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Several years ago, while I was examining a patient, an overhead fluorescent light began to flicker. I made a note to change it and returned to my desk to chart my findings. But as soon as I began typing, I discovered that half the computer screen was missing. It wasn't a bulb on the fritz; it was part of my brain. By the time the headache started a few minutes later, I knew what was up. I had just joined the ranks of the 28 million people in the United States who suffer from migraines, including the majority of my colleagues. Although the prevalence of migraines is just under 12 percent in the general population (17.1 percent of women and 5.6 percent of men), it is much higher among headache experts—a whopping 81 percent in women and 72 percent in men, according to a study in the journal Neurology.
So when the doctor is also the patient, what does she do to prevent these disabling attacks?
There are many types of triggers, not all of which can be modified, according to Maria-Carmen B. Wilson, M.D., director of the Headache and Pain Center at Tampa General Hospital in Tampa, Florida. But we can usually control sleep, she says. Dr. Wilson recommends that migraineurs (the technical term for people who get migraines) avoid napping, oversleeping, or sleeping too little. “Fatigue is a classic and often overlooked trigger,” she says. Most neurologists recommend getting seven to eight hours of sleep each night and maintaining a regular sleep cycle, which means getting up and going to bed around the same time—even on vacations and weekends.
For Alex Mauskop, M.D., director of the New York Headache Center in New York City, sleep deprivation and wine are both triggers. He began to experience migraines in his late thirties, well after having become a headache specialist, and finds that he is especially prone to migraines if he drinks wine when he's sleep-deprived.
High-carbohydrate meals seem to trigger migraines for Jan L. Brandes, M.D., assistant clinical professor of neurology at Vanderbilt University in Nashville, Tenn. Dr. Brandes has suffered from migraines for 30 years. Experts think that the sudden rise in blood sugar caused by a high-carb meal—followed by the rapid fall when insulin is released—can set off a migraine. So Dr. Brandes eats smaller, more frequent meals. She also rarely drinks alcohol anymore, especially red wine, because it's one of her prime triggers. Like many headache doctors, she's discovered that if she “stacks” her triggers—say, by washing down a big plate of spaghetti with a couple of glasses of Chianti—she's even more likely to get a migraine. Dr. Brandes has also learned that she is at particularly high risk when crossing time zones, so she takes extra care with both eating and sleep habits whenever she travels.
Dr. Wilson recommends unmasking food triggers through a process of elimination. Patients should record all the foods they eat and when they eat them in a food diary. If an item seems to consistently trigger migraines, patients should remove only that food and see what the effect is on their headaches. The process, however, doesn't always yield crystal-clear results, as food triggers can be confusing, Dr. Wilson explains. Alcohol is a classic example. Many patients observe that at times they can take a drink or two and be fine; at other times, a very small amount will precipitate an attack. “The secret is to know when and how,” Dr. Wilson says. The American Council for Headache Education—a good resource for headache sufferers—lists foods that have been implicated in migraines at achenet.org/articles/45.php .
Dr. Mauskop avoids coffee because the amount of caffeine in as little as two cups a day has been linked to rebound headaches—often migraines—which are caused by withdrawal. One “Tall” Starbucks cup of coffee, which is their smallest cup, contains the equivalent of three regular cups of coffee, notes Dr. Mauskop. Other caffeinated drinks and foods include teas, sodas, and even chocolate.
“Many sufferers feel that caffeine actually makes them feel better,” Dr. Mauskop says, “but what they don't often realize is that they are just adding fuel to the fire.” For example, Excedrin and other caffeine-containing drugs may help at first, but they become less and less effective over time. If patients take these drugs frequently (more than two or three times a week), they can develop the same rebound headaches that dietary caffeine causes.
Dr. Mauskop advises that the only way to stop headaches in this scenario is by stopping the medication, but be forewarned: The headaches will get worse—usually for a day or two—before they get better, and full improvement may take up to several weeks.
Lawrence C. Newman, M.D., director of the Headache Institute at St. Luke's Roosevelt Hospital in New York City, has been getting migraines since he was 11, but he didn't realize what they were until he entered medical school. This past summer, when his headaches escalated to one or two a week, he started taking 200 milligrams of vitamin B2 (riboflavin) a day. He recommends B2, Petadolex (extract of the butterbur root), and coenzyme Q10 to his patients because several research studies have shown them to be helpful in migraine prevention.
Experts agree that regular exercise is one of the best preventive treatments, though exactly why exercise helps is not well known. Regular exercise reduces stress, which is associated with migraines. Exercise also increases levels of endorphins and other body chemicals that might reduce the number of episodes and the symptoms of migraine.
Dr. Mauskop exercises three to four days per week by doing Bikram Yoga (90 minutes of intense yoga done in a room heated to 100 degrees) as well as other aerobic exercises, such as using a rowing machine. Dr. Newman combines exercising on an elliptical trainer for aerobic benefits with light weight training and core exercises for his abdominals. He exercises for at least 30 minutes a day, three days a week, which is also the amount of time he recommends to his patients. Dr. Brandes likes to walk or use a stationary bike, but she tells patients who can't realistically exercise three times a week that they should try to walk for an hour or so on weekend days or find another time to fit in some form of activity.
Don't forget to exercise moderation while you work your muscles. “If you are out of shape, exercise in the heat, or overdo it,” Dr. Wilson cautions, “then you are more likely to actually provoke an attack.”
Dr. Newman drinks six to eight glasses of water a day and recommends that everyone—especially migraine patients—do the same. Drinking alcoholic beverages, especially at high doses, can increase urine output and lead to dehydration. Dehydration is an even greater problem than most people realize.
Beware of other situations that contribute to dehydration, such as heat, exercise, and flying. For example, if you do “hot” yoga, as Dr. Mauskop does, make sure to drink plenty of water before, during, and after class. The American College of Sports Medicine advises that it is important to pre-hydrate and slowly drink beverages at least four hours before exercising to allow the body to adequately absorb fluids.
Doctors don't know exactly why dehydration can trigger migraines, but lack of fluids may trigger pain receptors in the lining around the brain by reducing pressure in the arteries that supply blood to this area. Dehydration also causes the body to release histamine, which some researchers think can trigger migraines by constricting blood vessels.
“Managing stress will lead to a significant decline in the frequency of migraine attacks,” Dr. Wilson says. While stress alone doesn't trigger a migraine, it may reduce our susceptibility to triggers. “Stress is an indisputable factor of our lives,” Dr. Wilson adds, which means that stress-management should be an ongoing effort.
If you're having trouble coping with the demands of your daily life, ask your neurologist or internist to refer you to a psychotherapist. Some therapists are trained in biofeedback, a relaxation technique that uses monitoring devices to help people consciously regulate body functions such as heart rate, blood pressure, temperature, and muscle tension. Dr. Newman has witnessed the benefits of biofeedback firsthand, for his two migraineur sons.
Patients may also benefit from a variety of other stress-reduction methods, including meditation, yoga, or simply making time for an activity that they find relaxing.
“Do not overuse over-the-counter or prescription medications to treat an attack,” says Dr. Wilson. “This advice cannot be overemphasized.” Taking medication to eliminate headaches more than two days a week on a regular basis may provoke rebound headaches and therefore drug dependence. Like coffee, regular use of caffeinated medications is likely to backfire and ultimately make you worse. Neurologists encounter this situation frequently in patients who attempt to treat themselves. It's better to see a neurologist first and avoid the frustration.
Dr. Brandes, who recently wrote an article in the Journal of the American Medical Association about the influence of estrogen in migraines, says that many women can “map out” the migraines that are caused by hormonal influences. Menstrual migraines are usually more resistant to treatment, longer in duration, and more debilitating than attacks at other times of the month, according to the article. This means that while you're menstruating, it is even more important to get proper sleep and avoid alcohol. Track your headaches and cycle on a calendar for a few months and bring the record to your doctor's visit.
Dr. Brandes notes that perimenopause—the period of declining estrogen that all women go through—may affect the onset of migraines. She often suggests hormonal strategies to treat these patients. She also points out that during perimenopause itself, sleep is often fragmented, further adding to the risk of migraines. Let your doctors know about any perimenopausal symptoms you are experiencing so they can offer their assistance.
When Dr. Newman started to get frequent migraines as a pre-teen, the doctors convinced his parents that his headaches were due to anxiety over getting into a good college. “But I was only 11 years old,” he says. “I wasn't even thinking about my future.” Having a correct diagnosis and getting the right treatment would have saved him many headaches.
In addition to being misdiagnosed as anxiety, migraines are often wrongly diagnosed as tension headaches and sinus-related headaches. Dr. Newman encourages patients not to give up if they aren't getting relief. “Keep looking until you find someone who can give you the right diagnosis and treatment,” he advises. It may take time, but if you're persistent and work together with your neurologist, you can prevent migraines from interfering with your life.