemiplegic migraine, where one side of the body may be paralysed and the person rendered speechless, the symptoms are never permanent. We know of patients who have attacks even into their seventies without any disability. Very rarely, migraine is associated with other conditions and diseases, but statistical analysis shows that this is pure coincidence and therefore the migraine sufferer need have no fear of any underlying disease.