Both more and less sympathy for migraine sufferers

If half of your head has a pain

And you’re sure that it is migraine

     It only figures

     Avoidance of triggers

Beats having the problem again

I had my first migraine when I was 26.  I’ve had three since.  I figured out the circumstances precipitating the event and I have avoided them.  

When the first one hit I thought I was having a stroke.   The beautiful flashing lights puzzled but did not displease me; I didn’t have the medical background at that time to be able to give them their proper name, scintilliating scotoma.  Most of the left half of my vision blanked out, and, as a second year medical student at the time, I thought to myself “left-sided bilateral hemianopsia.”   Then the nausea and the blinding, hammering pain started and made me sure, for about two hours, that I would end up crippled if not dead.  After the pain left and I got back to Michigan and out of a sociologically hostile environment, I figured out I’d had a migraine.

My sister had been having them for years.

I had my next migraine my first week as a third year med student in Saginaw, Michigan, during a gratuitously hostile instructional session.  We were supposed to learn how to do peripheral smears of our own blood, but mostly the lecturer convinced us of our dangerous incompetence.

I have taken care since then to bring an ally with me if I go someplace hostile, and I’ve only had one migraine since.

I still get the aura, the neurological warning shot across the bow.  The beautiful yellow and blue lights, spread slowly in shimmering bars in a semicircle across my vision.  Most of the time I have to keep working, but on two occasions I’ve been able to just kick back and shut my eyes and watch the light show.

The experience gave me sympathy for people with migraines.  It also taught me to approach the problem by teaching avoidance of triggers.

On the other hand, I don’ t have a lot of patience for people who keep doing things to get migraines and then ask me for Vicodin, Percodan, or Lortab.

Diagnosis of migraine properly would take about ten pages, and remains far from simple.

(I had a patient with a long history of migraines that experienced a change in headache pattern, and only because I listened well could I determine the necessity of an MRI, which in turn led to treatment and thus avoided  death.  Another patient with more talent for dramatics than communication needed a sequence MRIs and a really, really sharp neurologist colleague to find three aneurysms. The pathological evaluation showed giant cell arteritis inside two of them.  The patient fired me anyway.)

If I have a firm diagnosis of migraine, I divide the current frequency by four, and ask the patient if that would a “good enough” goal; most respond enthusiastically in the  affirmative, and we talk about triggers:

     Nicotine.  Of course I tell smokers to quit, but especially migraineurs.  Some express surprise on hearing that nicotine causes migraines

     Caffeine.  A distressing percentage of migraines are really caffeine withdrawal headaches.  To put it another way, caffeine relieves the headache only because the person hit the caffeine withdrawal threshold.  I tell the patient to cut the caffeine intake by one dose per day till they get to zero, and then avoid caffeine completely for 2 weeks, then rechallenge.  Most don’t rechallenge. 

     Alcohol.  Yes, strangely, hangovers include headaches.  Some people only have their migraines after drinking.

     Sleep.  Too much or too little sleep can precipitate migraine in a lot  of people

     Nutrasweet.  Just one more reason to avoid artificial sweeteners.

     Cheese.  This low-item applies to a very small minority of migraine sufferers

     Hot dogs:  This is an even lower yield item.  Most people who get the hot dog headache know it before they get to me and have stopped eating hotdogs.

     Hormonal Birth Control:  Bad migraines in the presence of prescribed hormones greatly increases the risk of disabling stroke.  Thus I ask about migraines (and other things) before I prescribe birth control pills.  Or patches.  Or shots.  Or rings.

     Pain reliever overuse.  People sometimes get into a cycle of using increasingly frequent doses of ibuprofen, acetaminophen, naproxen, or aspirin to stop the headaches, and don’t realize that so much analgesic use leads to worsening migraines.  Those cases can be very difficult to treat, and on occasion I’ve hospitalized patients to do so.

Ninety percent of my migraine patients get to goal with no medication. 

Ninety percent of the rest get to goal on 10 to 20 mg of propranolol a day.

After that it’s a toss-up between other daily medications and acupuncture.

A very few patients can tolerate no migraines at all, and they get prescriptions for triptans.

If a patient shows up with a migraine in progress, I order a 60 mg injection of ketoralac.

I NEVER prescribe narcotics for migraines.


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2 Responses to “Both more and less sympathy for migraine sufferers”

  1. vaguelycrazy Says:

    I learned a term I have always wondered about – scintillating scotoma. Thanks! I’ve never been able to adequately describe the light show to people but now I can send them right to the wikipedia entry. My migraines have disappeared and now I only get slight headaches but they are always prefaced by the light show, which is actually very uncomfortable for me.

  2. Deena Says:

    Not everyone knows they have migraines, or is given proper advice- so you should probably rethink some of your variables.

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