Dr. Alan Zacharias on Migraines: How to Fight Back

There’s no mistaking a migraine headache — the excruciating head pain, nausea and sensitivity to light and sound. The incapacitating attacks can last for hours or days and are sometimes frequent enough to cause moderate or severe disability.

“Fortunately, the list of both acute relief and preventive treatments continues to grow. Although there’s no cure for migraines, usually the right medicines, combined with self-help remedies, work fairly well for many sufferers,” Alan Zacharias, MD, of Associated Neurologists said during a free online health lecture.

“Careful joint decision-making with your doctor is needed. Together, you can often find ways to treat your migraine attacks and make them less frequent and severe.”

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Watch "Controlling Migraine Pain."
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Migraine is a Chronic Illness

Migraine headaches are considered a chronic illness, although many people don’t think of them that way. Roughly 15% of women and 5% of men suffer from this recurrent and often lifelong condition.

According to Dr. Zacharias, migraines usually start in adolescence or early adulthood and tend to become less frequent as we age. “Interestingly, in childhood it's more common in males than females, but after menstruation there is a significant change. So, we know there's a hormonal component that carries on throughout life until menopause,” he said.

The frequency with which migraines occur varies from person to person. While most sufferers experience attacks once or twice a month, more than 4 million people have chronic daily migraine, with at least 15 migraine days per month.

“Often there's a genetic component,” said Dr. Zacharias. In fact, about 90% of migraine sufferers have a family history of migraine.

Symptoms of an Attack
Dr. Zacharias said that during a migraine attack, you may experience:

• Disabling throbbing or pounding head pain that is usually one-sided. The pain usually lasts more than 2 hours, if untreated.
• Nausea, vomiting and sensitivity to light or sound.
• Confusion and irritability.

Dr. Zacharias explained, “You don't have to have all of those for us to say it fits the criteria for migraine but quite typically some will have at least one of those features.”

Migraine auras, which are a series of sensory disturbances, can happen shortly before or during a migraine attack. These usually cause visual disturbances such as flashes of light or wavy zigzag vision.

“This happens in about 10 to 15% of patients and last about 30 minutes. Visual auras are the most common. You can also feel numbness or tingling in the face or hands that slowly spreads over many minutes. Additionally, with auras you might experience a disturbed sense of smell, taste or touch and have problems with language,” Dr. Zacharias said.

Migraine Triggers
Factors and events that can set off an attack are called migraine triggers. They include:

• Hormone changes during the menstrual cycle
• Lack of sleep
• Exercise
• Stress and anxiety
• Alcohol (often red wine)
• Perfumes and strong odors
• Bright lights
• Chocolate
• Fermented cheeses and cured meats
• Caffeine (too much or withdrawal)
• Weather changes

“Triggers are highly individualized. Your specific triggers might not be entirely clear. To pinpoint them, keep a migraine diary or log, which can lead to insights into your triggers,” Dr. Zacharias said.

He added, “What's being understood now is it may be that we crave some of these items, such as chocolate, as the early manifestation of our migraine — that the craving may be part of the migraine itself rather than an actual trigger.”

Physiology of Migraine

Scientists used to believe migraines were caused by a constriction and dilation of blood vessels. They saw migraines as being primarily a vascular disorder. “The constriction phase is when you might get the aura and the dilation phase is when you might wind up with the intense headache. It’s still partially true but we've shifted.”

Instead of a purely vascular theory, he said there’s a new neurovascular hypothesis. “We now know that a migraine is triggered deep within the brain structures, predominantly in the brainstem and through portions of the trigeminal nerve and its nucleus in the neck, and then moves upward. Electrical discharges of neurons then spread out and create what we refer to as a sterile inflammation,” said Dr. Zacharias. “Various neurotransmitters and proteins then wreak havoc and cause pain, hypersensitivity to light and sound, variation in blood vessel size and the suppression of neuronal activity so you can’t feel or think very clearly during the migraine.”

However, the exact cause of why these changes in the nerve pathway occur is not fully understood, Dr. Zacharias explained.

Treating an Attack
Migraines can be managed with a doctor's help. Dr. Zacharias said your treatment plan may include some or all of these methods for stopping an attack:

• Caffeine and sleep: Migraine sufferers often report that a strong cup of coffee or restful sleep can improve the headache.
• Over-the-counter drugs: NSAIDs (nonsteroidal anti-inflammatory) drugs such as acetaminophen and ibuprofen or combination NSAID-caffeine pills can help. Benadryl can also have a calming effect to sight and sound disturbances.
• Traditional prescription medications: Two types of medications doctors often try first are triptans and ergotamine, which work by balancing the chemicals in the brain. However, Dr. Zacharias said that both of these types of medications have some side effects that limit their use and contraindicated for those with heart disease or high blood pressure.
• Prescription lidocaine nasal: Nasal spray or drops applied directly to nerves in the back of the nasal cavity appears to offer significant relief to migraine sufferers.
• Newer prescription medications for patients with cardiovascular risks: Dr. Zacharias described newer agents that tend to have fewer side effects and lack the cardiovascular concerns seen with some earlier agents. These include CGRP inhibitors or “gepants” and Ditans.

For people with extreme migraine pain, your doctor might prescribe powerful “rescue” drugs such as barbiturates, narcotics and IV infusions of anti-seizure medications.

Dr. Zacharias then discussed alternatives to medications for both preventing and relieving migraine pain, which include:

• Vagal nerve stimulation
• Supraorbital nerve stimulation
• Transcranial magnetic stimulation
• Brachial electrical stimulator: Nerivio Migra

What to Do First for an Attack
“I get asked this a lot. Do I go to Advil first or to a triptan?” said Dr. Zacharias. “Most prescription drugs for migraine attack work best when taken right away, when symptoms first begin, which is why I usually recommend going straight to the big guns. It’s best to treat the migraine at an aggressive level with your prescription medication, because once you pass a certain threshold, it’s hard to go back.”

He added that this recommendation is always tailored to patient preference and any known illnesses or chronic conditions.

Prevention Strategies
“When you only treat attacks, they come back. The goal is to figure out a prevention ‘cocktail’ to give patients sustainable relief,” said Dr. Zacharias.

Prevention strategies can include the following:

• Supplements such as magnesium citrate (400-600mg), riboflavin (400mg), feverfew (50-300mg) and CoQ 10 (300mg) have the most supportive data for effectiveness, according to Dr. Zacharias. However, the FDA only regulates prescription medicines and not vitamin and mineral supplements. "Because of this, it's important to research supplement manufacturers to make sure they have a long track record of safety and quality,” he warned.
• Prescription medications, taken daily, can help prevent attacks. “Many of these medications were designed to treat other health conditions such as depression or epilepsy.” Some examples are antidepressants, seizure medications, blood pressure medications and botulinum toxin.
• Relaxation techniques such as biofeedback and cognitive behavioral therapy can help calm down the nervous system without drugs. Biofeedback involves learning how to monitor and control your body's responses to stress, which lowers heart rate and eases muscle tension. The goal of cognitive behavioral therapy is to change patterns of thinking or behavior that may increase or maintain headaches. There’s strong evidence that these options can reduce the frequency of attacks.

“Treatment for prevention of migraines can work for one person but may not work for another. About 60% of patients get a 50% reduction in frequency of migraine,” Dr. Zacharias stated. “Sometimes we’ll need to use more than one treatment approach for prevention.”

Migraine and Stroke
Dr. Zacharias warned that there is a small increase in the risk of stroke with migraine for those who smoke or take birth control pills, especially for those who experience migraine with aura.

He said to see your doctor immediately or go to the emergency room if you experience any of the following signs and symptoms, which may indicate a stroke instead of a migraine:

• The worst headache of your life.
• Severe nausea and vomiting from the start of the headache.
• One sided weakness, numbness or persistent visual loss.
• Failure to respond to any treatment after 12 hours.

“Also, aura symptoms that last longer than one hour can also signal a stroke and should be evaluated,” Dr. Zacharias cautioned.

To make an appointment with neurologist Alan Zacharias, MD, call Associated Neurologists at (303) 415-8800.

Click here to view/download a PDF of slides shown during Dr. Zacharias' lecture on “Controlling Migraine Pain.”

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