Before enlisting in the United States Army and being sent to Iraq as a supply clerk in 2003, Jessica Lynch experienced migraines a few days a month. Her mother had them too. She considered them tolerable and treated them with over-the-counter (OTC) migraine medications.
That all changed after Lynch's convoy was ambushed in April 2003. Her vehicle was struck by a rocket-propelled grenade in the ensuing firefight, and Lynch was knocked unconscious and seriously injured. She was captured by Iraqi forces and brought to the local hospital where she was held prisoner while being treated for her injuries. Eight days later, she was rescued in a dramatic nighttime raid by US Army Special Forces.
At 19, Lynch became the first female American prisoner of war (POW) in history and the first POW successfully rescued since the Vietnam War. At the time she was hailed as a hero, but Lynch considers her colleagues, 11 of whom died in the ambush, the real heroes.
After her return from the Middle East, Lynch's migraines became more frequent—as many as two to three per week—and more severe. "It was so bad that I would shut off all lights and hide," Lynch recalls. She sustained other injuries in the ambush, which required numerous operations and years of recovery. Her migraines seemed minor by comparison—one reason she waited 12 years before asking her family doctor for help. He referred her to a neurologist and headache specialist, David Watson, MD, FAHS, associate professor of neurology and director of the West Virginia University Headache Center at the West Virginia University School of Medicine.
More Than a Headache
It is estimated that 13 percent of Americans experience migraines; women report them more often than men. Common symptoms include severe, throbbing pain; sensitivity to light, sound, and movement; nausea; and vomiting, says Teshamae Monteith, MD, FAHS, assistant professor of clinical neurology at the University of Miami Miller School of Medicine. Less common symptoms include cognitive dysfunction, vertigo, weakness, and numbness on one side of the body that can be mistaken for a stroke.
"The pain feels like someone is hammering the inside of your skull," says Anjan Chatterjee, MD, MPH, FAAN, a professor of neurology at the University of Pennsylvania Perelman School of Medicine who has had migraines since age 4.
A Genetic Disorder
"We believe migraine is a genetic disorder; the majority of [people who get it] are born with a predisposition," says Stephen D. Silberstein, MD, FACP, FAAN, FAHS, professor of neurology and director of the Jefferson Headache Center at Thomas Jefferson University Hospital in Philadelphia. He believes multiple genes are involved and that they interact in complex ways not yet fully understood.
Experts initially suspected that people with migraines had low levels of serotonin, a neurotransmitter involved in processing and interpreting pain signals. Now experts believe the mechanism is far more complex, involving other neurotransmitters, such as glutamate and dopamine. Additionally, there may be differences in the way certain brain regions function and connect in people who experience migraine compared with those who don't. They also believe that excitement or oversensitivity of the trigeminal nerve, a cranial nerve responsible for sensation in the face and movement of the jaw, may be part of the complex process.
Migraines trigger inflammation in and around the blood vessels around the brain, which stimulates the nerve endings in the vicinity of those blood vessels, says Dr. Watson. "The brain becomes oversensitive to signals from those nerves and interprets the information as being painful."
Typical Triggers
Drinking alcohol, not getting enough sleep, eating certain foods, stress, and changes in the weather are all potential triggers of a migraine attack.
People who have migraines may need to avoid monosodium glutamate (found in many packaged and processed foods) and skipping meals—two common triggers, says Dr. Silberstein. Additionally, preservatives, particularly nitrates in hot dogs and bacon, may bring on an attack by releasing nitric oxide, which can relax blood vessels and activate regions of the brain implicated in migraine, says Dr. Monteith.
Doctors recommend that patients keep a diary to look for patterns—foods they ate, environments or situations they were in, things they did—that precede migraines. If they can identify patterns, they can eliminate triggers to help reduce the number of migraines. Of course, not all triggers can be eliminated or identified, and they may provoke attacks inconsistently. Changes in estrogen levels, for example, are a common trigger for women, with increased migraine frequency and intensity just before, during, or after menstruation.
Lynch couldn't identify any obvious food or chemical triggers for her worsening migraines, but her neurologist, Dr. Watson, had several theories. She was doing many talks and presentations about her capture, rescue, and life since Iraq, and the travel and appearances before audiences caused her stress, he says. She also most likely had posttraumatic stress disorder (PTSD) from her combat experiences, and she had difficulty sleeping, which is a known migraine trigger. But Dr. Watson believes the head trauma Lynch sustained in Iraq is most likely the primary reason her migraines became more severe. Head trauma is a common contributor to worsening migraines, he says.
Treating Acute Migraines
People with infrequent migraines usually take nonprescription headache drugs, says Dr. Silberstein. "If OTC medications don't work, prescription migraine medications such as triptans are very effective."
Triptans increase levels of serotonin, which constricts blood vessels and reduces inflammation. They also reduce levels of calcitonin gene-related peptide (CGRP), a neuropeptide associated with pain and inflammation. (Neuropeptides are protein-like molecules used by neurons to communicate with each other.) Triptans are most effective when taken as soon as possible after the start of an attack. Most commonly prescribed in pill form, triptans can also be injected or delivered as a nasal spray, a patch, or a fast-dissolving pill for those who have nausea and vomiting during a migraine and can't keep a pill down.
Dr. Watson prescribed sumatriptan for Lynch. "As soon as I feel [a migraine] coming on, I take the medication, and within a moment it stops it and I'm back doing my normal activities," says Lynch.
Triptans are generally considered safe, but because they constrict blood vessels, they may not be suitable for people with a history of heart attack, stroke, or severe vascular disease.
Ergotamines are another family of drugs used to stop acute migraines. By binding to serotonin receptors in nerve cells, they inhibit pain signals. Most commonly formulated as dihydroergotamine (DHE) because it has fewer adverse side effects than other ergotamines, DHE can be injected by a medical professional or the patient, or administered as a nasal spray. An inhaled form has shown efficacy in large randomized phase 3 trials and is currently under review by the US Food and Drug Administration (FDA).
Preventing Migraines
Preventive medications may be prescribed for people whose migraines are not adequately controlled by acute medications or whose migraines increase in frequency or severity; they are usually taken daily year-round. Women whose migraines are closely tied to their menstrual cycle may be prescribed extended-release medications that are taken only during their cycles. "[Preventive] medications can reduce the severity or the frequency of the attacks, and they can sometimes make acute treatments more effective," says Dr. Monteith.
Generally, preventive drugs are considered appropriate for people who have one or more migraines a week, or four to six a month. Dr. Monteith says she discusses various options and preferences with her patients. So, for example, people who have one to two migraines a week that are easily controlled with an acute medication may not prefer a preventive, while those who have three severe migraines a month that affect them for days afterwards may opt for a preventive.
Most of the preventive drugs were discovered by accident and are used to treat other conditions. For example, some beta-blockers, antiseizure medications, and antidepressants were found to reduce migraine frequency. When choosing a preventive, Dr. Watson says he looks for one with a secondary benefit, such as improving sleep, appetite, or mood. In Lynch's case, because she was having trouble sleeping, Dr. Watson chose amitriptyline, an antidepressant that can cause sleepiness. Since taking it, Lynch says she has less trouble sleeping and experiences fewer migraines—two a month versus two to three a week.
Dr. Monteith involves her patients in decisions about medication. "We go through the different drugs and their potential side effects based on the best evidence from the American Academy of Neurology/American Headache Society guidelines," she says. "We discuss the patients' co-existing conditions and their concerns about side effects." Together they decide which drugs may offer a secondary benefit or are the least likely to have adverse side effects. For example, if a patient is concerned about weight gain, Dr. Monteith will choose a drug that doesn't have that effect. Or she may choose a drug that suppresses appetite, such as the anticonvulsant topiramate.
Promising New Preventatives
The FDA has recently approved two external devices that stimulate the brain or nerves of the head and face using electrical or magnetic pulses—the transcranial magnetic stimulator (TMS) and the Cefaly headband—and one anesthetic procedure to prevent an attack.
Transcranial Magnetic Stimulator
The TMS has been approved for people who experience an aura (a perceptual change such as a bad odor or flashing lights or wavy lines), before their migraines begin. Patients hold the device to the back of the head and press a button to send a magnetic pulse to the occipital lobe, a part of the brain at the back of the head that processes visual information. "The TMS stimulates the brain's surface and calms it down," explains Dr. Silberstein, who says it appears to be relatively safe and have few side effects. It is available only through participating headache specialists as a renewable three-month prescription for $750. Dr. Monteith has prescribed TMS to several patients and is hopeful that it may help those prone to side effects or who have contraindications such as pregnancy.
Cefaly Headband
A lightweight battery-powered device that wraps around the forehead from ear to ear, the headband sends electrical signals through the skin to branches of the trigeminal nerve. It's worn 20 minutes a day. "By stimulating the nerve at a certain rate over a certain period, it inhibits the nerve's ability to transmit pain," says Dr. Chatterjee, who has found relief with the device.
Local Anesthetic
Another preventive approach involves injecting a liquid anesthetic, 0.5 percent bupivacaine, into the sphenopalatine ganglion, a nerve cluster at the back of the nose. The anesthetic is delivered deep into the nasal cavity by a syringe-like device with a catheter at the end. As with the TMS and Cefaly devices, the procedure works on the principle that by targeting a nerve branch on the periphery of the brain, the effect is transmitted to the main branches of the nerve within the brain.
Pinpointing a Peptide
In laboratory experiments, researchers have observed that calcitonin gene-related peptide (CGRP) is released during severe attacks and can provoke migraine pain, Dr. Monteith says. Triptans normalize CGRP levels, and drugs that can lower or alter CGRP levels hold out hope for new therapies. Researchers and pharmaceutical companies are exploring both CGRP antagonists (chemicals that block the action of the peptide) and CGRP antibodies (immune-mediated chemicals that bind to CGRP or its target) to prevent migraines before they begin. Both show promise, but neither is ready for FDA approval.
Other drugs in development include a new type of triptan that it is less toxic for those with cardiac problems. And researchers are working on a device that stimulates the vagus nerve, another cranial nerve, at the base of the skull, says Dr. Silberstein. The idea is that by stimulating this nerve, it may dampen the general excitement of the brain present in migraine.
Don't Delay
Dr. Monteith is hopeful about new treatments, but she thinks more can be done to help patients now. "Too many patients are still not diagnosed. And of those who are, many are not put on preventive treatments. Headache is one of the most modifiable conditions, and when [patients] do get the correct care it's a life-changer."
Lynch agrees. "I wish I had been proactive years ago. I wouldn't have had to deal with years of pain and suffering," she says.
When Migraines Become Chronic
For people who experience 15 or more headache days a month, botulinum toxin (Botox) is the only FDA-approved treatment.
Migraines are categorized as either episodic or chronic. Episodic migraines, which are more common, are diagnosed when people have 14 or fewer headache days a month. Migraines are considered chronic when they occur 15 or more days a month for more than three months.
In the past, chronic migraines were regarded as untreatable, says Stephen D. Silberstein, MD, FACP, FAAN, FAHS, professor of neurology, and director of the Jefferson Headache Center at Thomas Jefferson University Hospital in Philadelphia. Now we know that many people outgrow migraines, he says.
Current treatment includes botulinum toxin type A (Botox), the only US Food and Drug Administration-approved therapy for chronic migraine. The drug is injected into the back of the neck and the muscles in the forehead and at the side of the head. "We believe it works by calming nerve endings; the nerves in the head communicate with the nerves in the brain, quieting them," explains Dr. Silberstein.
Botulinum toxin may break the cycle of chronic migraine, says David Watson, MD, FAHS, associate professor of neurology and director of the West Virginia University Headache Center at the West Virginia University School of Medicine. "In some cases, the degree of reactivity in those areas of the brain is reduced and migraines become episodic." At that point, people can stop using botulinum toxin and return to episodic treatments, he says.
Mind Your Medication
Relying too heavily on one drug too many days of the month can result in medication-overuse headaches. Here's how to break the cycle.
People with migraines who use a medication too often are vulnerable to a cruel trap: Their brain becomes sensitized to the drug in the bloodstream. As soon as levels of the drug decrease, the brain responds by triggering more headaches. People then take more of the drug, which dampens the pain but only until the levels of the drug taper off again, which triggers a new headache, and the cycle continues.
Medication-overuse headaches, previously known as rebound headaches, can occur with both over-the-counter and prescription drugs. Taking too much acute medication can put people at risk for more severe bouts of pain. In extreme cases, people may be hospitalized for a few days to break the cycle, and some may even have to be treated for symptoms of drug withdrawal, such as raised heartbeat and/or anxiety.
It is important to catch and stop this cycle early, not only because it is painful and debilitating, but also because it can lead to chronic migraine. It's also important to determine if the increase in headaches is due to medication overuse or to progression of the headache disorder, says Teshamae Monteith, MD, FAHS, of the University of Miami Miller School of Medicine.
For some people, the simplest remedy is being aware of the risks of using too much acute medication. Physicians can also vary the medications to treat this type of headache. So, for example, if the medication-overuse headache can be attributed to a triptan, a doctor might inject a shot of dihydroergotamine. Once the cycle is broken, patients and physicians should discuss both preventive and acute medications to find a combination that will prevent a future cycle.
Minimize Your Migraine
Headache specialist Dr. Teshamae Monteith routinely shares these strategies with her patients.
- Educate yourself. Learn as much as you can about migraines from accurate, reliable, and up-to-date sources such as the American Migraine Foundation.
- Know your triggers. Keep a headache diary to identify potential triggers, including food, stress, hormonal factors, and changes in sleep or other habits.
- Find a specialist. Ask your doctor for a referral to a headache specialist, who can help you customize a treatment plan.
- Assess your treatment regimen. If a medication isn't working, talk to your doctor about other options. Be patient but don't give up until you're satisfied.
- Stay hydrated. Aim to drink 10 to 12 eight-ounce glasses of water each day to support your body and help reduce attacks. Consider adding sliced cucumber or fruits to your glass or water bottle, for taste.
- Maintain a healthy diet and weight. Commit to eating a whole-food plant-based diet, including whole grains, legumes, vegetables, fruits, and healthy fats. Avoid alcohol, excessive caffeine, red meat, dairy, and processed foods containing a lot of artificial additives. And don't skip meals. Pay close attention to food triggers and record them in a diary. Also, consider following the 2015-2020 Dietary Guidelines for Americans.
- Get moving. Exercise four to five times a week for about 45 minutes to help maintain a healthy weight and increase your energy.
- Manage and reduce stress. Try yoga, biofeedback, meditation, deep breathing, or other relaxation techniques.
- Get adequate sleep. Migraines are linked to lack of sleep, so try to keep a regular schedule of about seven hours of restful sleep per night.
- Invest in yourself. Focus on gratitude, and schedule time for activities that make you feel good, whether that's getting a massage, gardening, volunteering, taking regular naps, or meditating, to minimize the effects of migraine on your quality of life.
- Communicate your needs. Migraine is nothing to be ashamed of. Being accepting and open about it can help you gain support among family, friends, coworkers, and employers.
Help for Headaches
Read our Basics sheet and visit one of these resources.
- American Academy of Neurology
- American Headache Society; 856-423-0043
- American Migraine Foundation; 856-423-0043
- National Headache Foundation; 312-274-2650
