The headaches would come on like bad weather. First the shadow of a cloud, then a slow wave of nausea and flashes of pain in my head. Soon the throbbing would seize me, a storm so roiling my whole body would shake. I couldn’t think or speak, and the only relief was a cool, dark, silent room where I’d lie for a day, sometimes two, until the storm passed. Work day? I’d call in sick. Kids to care for? I’d lie on the couch near the action, trying to keep them safe while I kept sounds muted and the lights low. Every two or three weeks, another migraine would knock me flat.
Migraine headaches are the world’s most pervasive neurological disorder. More than a billion people worldwide, including 13 percent of U.S. adults, suffer them in any given year. For as many as 90 percent of the 38 million Americans who experience migraines, the headaches compromise the ability to work and function normally.
Getting to the root causes for this disorder can be challenging. In the past, medical professionals viewed it as a vascular problem — dilation of blood vessels in the brain. But recent research demonstrates that a migraine is a processing disorder in which sensory inputs from light, sound, and a variety of other triggers overload the brain. Oftentimes, a migraine is misdiagnosed as a sinus, stress, or tension headache, which delays effective treatment. And some of us are more sensitive than others.
A migraine diagnosis is based on symptoms and medical history, explains neurologist and headache specialist Amaal Starling, MD, who practices at the Mayo Clinic in Scottsdale, Ariz. Lab tests, magnetic resonance imaging (MRI), and computed tomography (CT) scans cannot detect a propensity for the disorder.
Still, vulnerable brain circuits play a role. During the last decade, Kings College London neurologist Peter Goadsby, MD, PhD, and other neuroscientists have been focusing on the trigeminovascular pathway, the brainstem circuitry that is the seat of a migraine and the source of the biochemical cascade that produces the accompanying pain. (The trigeminal nerve is the cranial nerve responsible for sensations in the face and head.) Goadsby says this work has led to important new preventive treatments.
It’s about time. Until recently, migraine sufferers relied solely on “rescue” drugs they could take once symptoms (nausea, light and sound sensitivity, and severe headache) were already in full swing. Such treatments might relieve discomfort temporarily, but they often lead to worse symptoms — as well as side effects — over time. (See “Pharmaceuticals and Migraines” below.)
The new research focuses on prevention, which includes understanding and respecting one’s individual “migraine threshold,” as the key to recovery.
Lighten Your Load
For a long time, I accepted my headaches as a part of life; my mother had them, and my brother, too. Then in 2010, while interviewing several preeminent experts for an Experience Life story on headaches, I learned that migraines are not just random. They are often triggered by pollutants, toxins, and pollen and other allergens, as well as particular foods; different things provoke different people.
My sources suggested I keep a diary to help uncover triggers, like specific foods or cleaning products. It was important to keep track, they said, because headaches might not manifest immediately upon exposure: One trigger might cause a migraine in hours; another, in days. Careful record keeping can help prevent future headaches by revealing these patterns.
Using a diary, I found mine: red wine and monosodium glutamate (MSG). One sip of red wine could slay me for a day — but the pain didn’t start until 24 hours later. Purging these from my diet prevented more than half my headaches. Avoiding dust and environmental mold offered further relief, but I couldn’t seem to avoid the stress-provoked migraines.
Everyone has a trigger threshold — a point where one more stressor tips the balance toward migraine. But people with severe headaches have a lower threshold than others. It takes less disturbance — just a sip of red wine or a flickering light — to activate their brains’ trigeminovascular pathway.
An avalanche of incoming signals can plague anyone, says Johns Hopkins neurologist David Buchholz, MD, author of Heal Your Headache. Yet some of us can tolerate more triggers than others. “If you are lucky, you can pile on the triggers with impunity and rarely cross the line,” he explains.
Not everyone is so fortunate. For some of us, whenever the trigger load exceeds the threshold, the brain unleashes a full-blown migraine instead of a routine headache. So, learning to identify, manage, and reduce migraine triggers is key to reducing headache frequency. This involves addressing what Buchholz calls “lifestyle load,” or the sum of stressors that lead to toxic overload in the brain.
Crossing the Threshold
Migraine triggers vary, and the reason why particular substances provoke a headache isn’t always clear. Yet certain factors are more likely to cause a problem: lack of sleep, dehydration, allergens and molds, perfumes and scented body-care products, household-cleaning products, hormones from birth-control pills, emotional distress, noise and air pollution, and allergenic foods.
Common food triggers include high-histamine foods, such as chocolate, nuts, deli meats, hard cheeses, and red wine. MSG bedevils many. The artificial sweetener aspartame contains excitotoxins known to affect nerve cells, triggering migraines. Sugar (because of its connection to blood-sugar crashes and hypoglycemia) is equally hazardous, says neurologist Alexander Mauskop, MD, director of the New York Headache Center.
Gluten is another common culprit, possibly because of its inflammatory effects, which can unleash the body’s stress response. Mauskop sometimes puts his patients on a gluten-free diet, which often reduces their trigger load.
Neurologist David Perlmutter, MD, author of Brain Maker, describes a patient with a 30-year history of debilitating migraine headaches; none of the conventional drugs had helped. “Panels for gluten and cross-reactive foods . . . revealed significantly high levels of antibodies against wheat and dairy,” he notes. When the patient eliminated both of these food groups from his diet, not only were his headaches dramatically reduced, but his antibodies declined as well.
Inflammation is a likely connection between idiosyncratic triggers, Perlmutter believes. “We are becoming more inflamed,” he says, due to the combined effects of poorer food quality, increased pollution, and stress.
All these factors can alter gut bacteria and lead to leaky gut syndrome, which is connected to migraines through the gut–brain pathway. A 2014 study published in Frontiers in Neurology found that gut disorders — including inflammatory bowel disease, irritable bowel syndrome, and celiac disease — involve “leaked” inflammatory molecules that provoke pain receptors in the trigeminal nerve.
The gut also plays a key role in how we handle emotional stress: Up to 90 percent of the body’s serotonin is produced there. Studies show that migraine sufferers often have issues with serotonin metabolism, which can add to their overall toxic load. Changes in serotonin prime the trigeminal nerve to release neuropeptides, initiating a cycle of pain.
Likewise, fluctuations in a woman’s estrogen levels can provoke the pain receptors. About three times more women than men suffer migraines; estrogen may be one reason why.
Though genes are not a known trigger for migraines, they can set us up to be more vulnerable.
A Focus on Lifestyle Changes
It’s impossible to eliminate every trigger. We can’t control low barometric pressure, the stress of a child’s illness, or hormonal changes, for example. But basic lifestyle shifts can strengthen the brain and increase the migraine threshold.
Simply staying hydrated is a good place to start. Starling begins any treatment protocol by instructing patients to drink more water. (For more on hydration, see “All About Hydration.”)
She also recommends getting adequate rest: Lack of sleep can trigger migraines because it upsets neurochemical balance. A good night’s sleep, by contrast, helps raise the migraine threshold. Try to keep regular hours, and sleep in a room that’s dark, cool, and quiet. (Learn more about sleep rhythms at “Get in Sync.”)
Yoga, mindfulness meditation, cognitive behavioral therapy, and other relaxation practices have also helped migraine patients. “These techniques lower stress and inflammation,” Mauskop says, which are major triggers.
Starling also recommends an exercise and stress-reduction program. A 2014 study conducted at Wake Forest Baptist Medical Center assigned 19 migraine patients to either standard medical care or an eight-week program in mindfulness-based stress reduction, a technique that combines meditation and yoga. Those in the meditation group had fewer, less severe, and shorter headache episodes.
Last year, Italian researchers reported similar improvement for 44 headache patients treated with mindfulness meditation versus drugs: Half of the patients in both groups experienced about 50 percent improvement.
Other studies have shown that aerobic exercise similarly raises the trigger threshold by reducing stress and stabilizing neurotransmitters while regulating sleep and increasing levels of feel-good endorphins. At Sweden’s University of Gothenburg, researchers asked a third of 91 migraine-suffering subjects to exercise for 40 minutes three times a week; another third to practice relaxation exercises; and the final third to take a popular migraine drug. After three months, researchers found that the treatments reduced migraine headaches equally in all groups.
Studies also indicate that acupuncture brings relief. A 2017 meta-analysis published in the Cochrane Database of Systematic Reviews found it eased migraine headaches more effectively than drugs. The analysis compared 22 trials in which participants received acupuncture, sham acupuncture, pharmaceutical treatment, or no treatment at all. They found that headache frequency was reduced by half in 41 percent of participants receiving acupuncture, but by only 17 percent for all the others. (For more on acupuncture, see “Acupuncture: Getting to the Point.”)
Finally, developing and maintaining a consistent routine is essential. “Migraine patients must be regular in life,” says Amynah Pradhan, PhD, who studies opioid receptors at the University of Illinois at Chicago. Regular sleep, exercise, and good food habits can all help create more stability for the brain.
Mauskop is a big believer in lifestyle adjustments for migraine sufferers, but for some of his patients, he finds that these interventions aren’t enough. These patients appear to have a threshold so low that ordinary life pushes them over the edge.
The good news for them is that a host of natural preventives and nutraceuticals (food components used as medicine), taken prior to the onset of a migraine, can provide additional support; they can also help migraine sufferers in general.
Mauskop’s first recommendation is often magnesium, which is critical for proper cell function. “About 50 percent of migraine sufferers are low in magnesium, as measured within red blood cells,” he says. For those who test low, Mauskop recommends 400 mg daily, which he has found reduces migraine attacks.
He also prescribes a nonpharmaceutical “migraine cocktail” that contains vitamin B2 (riboflavin) and feverfew, a time-tested herb used to relieve headaches. And because about a third of migraine sufferers are -deficient in the antioxidant coenzyme Q10 (CoQ10), he recommends that as well. Starling uses the same combination of vitamin B2, magnesium, feverfew, and CoQ10 with her patients.
“Saying you have migraine is like saying you have asthma — you might not always be in the midst of an asthma or migraine attack, but the underlying disease is lifelong,” explains Starling. That’s why it’s important to maintain a healthy respect for your trigger threshold, even once the headaches are reasonably under control.
I still get migraine headaches, but only rarely, as long as I avoid the exposures that set me off. This requires vigilance. A few years after I managed to eliminate my headaches, they returned with a vengeance. Combing through my routine, I realized I’d been ordering food from a takeout place near my office. They had told me they used no MSG, but as soon as I stopped buying those rice baskets, the headaches disappeared. I missed my favorite lunch, but it was a small price to pay for relief.
This originally appeared as “Getting Ahead of Migraines” in the May 2018 print issue of Experience Life.
Pharmaceuticals and Migraines: Risks versus Relief
For especially vulnerable migraine sufferers, lifestyle changes are not enough; only pharmaceuticals seem to keep headaches at bay. Yet none of the drugs used to prevent migraines were developed specifically for headaches, so they work imperfectly, and side effects abound.
Triptans, a popular treatment, can limit the intensity and duration of a headache. But because they may narrow blood vessels, those with coronary artery disease or a history of stroke must avoid them, says Mayo Clinic headache specialist Amaal Starling, MD.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, and migraine-specific painkillers (which usually contain caffeine) can diminish an individual migraine attack, but they may also increase the frequency and intensity of attacks by lowering the trigger threshold over time, Starling notes.
There are, however, some promising new drug interventions. Neurologist Peter Goadsby, MD, PhD, and his research team at King’s College London study the biochemicals that patients with severe migraines produce. One observation stood out: When pain erupted, a neuropeptide called calcitonin gene-related peptide (CGRP) surged.
“We think it activates the pain pathway,” Goadsby says. His team is seeking ways to clear CGRP (currently with an injectable drug) as a way of preventing migraines. He says the anti-CGRP antibodies are game-changers. “Finally, we have a bespoke migraine medicine.”
While this is an encouraging development, the treatments currently cost $8,500 per injection. This means that for most people, lifestyle and nutritional interventions — and for the most afflicted, imperfect preventive and rescue drugs — remain the more practical option.|
Common Medications That Can Exacerbate Migraine
Commonly used drugs, such as those for acid reflux, depression, or even migraine itself, can lower a person’s migraine threshold, says Johns Hopkins neurologist David Buchholz, MD. These medications may contribute to trigger load:
- Proton pump inhibitors (PPIs) for acid reflux
- Birth-control pills
- Decongestants for sinus headaches and allergic reactions
- Erectile-dysfunction drugs
- Nitroglycerine, used to treat angina
- Selective serotonin reuptake inhibitor (SSRI) and serotonin–norepinephrine reuptake inhibitor (SNRI) antidepressants
- Diet and weight-loss medicines and protein supplements, including powdered drinks