January 9, 2019 // Perspective

Oh, my aching head

Dr. David Kaminskas

The Catholic Doctor Is In

Migraines affect millions of people in this country every year. I am fortunate to not have recurring migraines, but I did experience a severe migraine once. About 10 years ago while I was doing my federal tax return (not kidding), I suddenly saw flashing lights and then, after a few minutes, lost part of my vision. I surmised I was having the onset of my first migraine ever, or I was having a stroke. I was actually very happy and relieved when I began to have a splitting headache, confirming it was a migraine.

My wife also gave me a scare about 20 years ago. She was driving with one of my daughters when she suddenly had visual changes followed by difficulty talking and right-sided numbness. She pulled to the side of the road and had my daughter take over. When she got home, I immediately was concerned that she was having a stroke and took her to the emergency room. After a brain MRI and neurology consult, we were told by the neurologist that she was having a migraine without the headache and that she would be fine. Yes, there are migraines that never culminate in a headache.

If you have a sudden neurologic deficit such as visual loss, droopy face, numbness or paralysis, I urge you to seek medical attention immediately because this could be a stroke and every minute counts in minimizing long-term brain damage. If you have a pattern of migraines that usually begins with certain specific symptoms every time, like visual changes, then when these occur you can be more reassured and not run to the emergency room.

Migraines occur in about 12 percent of the population. Females are affected much more than males. The incidence in women is 17 percent, while in men it is about 6 percent. Migraines peak between the ages of 30 and 40. They are frequently hereditary. I have family members whose lives have been majorly impacted by frequent migraines that interrupt not only their work but also their ability to travel and vacation.

Research has proven that the cause of migraines is very complex. Years ago, it was thought that vasodilatation and vasoconstriction of blood vessels were the drivers of this phenomenon. More recent research indicates that the situation is much more complex. For the brainiacs reading this, let me try to describe the pathophysiology of the migraine. There is activation of the trigeminovascular system. A self-propagating wave of neuronal and glial depolarization spreads across the cerebral cortex that is called “cortical spreading depression.” This then activates the trigeminal nerve afferents, which inflame the meninges (brain covering), which in turn cause the severe headache.

Before all our heads explode with a migraine, I will get back to using terms that we can all understand. That includes me.

There are four phases to the typical migraine, but not everyone gets all phases with each migraine. The first is the prodrome, which occurs hours to several days before the migraine hits. This can be manifested by an array of symptoms that include irritability, yawning, food cravings, depression and even a feeling of euphoria. The second, and to me the most interesting, phase is the aura. The most common type is visual. There may be bright zigzagging lines, shapes or loss of vision. The aura may also be auditory (ringing or various noises), sensory (numbness or burning pain), motor (paralysis or jerking movements) or confusion. All of these can be easily misinterpreted as the possible onset of a stroke. The aura may precede each migraine, but it can be variable, and some migraine sufferers rarely have an aura. The third stage is the headache itself. Usually it is a throbbing or pulsatile headache. It is commonly accompanied by nausea and sometimes vomiting, and there is photophobia, leading many migraine victims to disappear into a dark, quiet room.

The final stage is postdrome. There frequently is a feeling of total exhaustion, but also can also be a feeling of elation (Yea, it’s over!).

Factors that can precipitate a migraine include stress, weather, menstruation, fasting, odors and food. Some foods contain high levels of tyramine, which is an established trigger for migraines. Certain cheeses have high tyramine. It is usually the stinky cheeses, like sharp cheddar or aged brie that can be a problem for migraine sufferers. Cured meats like salami may also be a trigger. Alcohol can be a cause.

Here is an interesting caveat. Beer on tap, which contains high levels of tyramines, is 20 times more likely to trigger a migraine then beer out of a bottle. Many people have correlated their migraines with consumption of MSG, or monosodium glutamate, chocolate and red wine, but studies have failed to reliably prove this. If you get frequent migraines, keeping a food diary is strongly recommended. What triggers a migraine in one person is frequently different than another.

There are many medicines prescribed for migraine prevention and for acute treatment. The truth is that medicines for prevention frequently fail. One just has to try them and gauge the response. I should also mention that Botox injections in the head and neck are helpful for some people.

There is a new and exciting treatment for migraine sufferers that I want to share. It has been shown that calcitonin gene-related peptide is elevated in the blood when people suffer from migraines. CGRP is produced by nerve cells in the brain and spinal cord. CGRP transmits pain signals in the brain and these receptors can be blocked by this new treatment. This first CGRP inhibitor released is erenumab and is actually a monoclonal antibody, rather than a typical pharmaceutical. Several other drugs (eptinezumab, fremanezumab, galcanezumab) were just released that also attack CGRP. They are self-administered subcutaneous injections given once a month or at a higher dose every three months. They are not a cure, but in several controlled scientific studies they reduced migraines by 50 percent in about half the people who took them. In another study, one-third of the injection recipients obtained a 75 percent reduction. There was a small percentage of people who had their migraines reduced to nearly zero!

Here is the bad news: Unless a person has failed multiple other migraine treatment medicines that are less expensive, it is unlikely his insurance will approve it. Erenumab costs $575 for each monthly injection, or about $7,000 per year. If your life is being majorly affected by migraines it may be worth the investment, though, so that you can be more productive in your daily life.

Both doctors and patients can become frustrated when there are not successful outcomes despite all efforts. When I don’t have all the answers for my patients, I sometimes tell them that they are “fearfully, wonderfully made” taken from Psalm 139:13-14, which says: “Truly you have formed my inmost being; you knit me in my mother’s womb. I give you thanks that I am fearfully, wonderfully made; wonderful are your works.”

Special thanks to Dr. Natalie Manalo, a local neurologist, migraine specialist and Catholic Medical Association member, who kindly reviewed this document before publication.