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Military Migraine Topic Sheet

More than 29.5 million Americans suffer from migraine, with women being affected three times more often than men. They are most commonly experienced between the ages of 15 and 55, and 70% to 80% of sufferers have a family history of migraine. Less than half of all migraine sufferers have received a diagnosis of migraine from their healthcare provider. Migraine is often misdiagnosed as sinus headache or tension-type headache.

HOW COMMON IS MIGRAINE IN WAR VETERANS?

Migraine is extremely common in war veterans. In fact, one study reported that 36% of those returning from Iraq after deployment for Operation Iraqi Freedom experienced attacks of migraine-like headaches. Another study reported that 37% of soldiers with concussion injuries had headaches within one week of the concussion. Of these headaches, 91% had characteristics of migraine headache.

WHAT ARE SOME OF THE TRIGGER FACTORS FOR MIGRANE?

Many factors can trigger migraine attacks, such as alteration of sleep-wake cycle; missing or delaying a meal; medications that cause a swelling of the blood vessels; daily or near daily use of medications designed for relieving Stress and/or underlying depression are important trigger factors that can be diagnosed and treated adequately. Blast injuries sustained during combat may also trigger attacks of migraine in returning war veterans.

HOW IS MIGRAINE DIAGNOSED?

  • Pain typically on one side of the head
  • Pain has a pulsating or throbbing quality
  • Moderate to intense pain affecting daily activities
  • Nausea or vomiting
  • Sensitivity to light and sound
  • Attacks last four to 72 hours, sometimes longer
  • Visual disturbances or aura
  • Exertion such as climbing stairs makes headache worse

Approximately one-fifth of migraine sufferers experience aura, the warning associated with migraine, prior to the headache pain. Visual disturbances such as wavy lines, dots or flashing lights and blind spots begin from twenty minutes to one hour before the actual onset of migraine. Some people will have tingling in their arm or face or difficulty speaking. Aura was once thought to be caused by constriction of small arteries supplying specific areas of the brain. Now we know that aura is due to transient changes in the activity of specific nerve cells.

Diagnosis of migraine headache is made by establishing the history of the migraine-related symptoms and other headache characteristics as well as a family history of similar headaches. By definition, the physical examination of a patient with migraine headache in between the attacks of migraine does not reveal any other causes for the headaches.

WHAT CAUSES MIGRAINE?

In most cases the cause is genetic. If one of your parents has migraine then each of their children has a 1 in 2 chance of having migraine while if both parents have migraine then the chance is 3 out of 4. Migraine patients are believed to inherit certain genes that render nerve cells “more excitable” and thus more likely to respond to stimuli in the environment that trigger migraine headaches (stress, lights, hormonal changes, etc). Therefore, migraine patients are thought to have a “hypersensitive brain”.

The pain of migraine occurs when excited brain cells trigger the trigeminal nerve to release chemicals that irritate and cause swelling of blood vessels on the surface of the brain. These swollen blood vessels send pain signals to the brainstem, an area of the brain that processes pain information. The pain of migraine is a “referred” pain that is typically felt around the eye or temple area. Pain can also occur in the face, sinus, jaw or neck area. Once the attack is full-blown, many people will be sensitive to anything touching their head. Activities such as combing their hair or shaving may be painful or unpleasant.

WHAT ARE ABORTIVE AND PREVENTATIVE THERAPIES?

There are two kinds of therapies for migraine- abortive and preventative therapies. Abortive therapies are only used several times per month to treat headaches when they are experienced. Examples include anti-inflammatories (ibuprofen, naproxen, diclofenac), triptans (almotriptan, frovatriptan, eletrigtan, naratriptan, rizatriptan, sumatriptan and zolmitriptan), isometheptane-containing meds, narcotics and butalbital-containing medications. Preventative therapies are given daily in an attempt to prevent migraine attacks. Examples include beta-blockers (propranolol, timolol), calcium blockers (verapamil), anitdepressants (amitriptyline, venlafaxine), seizure meds (topiramate, divalproex sodium, gabapentin), onabotulinum toxin A (Botox®) and muscle relaxants (tizanidine).

HOW SHOULD ABORTIVE MEDICATIONS BE USED?

The Food and Drug Administration (FDA) has approved three over-the-counter products to treat migraine. Excedrin® Migraine (a combination of aspirin, acetaminophen and caffeine) is indicated for migraine and its associated symptoms. Advil® Migraine and Motrin® Migraine Pain, both ibuprofen medications, are approved to treat migraine headache and its pain. Generally, over-the counter medications are best used to treat migraine attacks that have mild to moderate pain intensity as their effectiveness has not been established for more severe attacks.

Prescription anti-inflammatory agents (ibuprofen, naproxen, ketoprofen, ketorolac, diclofenac) may be effective for the entire spectrum of migraines attacks (mild, moderate and severe). They tend to be administered in higher dosages than are typically used in over-the-counter medications. They are primarily given as tablets or capsules, but can also be administered by injection (ketorolac) or in a powder that is mixed in water (diclofenac potassium; Cambia®). These meds can produce inflammation and ulcers of the stomach as well as rare kidney disease. Anti-inflammatories can treat attacks of both migraine and tension-type headaches.

Migraine-specific therapies are medications that designed specifically to treat only migraine attacks and include ergots and triptans. Dihydroergotamine (DHE) is an ergot and can be administered as an injection or nasal spray (Migranal®). Sumatriptan (Imitrex®), a triptan, is available in self-injectable, nasal spray and rapidly-dissolving tablet forms. Other triptans are almotriptan (Axert®), naratriptan (Amerge®), rizatriptan (Maxalt®), zolmitriptan (Zomig®), frovatriptan (Frova®) and eletriptan (Relpax®). All are available in tablet form. Both rizatriptan and zolmitriptan are available in an orally disintegrating tablet (Maxalt-MLT® and Zomig-ZMT®), which can be taken without water. Recently a sumatriptan/naproxen combination tablet (Treximet®) has approved by the FDA and appears to be more effective than sumatriptan tablets alone. Zolmitriptan and sumatripan also comes in a nasal spray. The injectable and nasal sprays can be used in patients that have been vomiting with a migraine attack.

Narcotic medications reduce the pain of a migraine attack, but rarely get rid of an attack. These medications include hydrocodone, meperidine (Demerol®), codeine and propoxyphene. Often these medications are combined with acetaminophen (hydrocodone/acetaminophen (Vicodin®), codeine/acetaminophen (Tylenol #2 or #3®) propoxyphene/acetaminophen (Darvocet®). Recently they have fallen “out of vogue” for the treatment of migraine as recent studies suggest that their overuse may actually produce more frequent migraine attacks called “rebound headaches”. If used, they should not be given more than 2 days per week on average to treat migraine attacks.

Butalbital-containing medications (Fioricet®, Fiorinal®, Phrenilin®, Isocet®) have not been proven to be effective for the treatment of migraine headaches. These medications may have an even greater propensity of producing rebound headaches than narcotics. One study suggested that use of butalbital-containing medications for five or more days per month could lead to more frequent attacks of migraine headache. Therefore, most headache physicians recommend not using these medications for migraines unless patients do not respond to any other abortive medications.

Certain nausea medications can be used as abortive medications for migraine and to treat the nausea associated with the attack. These include prochlorperazine (Compazine®) and metoclopramide (Reglan®). Prochlorperazine can be given orally, rectally or by injection while metoclopramide can be given orally or by injection. Metoclopramide however has a rare side effect of tardive dyskinesia, which causes involuntary movements of the mouth (lip smacking movements) and rigidity of the arms and legs. Since this symptom may not be reversible prochlorperazine (Compazine®) is more commonly used. Another nausea medication call promethazine (Pheregan®) can be used to treat the nausea, but there is little evidence that it aborts the pain of the migraine attack.

Abortive medications are most effective when taken early in an attack, while the pain is still mild and before skin sensitivity increases. The goal is complete relief of pain and associated symptoms, allowing the sufferer to quickly return to normal functioning. Some attacks may not be eliminated by initial abortive medication that had been used. Therefore, it is not uncommon for patients to require a “rescue medication” after the first to reduce its pain severity. Anti-inflammatories and nausea medications are common rescue medications after a use of migraine specific therapies. Patients with prolonged migraine attacks lasting more than 72 hours are experiencing status migraine and corticosteroids may be used in these cases due to their anti-inflammatory effects.

If patients have frequent migraine attacks (greater than 2-5 days per month with migraine), if the attacks do not respond consistently to migraine specific acute treatments, or if the migraine specific medications are ineffective or contraindicated because of other medical problems, then preventive medications should be given to reduce the migraine frequency and improve the response to the acute migraine medicines. Patients should be aware that it may take 1-2 months after the start of a preventative medication to see an effect. In addition, it may be necessary to increase the preventative medication over time. Therefore, a trial of a preventative medication may take 3-4 months to determine if its effectiveness.

The FDA has approved four drugs for migraine prevention. These include propranolol (Inderal®), timolol (Blocadren®), topiramate (Topamax®) and divalproex sodium (Depakote®). These have had many years of use and make up the majority of the items considered “first line” therapy for migraine prevention. Amitriptyline, which is an antidepressant, may also be very effective as a migraine preventive. Recently onabotulinum toxin A (Botox®) has been approved for the treatment of migraine patients if they experience greater than 15 days per month of headache of any kind. Onabotulinum toxin A is a series of injections in the scalp, forehead and neck that paralyzes the muscles for 3 months. There are a host of alternative choices for patients whose headaches do not respond to the first line medications. These include calcium channel blockers, NSAIDs, a variety of antidepressants and several miscellaneous medications.

WHICH LIFESTYLE CHANGES CAN BE MADE TO PREVENT MIGRAINE?

Many factors may contribute to the occurrence of migraine attacks. They are known as trigger factors and may include diet, sleep, activity, psychological issues as well as many other factors. Common dietary triggers include caffeinated beverages, wheat, dairy products, foods that contain monosodium glutamate (flavor enhancer found in TV dinners, seasoning salts, boil in the bag foods), nitrates (found in processed meats) and alcohol (particularly beer and wine). The use of a diary to record foods, beverages and events that may play a role in triggering headaches can be useful for you and your healthcare provider. Avoidance of identifiable trigger factors reduces the number of headaches a patient may experience.

Healthful lifestyles including regular exercise and avoidance of stress through reasonable lifestyle choices and biofeedback (see below). Patients may also consider falling asleep and waking up at the same time each day as poor sleep habits can also trigger headaches.

WHAT ARE BIOFEEDBACK AND RELAXATION TECHNIQUES?

As an alternative to drug therapy, this training uses special equipment that monitors physical tension to teach the patient how to control the physical processes that are related to stress. Once familiar with this technique, people can use it, without the monitoring equipment, to stop an attack or reduce its effects. Self-hypnosis exercises are also taught to control both muscle contraction and the swelling of blood vessels. This patient-directed therapy, with the clinician serving as a guide or teacher, should be practiced daily. Children have an excellent response to biofeedback training, since they are open to new methods, learn quickly and have not become firmly entrenched in a chronic pain pattern.

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