June is Migraine and Headache Awareness Month. Nearly one in four U.S. households has someone living with migraine. It is the number two cause of disability in the world, according to a study in the Journal of Headache and Pain, yet some people still don’t recognize how debilitating migraine can be.
Abby Metzler, MD, an assistant professor of neurology at the University of Minnesota Medical School and a neurologist with M Health Fairview, explains migraine diagnosis, living with migraine and current treatment and prevention options.
Q: What are the symptoms of a migraine?
Dr. Metzler: A migraine attack is a headache and other debilitating symptoms that lasts at least four hours and can go up to 72 hours, if untreated. The headache is usually pulsing or throbbing. People typically think of the headache as being on one side of the head, which is common, but it is also common to have a migraine attack that affects both sides. In addition to headache, migraine attacks also cause nausea or vomiting, or sensitivity to light and sound. A migraine attack affects someone’s ability to think and function and worsens with routine physical activity, like going up and down stairs.
It is not a one-time event, and it stereotypically happens the same way each time. By criteria, it has to happen at least five times before you can officially be diagnosed with the disorder, migraine.
About one-third of people with migraine have migraine with aura. Aura is a neurological disturbance that leads to headache and other symptoms. This can include seeing zig-zag lines, flashing lights, blind spots, numbness/tingling or more.
Q: How can someone differentiate between a headache caused by migraine or something like a stroke or brain tumor?
Dr. Metzler: There are several features I look for when evaluating someone for secondary causes of headache or headaches that are not caused by a headache disorder itself. I like the acronym “SNOOP4” to review signs that might require more investigation. SNOOP4 stands for:
Systemic signs – fever, weight loss, history of cancer
Neurological exam abnormalities – facial drooping, weakness, numbness or other neurological sign that isn’t typical for the person
Older than 50 – developing new headaches after age 50
Onset is acute – pain level goes from zero to 10 in less than a minute. Someone experiencing a headache that comes all of a sudden and is very severe should go to the emergency department.
Pattern change – change in frequency, intensity or symptoms usually associated with someone’s headaches
Progressive – getting worse despite treating it how they normally do
Positional – headache only when standing up or laying down
Precipitated by valsalva – only happens with bearing down, coughing or sneezing
Q: How can someone alter the way they live to help reduce migraine attacks?
Dr. Metzler: I use another acronym, “SEEDS,” for a lifestyle management strategy for people with migraine. It is important to note that people with migraine do not cause their migraine attacks, which are instead caused by the genetic neurologic disorder of migraine. These are some actions to help reduce the number of triggers, which can help to reduce the number of attacks, sometimes in combination with medications.
Sleep routine – Go to bed and wake up at the same time.
Exercise – Be active more days than not. People with headaches who exercise do better than people who don’t.
Eating – Eat healthy. There is not a specific recommended diet, but making healthier choices in general and not skipping meals will produce better results.
Diary of symptoms – Keep track of when you have headaches and when they affect your functioning. This will help you and your doctor determine the best treatment plan.
Stress management – Stress is the most commonly reported trigger for migraine. It is important to find ways to step back and prioritize yourself.
Q: Are there things people can do to prevent getting migraine?
Dr. Metzler: Not really. Migraine is a genetic, neurologic disorder that is passed down in families. Research studies have identified dozens of genes in different families that cause the propensity for migraine attacks. There is about a 50/50 chance that the child of someone with migraine will also have migraine. However, the parent and child may be affected differently. For instance, the parent may have severe migraine disease and their child may have rare attacks. It is likely a combination of genetics and environment.
Q: What are some current treatment options for migraine?
Dr. Metzler: For migraine treatment, there are many different acute and preventative options. The FDA has also approved a number of newer treatments for migraine. Your doctor can determine whether you are a candidate for a newer treatment.
CGRP (calcitonin gene-related peptide) inhibitors are approved for migraine prevention. They include erenumab, fremanezumab, galcanezumab and eptinezumab. They are monoclonal antibodies and are administered via monthly injections, except eptinezumab which is administered via an infusion every three months.
Botulinum Toxin (Botox) injections are also used as a preventative treatment for chronic migraine. People who use this method receive a set of injections over the head, neck, and shoulders every 12 weeks.
Rimegepant and ubrogepant are CGRP inhibitor pills that treat migraine. As soon as someone realizes they have a migraine attack, they take a pill for acute treatment, or they may take a pill every other day for prevention.
Lasmiditan is a serotonin agonist pill that treats migraine when it occurs. It may be a good option for patients who cannot take triptan medications.
None of these medications are available or should be taken without the consultation of a doctor.
Abby Metzler, MD, is an assistant professor of neurology at the University of Minnesota Medical School and a neurologist with M Health Fairview. She treats patients living with headaches at M Health Fairview Clinics and Surgery Center – Minneapolis in the Neurology Clinic. She is board-certified by the American Board of Psychiatry & Neurology.
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