Genetic analysis of 594 members of 134 families by Spanish researchers confirmed the results of a previous study that discovered a genetic abnormality on the sixth chromosome that seems to be associated with migraines. This genetic marker is present only in a small proportion of migraine sufferers, but it is very likely that there are several or many other genetic abnormalities that predispose to migraine. In patients with familial hemiplegic migraine very specific genes have been identified, but even in this rare form of migraine different families had different genes that were abnormal. This wide variety of genetic factors will make it difficult to develop genetic therapies for migraine, when such therapies become available (probably 10 or more years from now). However, people who have genetic abnormalities are only predisposed to having migraines, but not necessarily will have them. This predisposition makes it more likely that the person will develop migraines, however, avoiding triggers and improving general health may prevent or at least reduce the frequency and the severity of attacks.

Women who suffer from both episodic and chronic migraines are more likely to have widespread chronic pain, which is often diagnosed as fibromyalgia. Brazilian researchers evaluated 179 women with episodic and chronic migraine. They discovered that the more frequent were their migraine attacks, the more likely they were to have widespread chronic pain. A likely explanation of this association is the phenomenon of allodynia. Allodynia is an increased sensitivity of the skin during and after a migraine attack, which affects many migraine sufferers. Patients often report not being able to brush their hair or wear glasses because the skin becomes very sensitive. This skin sensitivity can spread from the face and scalp to involve the upper body. It is logical to assume that with frequent migraine attacks this sensitivity spreads and can involve the entire body. This sensitivity is is a reflection of increased excitability of brain cells, which has been documented to be present in migraine sufferers. If migraines are frequent and are left untreated, this increased excitability can become persistent and may predispose to other chronic pain conditions. The obvious important lesson of this study is that migraine headaches need to be treated aggressively in order to avoid the development of additional pain syndromes and impaired quality of life. This treatment should utilize all available approaches – abortive drugs such as triptans (as well as Migralex and NSAIDs), and prophylactic therapies, including aerobic exercise, biofeedback, magnesium, CoQ10, Botox injections and prophylactic drugs.

Cyclic vomiting in childhood is often a precursor of migraines in adulthood. Usually a child has attacks of vomiting with or without a headache that can occur 10 – 20 times in a 24-hour period. Most children have family history of migraines and as they get older they develop migraines themselves. A study from the Cleveland Clinic led by Dr. David Rothner (a regular speaker at our annual headache symposium) shows that one third of these children may actually have a metabolic disorder and not just migraine. Most children feel perfectly fine between these episodes of vomiting. If these attacks are frequent Dr. Rothner recommends amitriptyline (Elavil), cyproheptadine (Periactin), and ondansetron (Zofran) to treat this condition. Some of the metabolic disorders could be possibly treated with supplements such as CoQ10, riboflavin (vitamin B2), as well as magnesium.

High blood pressure is not a common cause of chronic headaches. The pressure has to suddenly increase (from say 100/70 to 150/90) or to be very high (like 170/110, or higher) to cause a headache. Mild hypertension is called a silent killer because it does not cause headaches or any other symptoms for many years. Doctors have been debating for a long time what to consider normal blood pressure. A study by University of California researchers just published in Neurology looked at 12 previous studies that involved over half a million people. They determined that what was considered normal blood pressure in the past (130-139 systolic and 85 to 89 diastolic, sometimes called “prehypertension”) in fact is associated with a significant increase in the risk of strokes. This has a practical application in people suffering from migraine headaches. One of the three categories of drugs used for preventive treatment of migraines is drugs used to treat high blood pressure. So, someone with blood pressure is 130/85 may want to request that the doctor prescribes a blood pressure medication rather than a drug from two other categories – epilepsy drugs (Topamax, Depakote, Neurontin) or antidepressants (Elavil, Pamelor, Effexor, Cymbalta, etc). Fortunately, in most cases blood pressure medications tend to have fewer side effects than drugs in the other two categories. Some of the blood pressure medications that have been shown to be effective for the prevention of migraines are beta blockers, such as propanolol (Inderal), timolol (Blocadren), atenolol (Tenormin), nebivolol (Bystolic), and ACE receptor blockers (ARBs), such as candesartan (Atacand) although other ARBs, such as olmesartan (Benicar) may be also effective. Not all blood pressure drugs are equally effective for the prevention of migraine headaches. Calcium channel blockers, such as verapamil (Calan) and amlodipine (Norvasc) and diuretics are probably less effective.

Having migraines with aura increases the risk of having increased total cholesterol and triglycerides. This was found to be the case in a population-based study of 1,155 older people (average age 69) presented by Dr. Tobias Kurth at the International Headache Congress in Berlin. Although only 23 had migraines with aura the statistical data seems strong enough to warrant this conclusion. Having migraine with aura carried a six-fold increase in the risk of having abnormal levels of lipids. It is an established fact that people suffering from migraine with aura are at slightly higher risk of strokes and heart disease but the reason for this association is not known. It is possible that elevated cholesterol and triglycerides in those with migraine with aura lead to cholesterol deposits and clogging of the arteries. It is important to screen all older patients with migraine with aura for abnormal lipid levels. They also need to exercise and try to control other risk factors for strokes and coronary artery disease, such as high blood pressure, high blood glucose, obesity, and smoking.

Difficulty thinking and speaking is not unusual at the onset of a migraine attack. It is not always severe as with the reporter Serene Branson who jumbled words and appeared confused on camera. Many patients report that they have difficulty finding words, remembering well known facts, or unable to say what they want to say. This often happens at the beginning of a migraine attack, according to a study presented at the last scientific meeting of the American Headache Society. The doctors tested attention, processing speed, visual-motor reaction, and other brain functions and found that many patients had significantly lower scores at the onset of a migraine than between attacks. They also found that there was no correlation with the severity of pain – you can have severe cognitive dysfunction with a mild headache. Similarly, many patients get a very severe headache after a visual aura but others get a mild headache or no headache at all. There are no acute treatments that would stop an aura or the cognitive brain dysfunction once it starts. However, preventive treatments can be very effective. We always start with elimination of triggers, aerobic exercise, biofeedback, magnesium (sometimes intravenously) and CoQ10 supplements, and then Botox and preventive drugs. Some patients find that after the first Botox treatment they no longer develop a headache, but may still get an aura or have some other warning symptoms, including cognitive dysfunction. However, with repeated injections of Botox both headaches and other symptoms subside. This probably happens because with fewer headaches the brain becomes less irritable and stops generating auras and other neurological symptoms.

Abdominal migraine was the subject of a study by a group of doctors from a children’s hospital in Norfolk, VA was just published in the journal Headache. The physicians examined the records of 600 children with recurrent abdominal pain. They found that 4% of these children had definite and 11% had probable abdominal migraine. Shockingly, they also discovered that none of these children received correct diagnosis. Making a correct diagnosis is the first step to the correct treatment of this condition. Abdominal migraine is defined as a recurring condition which consists of abdominal pain, typically lasting one to 72 hours. The pain is usually in the middle of the abdomen or the child cannot localize it precisely. The pain is dull and aching and is of moderate or severe intensity. During the bout of pain the child usually has two other of the following features: loss of appetite, nausea, vomiting, or paleness. It is also very important for the doctors to make sure that there is no other possible cause for these attacks. Treatment usually involves avoiding foods which may trigger these attacks, including chocolate, caffeine, hot dogs, cheese and other known migraine-inducing foods. Irregular sleep schedule, skipping meals and stress are also frequent triggers. Regular sleep schedule, frequent exercise, biofeedback or relaxation training can all help. Magnesium and CoQ10 supplements have also been shown to help prevent migraines in kids. Migraine medications, such as sumatriptan (Imitrex) can be tried for severe attacks. When abdominal migraine occurs frequently preventive drugs, such as amitriptyline (Elavil), gabapentine (Neurontin), or cyproheptadine (Periactin). Considering its safety and efficacy in regular migraine, acupuncture may also be worth a try.

Dissection of the cervical artery is a dangerous condition which can lead to a stroke and even death, although in some it can be a benign condition with no lasting effects. A recently published study by Germain researchers in the journal Cephalalgia indicates that this condition is two times more common in people with migraine headaches. Dissection means that the wall of the artery is split and this can close off blood flow in the artery. In most people closing off of an artery is not a problem because there are 4 arteries in the neck that carry blood to the brain. However, in some one artery carries a large portion of the blood and the remaining 3 arteries cannot compensate, leading to a stroke. The dissection usually causes severe neck pain and if blood flow is compromised it also leads to neurological symptoms, such as a droopy eyelid, weakness or numbness on one side, difficulty speaking and other symptoms of a stroke. Neck pain is often the earliest and in benign cases the only symptom. Because migraine sufferers frequently have neck pains, this complaint can be dismissed by doctors as a symptom of their migraine. So, if someone’s neck pain is very severe and different from their usual neck pains it is very important to seek medical attention and insist on an evaluation. The diagnosis is made my an MRA (magnetic resonance angiography) scan. This increased risk of dissection is another reason why migraine sufferers particularly should avoid chiropractic adjustments, which can result in dissection even in non-migraineurs.

Migraine headaches are very common in chronic fatigue syndrome (CFS) sufferers, according to a new study just published by researchers from Georgetown University. Migraine headaches were present in 84% of patients with CFS (60% had migraine without aura and 24% had migraine with aura) and tension-type headaches were present in 81% of CFS sufferers. Only 4% of CFS patients had no headaches at all. This compares to 12% of the general population, or 18% of women (two thirds of CFS patients were women) who suffer from migraines. Fibromyalgia (diffuse muscle pains in four quadrants of the body) was much more common in CFS patients with migraines (about 50%) compared to healthy controls. The authors speculate that the same brain disturbances which cause migraine headaches may be also responsible for the fatigue in patients with CFS and that successful treatment of migraines may improve symptoms of CFS. It is well known that migraine sufferers have increased excitability of their brains, even between attacks, compared to healthy individuals. This may be why migraine sufferers are more likely to have other pain syndromes, such as fibromyalgia, back pain, irritable bowel syndrome, TMJ syndrome, and other. More importantly, several treatments have been shown to be effective (to various degrees) for all of these conditions. These include biofeedback and cognitive-behavioral therapy, tricyclic antidepressants, acupuncture, and aerobic exercise.

Temporo-mandibular joint disorders (TMD) have long been known to be associated with headaches.  A very interesting study conducted in Brazil and published in the Clinical Journal of Pain examined this association in 300 patients with TMD. The researchers carefully evaluated the type of TMD and its severity as well as the type of headache that might have been also present. Compared to those without TMD, patients with myofascial type of TMD were more likely to have chronic daily headaches, migraines and tension-type headaches. The more severe was TMD pain, the more likely it was that these headache conditions were present. An important question which is not answered by this study is, what comes first – TMD or headaches? It is likely that having one condition can cause and make the other worse, forming a vicious cycle. I see patients who can clearly identify that they first developed pain in the jaw and then headaches came along, but treating only their TMD does not seem to help. There are many more patients who present with headaches as the main complaint but who also have TMD. The treatment should always be directed at both conditions and many treatments we use have been shown to be effective for people with only TMD or only headaches. These treatments include regular aerobic exercise, biofeedback, acupuncture, Botox injections, massage, and medications. The list of medications include NSAIDs, such as aspirin (or Migralex), Advil, and Aleve, antidepressants, such as Elavil, Pamelor, and Cymbalta, epilepsy drugs, such as Neurontin and muscle relaxants, such as Zanaflex.

Vertigo and dizziness are common in migraine sufferers.  It is much less common for vertigo to be the only symptom of migraines.  This seems to be the case with vertigo that begin at menopause, according to a recent report presented at the last meeting of American Academy of Neurology.  The report describes symptoms in 12 women, so its conclusions cannot be accepted as definitive.  All of the women had history of menstrual migraines and all had a normal ear-nose-throat examination and a normal MRI scans.  They all suffered from vertigo for at least a year.  Treatment with standard migraine medications and hormonal therapy reduced attacks of vertigo by 50% and was more effective than non-hormonal treatment alone.  It is not surprising that the hormonal therapy helped because some women with menstrual attacks also improve with hormonal therapy, such as continuous contraception.  This report should raise awareness of the fact that menopausal women with vertigo may be suffering from migraines and may respond to hormonal and migraine therapies.