New Treatment Options for Women with Migraines

Carolyn Bernstein was sitting in a lecture hall one day during her second year at Boston University Medical School when her head began to pound and throb. She became dizzy and disoriented and felt so weak she thought she would faint. Bernstein managed to leave class and get home, where she collapsed into bed. She was suffering from her first migraine and she soon found out that there was no easy treatment. Bernstein says migraineurs—people who get migraines—are too often treated with condescension by doctors who tell them to "just deal with it."

Her experience led her to specialize in migraines. In addition to being on the faculty at Harvard Medical School, she also runs the Women's Headache Center in Cambridge, Mass. Unfortunately, such centers are rare and most migraineurs still struggle to find help. Bernstein says that's why she wrote her new book, "The Migraine Brain" (Free Press, 2008). Each migraineur's experiences are unique, Bernstein says. Some have attacks that last only a few hours; others can be in pain for days. Women are more likely to get migraines than men, for reasons doctors still don't fully understand. Migraines can't be cured, only treated with a range of medication and lifestyle changes. "I want to encourage people to seek help and not feel alone," Bernstein says. We asked Bernstein for a quick rundown on the science of migraines. Excerpts:

What is a migraine and why isn't it a headache?
Carolyn Bernstein: A migraine is actually part of an entire disease process and a headache is basically just pain in your head. Migraines are a constellation of symptoms that can include head pain but often times will include other symptoms as well, like nausea and vomiting. They can include changes in vision and abdominal pain. Some of the more-complex migraines can actually cause people to look like they are having a stroke. They are weak on one side or the other, and they have sensory changes. It's not nearly as clear-cut and straightforward as a headache, and it implies that something else is going on in the nervous system.

Is there any one symptom that defines a migraine?
There are many, many different kinds of described migraines. In order to make the diagnosis, you have to meet a certain diagnostic criteria, based on the number of headaches that you've had. If you've just had one headache with nausea and vomiting and some visual changes, you couldn't technically call that a migraine. You need to have had at least two. For kids, it has to be four or more.

Migraines don't always include the headache. There are some kinds of migraines, called migraine equivalents, where people will just have the visual symptoms, sometimes called the aura, but they will not have pain. Those can be hard to diagnose.
The question in the back of people's minds when they start to get one of these—and they are so dramatic and so extreme compared to a tension headache—is "Am I having a stroke? Do I have a tumor? Do I have an aneurysm that's bleeding in my brain?" The initial attack that you have is the one that you need to get checked out.

Would you advise someone who's had just one attack like this to tell her doctor about it?
Absolutely. You want to get a diagnosis. It can be really helpful in treatment. There are certain kinds of medication for other conditions that you shouldn't take. For women in particular, certain kinds of migraines are actually associated with an increased risk of stroke if you are taking birth control pills.

How is a "migraine brain" different from a regular brain?
It's a brain that's hyperexcitable. It's a brain that's more sensitive than the brain of someone who doesn't have migraines. Cells in the brain of a person with migraines tend to get irritated or excited and begin to send off signals when they shouldn't, whereas the brain of someone who doesn't have migraines probably wouldn't react.

There are certain triggers like bright lights or flashing lights. You could be very sensitive to alcohol. If you go to a party and have just a sip of wine, you could get a migraine. The brain of someone who doesn't have those triggers, who doesn't have those hyperexcitable brain cells, would be able to tolerate light or a night with no sleep or hormone changes that begin a menstrual period without having any symptoms like this.

What is going on in the brain that causes pain?
The abnormal discharging of the cells moves forward—to use a medical term, it propagates. And that means it travels through the brain. It can do a couple of things. It can trigger off pain centers, a lot of which run through a part of the brain called the thalamus. Most kinds of pain are modulated through that. What we think now is that the migraine discharges irritate and cause firing in a nerve called the trigeminal nerve. The trigeminal nerve is a nerve that supplies sensation and modulates pain in one side of the face or the other.

These cells that are a little too finicky begin to fire, the impulse moves forward through the brain and then they trigger off a nerve that is very, very irritable. When the nerve begins to fire, that's when the pain starts. There are probably a couple of other pieces of the pain; people disagree about precisely which is the causative factor. My feeling is that it is a little bit different for different people, but one way that the pain may be modulated is by a spasm of blood vessels in the brain. It is validating for people with migraines to hear this because they know there is a reason for what they are feeling.

Why are women more likely to get migraines than men?
It is probably related to hormones, but there may be something about women's physiological makeup that makes them more likely to have migraines. The most clear-cut reason is hormonal fluctuations. Until the age of about 12, boys and girls have migraines at about the same rate. Then the girls just take off. That's right around the time of puberty. For a lot of women, the headaches go away at menopause. So there are actually not a whole lot of women in my practice over the age of 60. Most of them are between 20 and 50.

If you think about a brain that's very sensitive, you can postulate that if there are changes in hormone levels causing all kinds of physiological changes, some of those are enough to trigger migraines. One component that's well described is menstrual migraines. If you get a migraine at the start of bleeding consistently, that would be consistent with menstrual migraines. There are other women who get hormonal headaches. They get headaches around the time of ovulation as well. There are probably very potent changes that we're just beginning to understand. You have to keep a journal and chart your periods with your headaches and see what correlation you can find.

What kinds of medications relieve symptoms?
There are a number of medications that are really helpful, and in the book I divide them up into preventive, abortive and rescue medicines. Preventive medications would be something that you take every day or you take for a set amount of time. Abortive medicines would be something that you take just as a migraine is starting to stop it. The rescue medicines are a last ditch.

I use something called the MIDAS. It stands for migraine index disability assessment score. It helps you figure out how many days over the last three months you were affected by the migraines. Based on that number, it divides you into mild, moderate or severe. I think that's really helpful.

Can lifestyle changes help?
Some people are really sensitive, and they need to get the same amount of sleep every night or they will get a migraine. Exercise can be really helpful. In addition to overall wellness, when you exercise, you get to a certain point where your body starts to make beta endorphins, chemicals that make you feel better and decrease pain. If you can exercise consistently, that can really help. A lot of people are taught the old food triggers of cheese and chocolate and red wine, and what we have found is that none of these except possibly red wine are known migraine triggers. As for cheese and chocolate and preservatives, it's very individualized. With our busy lives, we tend to eat really badly. And one thing that I think helps is to try to keep your glycemic index steady. What you want to do is try to keep your blood sugar from fluctuating tremendously by eating small amounts of food that are really nutritious fairly frequently during the day.

What kind of a doctor should you see if you have migraines?
In the ideal world, everyone would have access to a headache center with neurologists who have training in taking care of patients who get headaches. But it doesn't always happen. One thing that patients can do is to try to educate themselves and take that information to their physicians. It's important to find someone who is empathetic.