Migraine aura is a visual disturbance that usually precedes the headache in about 20% of migraine sufferers. The aura can sometimes occur without a headache and some people, myself included, always have migraines and auras independently of each other. A typical aura usually lasts 20-30 minutes and consists of partial loss of vision on one side of both eyes, or flashing lights, colored zigzags, or tunnel vision. Most headache specialists and neurologists have always believed that most people have an aura first and when it resolves, the headache begins. A study by Dr. Jakob Hansen suggests that this may not be the case. He examined diaries of 201 adults who experienced 861 migraine attacks and discovered that in 61% of attacks the headache was present within 15 minutes of the onset of aura. Nausea was present in 40%, sensitivity to light (photophobia) in 84% and to noise (phonophobia) in 67% within 15 minutes of the onset of visual aura. I have heard from some of my patients similar reports of a headache and aura starting at the same time, but it seemed that those were a small minority. I will have to be more thorough in questioning my patients. One practical application of this finding is that we usually tell patients who use injectable sumatriptan (Imitrex) to treat their migraine attacks to wait for the aura to resolve and then take the injection. The reason for this delay is a perception that the injection will not help if taken during the aura phase. It is speculated that if the medicine gets into the brain circulation before pain starts it may not be able to attach itself to certain receptors. We do recommend taking a tablet as soon as the aura starts because it takes at least 30 minutes for a tablet to be absorbed. If Dr. Hansen’s results are confirmed, then most people should not wait to give themselves an injection of sumatriptan.
Since we are on the subject of injections, I should point out that they are extremely underutilized. Doctors usually prescribe them if the patient has severe nausea or vomiting and cannot hold down the pill. However, an injection may also be very useful for someone who wakes up with a headache without severe nausea, but they know that the tablet may take 2 hours or longer to provide relief. Taking an injection, which can stop the headache within 10 – 15 minutes, can make a difference between being able to go to work or not. I sometimes take an injection even when I have a mild migraine if it happens at night. The tablet will usually work, but I may have to wait for two hours before I can fall asleep, so I take a shot. From left to right 3 types of sumatriptan injectors: Alsuma, Sumavel, Imitrex injections.

Children with epilepsy are more likely to suffer from migraine headaches than children without epilepsy, according to a study just published in Neurology by researchers from Johns Hopkins University. Dr. Sarah Kelley and her colleagues studied 400 children who were seen at an epilepsy clinic. They discovered that 25% of children with epilepsy also suffered from migraine headaches. Children aged 10 and older, as well as those with JME (juvenile myoclonic epilepsy) and BECTS (benign epilepsy with centrotemporal spikes) were more likely to have migraines than younger children or those with other types of epilepsy.
Unfortunately, pediatric neurologists who were seeing children who had both epilepsy and migraines (with migraines occurring once a week or more) did not discuss their migraines in half of such cases. Primary care doctors treating adults have also been shown to ignore complaints of migraine headaches in many patients, but in this study doctors were pediatric neurologists and they should know better. The education of all doctors, including adult and pediatric neurologists in the treatment of headaches leaves a lot to be desired. Many prominent neurology programs, including those at Cornell, Yale, NYU, and other medical schools lack a dedicated headache specialist. This is probably due to a combination of factors, including low prominence of headaches as compared to conditions such as epilepsy, Alzheimer’s, strokes, and MS, as well as lack of funding for research and lack of faculty trained in headache medicine.
Parents of children with migraines also sometimes minimize the seriousness of migraine as compared to epilepsy, however migraine is often more disabling than epilepsy, even if it is less dramatic in its manifestations. Migraine is highly treatable condition and children often do very well with biofeedback, magnesium, CoQ10 and other supplements and in case of very frequent attacks, Botox injections. If these, safer treatments fail, medications can be very effective. We use both abortive medications, such as sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig), eletriptan (Relpax), almotriptan (Axert) and other triptan drugs, as well as prophylactic medications, such as beta blockers (blood pressure medications), some epilepsy drugs, and antidepressants (although some antidepressants can make seizures worse). If the pediatric neurologist is aware that the child also has migraine headaches she may decide to use an epilepsy drug that can help both conditions. Migraines improved in about 28% of children in this study when they were prescribed an epilepsy drug, but this number potentially might have been higher if doctors were aware of the migraine diagnosis. None of the children with weekly or more frequent migraines were prescribed a triptan drug.

Until now, migraine headaches have not been associated with erectile dysfunction (ED). A study by Taiwanese doctors published in journal Cephalalgia makes a strong case that such a connection exists. The researchers analyzed electronic records of one million patients randomly selected out of almost 24 million who are covered by the Taiwan National Health Insurance. They eliminated from this analysis patients with mental illness and they also controlled for hypertension, diabetes, obesity and other condition known to cause ED. Men who suffer from migraines were 1.6 times more likely to have ED. Surprisingly, younger men with migraines, aged 30 to 39 had the highest risk of having erectile dysfunction – they were twice more likely to have ED than men of that age without migraines. The causes for this association are not clear. We do know that patients with chronic pain are more likely to have sexual dysfunction. We also know that migraine patients have impaired regulation of their brain blood vessels, so it is possible that penile blood vessels are also affected. Men are less likely to see doctors for all medical conditions compared to women and this includes migraines – I see about ten times as many women as men, while we know that women outnumber men only by 3 to 1 ratio. This may apply even more to such an embarrassing condition as sexual dysfunction, making these young men suffer unnecessarily from both migraines and ED. Encourage men with migraines to see a doctor, while in the office they may also get help for their sexual dysfunction, if they have it.

Many migraine sufferers complain of headaches on weekends, vacations, or after a period of stress. Researchers at the Montefiore Medical Center in the Bronx confirmed this observation by observing 17 migraine patients. The patients completed over 2,000 twice daily diary entries about their headaches and the amount of stress they had. The doctors found that patients had 20% higher chance of developing a migraine 12 to 24 hours after their mood changed from “sad” or “nervous” to “happy” or “relaxed”. There are several possible explanations for this phenomenon. One, is that some people have a certain amount of control over their headaches and do not allow themselves to have a headache when they know that they have to perform important functions, but as soon as this demand ends, they pay for the stress by getting a headache. Another possibility is that sleeping longer on weekends, vacations, or after the stress is over, triggers a migraine. Migraine sufferers can be very sensitive to changes in their sleep schedule with both too much and not enough sleep being a trigger. Weekend headaches can be also triggered by caffeine withdrawal – drinking your first cup of coffee at 10 instead of 8 in the morning.

Sinus inflammation can seriously worsen migraine attacks according to a recent presentation by Dr. V. Martin and his colleagues made at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles. Migraines are often mistaken for sinus headaches because pain of migraine is often felt in the area of sinuses and many migraine attacks are accompanied by a clear nasal discharge. These patients will naturally first see an ENT specialist and often undergo treatment with antibiotics and even surgery before the diagnosis of migraine is considered. However, sinus inflammation, both allergic and non-allergic in nature, can coexist and worsen migraines and increase disability caused by migraine according to these new findings. Many neurologists will often dismiss the diagnosis of sinus headaches and proceed with treating only migraine symptoms. On the other hand, many patients and ENT doctors will focus solely on treating sinus disease and ignore the possibility of migraines. As a neurologist, I also tend to be biased in the direction of migraine headaches, however, but now will try to always consider the possible contribution of sinus disease as an aggravating factor. This study may explain why some of my patients with definite migraines will often report at least some improvement from sinus or allergy medications.

Air pollution has been shown to worsen migraine headaches. Connection between pollution and risk of heart attacks has also been established. A recent study showed that even low levels of particulate matter can increase the risk of a stroke. Doctors looked at 1,705 patients who were admitted to the hospital with an acute stroke and checked pollution records on the days these strokes occurred. They found that strokes were more common within 12 hours of the rise in the level of pollution. The correlation was linear – the higher the pollution, the higher the risk of stroke. The risk of stroke was elevated even at pollution levels considered “satisfactory”.

Weather is a common trigger of migraine headaches. Review of studies linking weather to migraines suggests that there are three weather-related triggers. It is high humidity, high temperature, and drop in barometric pressure. Some migraine sufferers, just like many people with arthritis, can predict rainy weather. We can speculate that the drop in barometric pressure causes blood vessels inside the skull to dilate and trigger a migraine. This happens because of faulty regulation of blood vessels in those with migraine. This is also probably the reason why migraines are sometimes caused by exercise or sexual activity – blood vessels dilate excessively and trigger a migraine. High altitude headache or mountain sickness is another example of headaches caused by low barometric pressure. In fact, one study showed that people living at high altitudes, specifically in Denver, are more likely to have mgraines than those living at sea level. Treatment of barometric pressure headaches involves the usual approaches to migraines – regular exercise, biofeedback, magnesium, CoQ10, Botox, and drugs. Diamox (acetazolamide) is a diuretic drug that is particularly effective for mountain sickness and in some patients can also prevent weather-related headaches.
It is not clear why high humidity causes headaches, but high temperature may lead to a) dehydration, which is a trigger of migraines for many and b) again, dilatation of blood vessels which the body uses to cool itself by bringing more warm blood to the surface (this is why we look red in the heat).
There is an easy way to figure out if your headaches are triggered by weather – download our free app into your iPhone or iPad. Headache Relief Diary (also known as Migralex Diary) automatically downloads barometric pressure, humidity and temperature at the time of your headache. Just enter your zip code once and enter your headache information every time you get one and after a month or two you may be able to find your migraine triggers, including those related to the weather.

Headache is one of the most common complaints reported by patients suffering from AIDS, according to a new study by researchers from the University of Alabama. They evaluated 200 patients with HIV/AIDS and discovered that 107 or 54% of them had headaches. Only 4 of these patients had a serious underlying cause, while 88, or 44% had migraines and the rest had tension-type headaches. This is a much higher incidence of migraines than in the general population, where only 12% have migraines. The severity of HIV (CD4 cell count) correlated with the headache severity, frequency, and disability. The findings of this study suggest the importance of diagnosing and treating migraines in this population which already has reduced quality of life and which migraines make even worse.

Smoking by the mother during pregnancy increases the risk that the child will suffer from headaches. Brazilian researchers published results of their study in the journal Cephalalgia. They collected information on over 1,600 children aged 10 – 11 years and discovered that children of mothers who smoked 10 or more cigarettes a day were more likely to suffer from tension or migraine headaches. Surprisingly, exposure to second-hand smoke was not associated with an increased risk of headaches in children.

Depression is more likely to occur in people with migraines, but migraines are also more likely to develop in those who suffer from depression first. A new Canadian study reexamined this link in 15,254 people. They confirmed this association, but unlike in previous studies the researchers from Calgary discovered that this bi-directional relationship is symmetrical. That is, if you have migraines you are 80% more likely to develop a major depressive episode, but if suffer from depression first, you are only 40% more likely to develop migraines. They found that childhood trauma and stress may be a contributing factor to both conditions. The authors of the study discuss the fact that common genetic abnormalities may also predispose people to both conditions.