When people get a migraine headache, it’s called an attack for very good reason. Migraine is a chronic neurological condition, and it can exact a huge toll on those it affects: sufferers – as well as those around them.For this Forum On Migraine, we sat down with Dr. Werner Becker, neurologist at the University of Calgary and lead author of the proceedings of the Canadian Migraine Forum, and Georgina Kossivas, a Toronto finance executive and migraine sufferer. Kossivas has been living with migraine since she was 12, although she wasn’t diagnosed until the age of 21, when she experienced her first aura and asked her doctor about it. She is also a former chair of the (now-defunct) Migraine Association of Canada. Like Dr. Becker, Kossivas participated in the Canadian Migraine Forum, which brought together a multidisciplinary panel of 30 migraine experts and patients from across Canada to examine the country’s current state of migraine care and how the
lives of Canadians with migraine could be improved.
The Health Journal: How common is migraine?
Dr. Werner Becker: It’s more prevalent than osteoarthritis, diabetes, and asthma. Three million women and one million men in Canada have migraine. Approximately 60 percent have one or more headache attacks per month, and 25 percent of migraineurs have attacks at least once a week.
THJ: What distinguishes migraine from other types of headache?
WB: Migraine tends to be much more severe and disabling than other headaches, and migraines are often accompanied by nausea and/or light sensitivity, so they’re very different. Untreated, a migraine can last for as long as 72 hours. About one third of migraine patients will have an aura in advance of some of their attacks. Aura is a neurological symptom that generally precedes the headache phase. Auras are usually visual, causing visual loss, or phenomena like zigzag lines or bright lights, but in other cases, they may cause numbness and tingling on one side, or speech disturbance, and some people will get all three types of aura.
THJ: How does migraine affect those who live with it?
WB: It does cause significant disability for many people – the 2006 Canadian Women And Migraine survey found that women had difficulty continuing with their usual activities an average of 21 days per year. Lost productivity accounts for two-thirds of the cost of migraine to society. Only one-third of the cost is related to actual medical care. Yet migraine remains a widely under recognized and misunderstood condition. We’re trying to change that.
Georgina Kossivas: Migraine is one of the few chronic medical conditions that people refer to in jokes of many types and so can laugh at, and frankly don’t understand well at all. It has to be taken seriously as a chronic condition for more migraine sufferers to be comfortable discussing their condition with their employers and their families. The biggest challenge with migraines is the unpredictability. I have two daughters, ages five and 10, and a very supportive husband who has learned to deal with a last-minute change of plans. I rarely miss work, but it costs me – I end up in bed for extended periods of time at night and on weekends. So what I lose is huge amounts of my personal time. I have what I count as two to three migraines per month, but I’m typically affected for six to nine days of the month. That’s at the high end of the frequency scale.
THJ: What are some typical migraine triggers?
WB: Triggers vary from person to person – most people affected by migraine have more than one trigger. Stress and changes in weather are common triggers. Hormonal change, specifically, a fall in estrogen, triggers migraine in many women migraineurs, who are more likely to have a headache just before menstruation starts and at ovulation mid-month. Common food triggers include aged cheeses, processed meats like hot dogs and ham, and especially red wine. Not keeping to a regular lifestyle, for instance by skipping meals, sleeping too little or too long can be a big trigger for some. Any one these things on its own might not always trigger a headache; it may take several factors to add up to trigger an attack.
THJ: Do people with migraine need to see a neurologist?
WB: Not all migraine sufferers need to see a neurologist; if their headaches are relatively infrequent and not too disabling, they don’t need to. Family physicians are generally well equipped to treat migraine, but if treatment isn’t working well or there’s difficulty finding the right prophylactic (preventive) medication, referral to a neurologist would be reasonable.
THJ: How are migraines treated?
WB: Treatment should be selected based on the patient’s headache severity – so a nonsteroidal anti-inflammatory drug (nsaid) like ibuprofen might be enough for moderate attacks. For really severe attacks, those medications are very unlikely to be effective. We want to go for the best medication for that person right off the bat – otherwise, patients get discouraged, think there’s nothing the doctor can do for them and don’t come back.
IS IT MIGRAINE?
Ask yourself these four questions when you have a headache:
1. Do you feel sick to your stomach?
2. Does light bother you?
3. Is the headache limiting your activities for a day or more?
4. And if so, have other headaches also done so within the past three months?)
If you answered yes to one of more questions, see your doctor.
THJ: How well do migraine medications work?
WB: If your headache is relieved and/or you can function normally within two hours, that’s generally considered to be successful. That’s the goal. If people can’t function almost normally within two hours, it’s a signal they should try something else such as triptan, or a different triptan.
Some migraines can be very difficult to treat, but we do have good medications available. Unfortunately, many patients don’t seem to seek help: 48 percent of women in the Canadian survey had never actually consulted a doctor for their migraine and were just using over-the counter (otc) products. The triptan medications, which we think are the best for migraine attacks, are used by a very small percentage of patients, probably because most had never been prescribed them.
GK: I have to say I’m a fairly lucky migraine sufferer, in that my migraines are reasonably well controlled with aggressive use of medication. You have to take the medication very early on; medication taken after the headache has started is usually ineffective. So you have to guess whether you’re getting a migraine and should take medication. If you have frequent migraines, you have to be careful because you can overmedicate very easily. I could be taking medication 20 days a month: that’s how often my head doesn’t feel very good some months. So you have to find a balance between taking medications too often, and not taking them soon enough. I may decide to medicate earlier and more aggressively in the presence of triggers like hormonal changes that make it more likely that a migraine will develop.
THJ: What are the consequences of taking medication too often?
WB: The current thinking is that having migraine somehow makes you especially susceptible to getting more and more headaches if you overuse your medication. This may be true to some extent for some people with tension-type headache, but it’s not seen in people who take a lot of pain medication for other conditions like arthritis, unless they also have migraine. In migraine patients, overuse of medication causes changes in brain chemistry that lead to an increase of headaches. Use of most migraine-specific treatments, such as the triptans, should be limited to about 10 days per month, or 15 days for acetaminophen
and the non-steroidal anti-inflammatory drugs such as ibuprofen.
GK: I’ve met people, who overmedicated, and for two of them, the consequences were very serious – they had to be hospitalized,and ended up with permanent liver damage. It was very terrifying.
THJ: Why are the triptans not prescribed more often?
WB: They’re the most expensive migraine medications, so drug coverage is an issue in some provinces. And like all migraine specific medications (like ergotamines), triptans work by constricting the blood vessels, so they cannot be used by people with heart disease or stroke. That’s not a concern for most migraine patients who are otherwise young and healthy, but because of how these drugs work, some physicians may be hesitant to prescribe them. In fact, they’re very well tolerated and safe medications, and have been used worldwide by millions – it’s fair to say they’re probably safer than the nsaids, which can cause gastrointestinal (gi) bleeding and ulcers.
GK: Many people who give up on triptans don’t realize that all triptans are not the same. There are many generations of triptans. It’s not predictable which triptan will work for any individual, nor is it consistent that the triptan will work every time. So a lot of migraine sufferers don’t realize that they can try different ones, or that if they try the same triptan under different conditions, it may work. They may give up trying and miss the opportunity for relieving their migraines.
THJ: What about preventive treatment for migraines?
WB: If the migraine medications are tuned up and a patient still has significant disability, say they end up in bed or miss work, then it’s time to consider prophylactic treatment, that is, a medication taken daily to make their headaches less frequent. Or if your medication is working well, but you are taking it more than 10 to 15 days a month, it’s time to try a prophylactic before you get into medication overuse. A range of very different medications, including some blood pressure medications, antidepressants, and anticonvulsants, have been used as migraine prophylaxis. The goal of prophylactic treatment is to cut the number of attacks by half. They require a trial of a few months. Response is very individual and unpredictable, but like the triptans, these drugs are also underused – only about half of the migraine patients who could benefit are taking a prophylactic medication.
THJ: How important is self-management of migraine?
WB: People can do a lot to reduce their headache frequency and to cope with attacks, if they’re willing to make the effort. It does require some education and planning, and often, significant lifestyle changes. You can learn to identify your triggers and where possible, avoid them. Learning stress management and relaxation techniques can help. And knowing appropriate medication use for both symptomatic and prophylactic treatment helps you get the best results from treatment. And last but not least, a healthy lifestyle can make a big difference.
GK: I’ve spent 25 years staying on top of everything I could learn about migraine. Because every type of treatment, medication and non-medication, is so individual to the patient, you have to keep learning and trying new things until you find a way to manage your migraines. I actively manage my medications and lifestyle to minimize my migraines. Sometimes you can do everything right, and still get a migraine. But if you don’t do all the right things, the odds of getting one go up. So that’s where biofeedback, relaxation training, and meditation have all helped.
Want to learn more? Visit www.headachenetwork.ca
CHILDHOOD MIGRAINE
According to migraine sufferer Georgina Kossivas, whose 10-year-old daughter started experiencing migraine attacks at the age of eight, childhood migraines can come on a lot faster than the adult variety.
“The child is perfectly fine one moment, and five minutes later, they’re complaining of a pounding headache, and often, nausea. They will often then throw up. It’s easy to think it’s some kind of stomach flu or food poisoning,” says Kossivas.
Sound familiar? Make an appointment with your child’s family doctor or paediatrician to get to the bottom of the situation. “I suspect I had a childhood migraine, but no one had a clue because it’s so different from adult migraine,” says Kossivas.