My cousin's question about migraine headache

I was asked by a cousin recently if I was aware of any new medications for migraine headache... actually, she asked me this question quite a while back, so a "recent" question is now getting a delayed answer. Fortunately she is not the victim of this bad disease, or this delay would have made her really angry with a procrastinating cousin. Well, she may still be angry with me, for instance, why I choose to answer this question using this column intended for the "middle age". My cousin is a lovely, YOUNG (not middle age!) lady herself, see... well I am straying too far from this topic.

While migraine is not something unique to the middle age population -- in fact, it is usually something that starts at a much younger age -- it certainly can happen with increasing frequency by the time someone reaches middle age. The reason is that a multitude of factors that trigger migraine headaches are common in daily life. As we mature from the carefree days of young adulthood, these factors are encountered increasingly, making us feel like headache are becoming more and more common. One major factor, stress for example -- which I used to associate only with homework & final exams -- only gets worse after teenage years. Until the era of Starbuck and Red Bull, caffeine overloading (which certainly is a trigger) has always been the privilege of the middle age -- I don't know about you, but for me caffeine has never been a necessity until medical school. Of course there are other triggers that are not the privilege of any age group: strong smells, loud noises, bright lights, certain food additives (such as MSG), alcohol, sexual activities. Virtually anything that represents sensory stimulation seems to be capable of precipitating a migraine attack.

Unbelievable, isn't it? That sensory stimulation -- even pleasant ones like coffee, alcohol and sex -- may cause headache is somewhat counterintuitive. In a way, migraine is intrinsically different from the much more common type of headache that we call tension headache -- which was typically caused by unpleasant factors like being angry at procrastinating cousins -- and I may write a bit more about that if I have time. For those of you who have already experienced the "classic" migraine attacks, it should be pretty obvious what I am talking about. For the fortunate majority among us, however, it may be worthwhile to briefly describe what migraine feels like.

I have treated quite a few patients suffering from the classic migraine. Usually described as "splitting", "throbbing" and "sharp", migraine attacks can be extremely intense and debilitating. Often these patients would feel nauseous, ready to vomit. Another distinguishing characteristic is the distress light and sound would bring to these patients. More often than not, these patients would literally "wait in the dark" for my arrival, because they would be so bothered by the light in the exam room that they would ask my assistants to turn it off until I can see them. By habit, I am not a soft speaker. So as I asked, "how are you feeling" walking into the exam room, the answer would be expressed by the painful expression on their faces as they try politely not to cover their ears. Sometimes a migraine will literally cause tears to come out of the eye(s).  In fact, there are variants of migraine headache, like the so-called cluster headache which is characterized by profuse tearing, or what eye doctors called "ocular migraine" which is characterized by transient, mild, partial visual loss but without a headache. The classic migraine is also associated with colorful lights, flashes either before, or with the headache. Most patients can also "sense" the onset of a migraine attack, minutes to hours before the pain in the head starts. Interestingly, these may be the "flashing lights" (called "aura") or simply a sense of imminent gloom.

Now these features are by no means unique to migraine headaches. In fact, serious infections and even minor colds can also cause these characteristic aversions to light and sound. Strokes, detached retina or seizures can also be associated with "aura". That is why one should never assume a headache to be "migraine" by a single feature. In fact, since more serious illnesses such as strokes, bleeding and tumors can start just like a migraine, anyone with a bad headache should consult the doctor who knows him/her the best - usually the primary doctor but in some cases may be a neurologist.

Are there new medications for migraine? To answer the question my cousin asked, I must also go over what the "traditional" treatments have been until about 20 years ago. Basically, treatment had been targeted at the symptoms simply because we had no clue about the pathophysiology of migraines. Pathophysiology is just the medical scientist's way of saying "what's happening in our body when a disease causes problem". Contrary to common belief, modern medicine has NOT made us smarter really knowing the causes of diseases. Our ancestors - Native Americans, Greeks, Chinese, Tibetans, Indians or whatever ethnic group we are in - actually had a very sophisticated understanding about the real causes of diseases ("etiology" in modern day terms) for millennia, and I have never been impressed by what scientists, or for that matter, modern physicians, can tell us about "etiologies". Where the scientific discipline has impressed me the most is the way "pathophysiology" has been figured out (approximately since the 19th century), and based on these insights, a much more rational (note how I avoid using the word "better") way to deal with diseases.

So in the case of treating migraine, for a long time we could do no better than offering painkillers: morphine, codeine, and aspirin for example. This approach, which is called "rescue therapy" only addresses the symptom. We dislike using it because painkillers make people drowsy, constipated, or worse -- some patients can get addicted, or hooked, by narcotics. Then an understanding of pathophysiology began to lead physicians to try a different class of medicine called beta-blockers. As it turned out, some smart scientists have figured out that migraine attacks are ALWAYS associated with constriction of blood vessels inside the brain, which happens BEFORE the headache. During this phase of constriction of blood vessels, some parts of the brain may have been deprived of blood supply for a limited time (which seems to be the reason why patients may see lights and sense the coming of an attack). Interestingly, patients would NOT feel the headache during this phase. Then those same blood vessels go to the other extreme, and dilate or expand, literally allow a rush of blood into the same areas of the brain previously deprived of blood. That seems to be the moment the bad headache starts. It also seems that the severe headache of a migraine attack can be prevented, if the expansion or dilation of these constricted blood vessels can be stopped.  Generally speaking, just because smart scientists have figured out the pathophysiology of migraine does not mean that there are physicians smart enough to utilize that knowledge to treat patients. In this case, however, some smart and bold physicians picked up the information and started trying a drug, which has been used for decades for manipulating blood vessels -- the beta-blockers. Even though physicians have used beta-blockers to treat the heart, blood pressure, and strokes for a long time, I bet they would never have thought about using it for headache had it not been for this new knowledge. So I still give credit to the scientists as much as I respect my physician pioneers. In any event, it seemed to work in many cases. The same beta-blocker (named propanolol) that has helped slowing down heartbeats, lowering blood pressures, and preventing strokes has also worked in giving patients longer periods of their life free of migraine attacks. This is not the same as saying that propanolol is a cure. It only reduces the frequency of the attacks rather than completely preventing it. The annoying fact is that it does not seem to work fast enough, and so by the time a patient senses an attack is on the way, taking the pill is not likely to make a difference. Hence, it works only when patients are taking the medicine day in and day out. So for the majority of migraine patients, it may not be worth the while -- taking a pill every day to prevent what may only be 1 or 2 attacks a year may not be a good bargain to some. In fact, before the new versions of propanolol has become widely available in this millennium, propanolol had to be taken several times a day which made it very hard for patients to follow the instructions perfectly.

Then approximately in the 1990's, an entirely new class of drugs became available. Again this smart approach was based on the pathophysiology of migraine. These are the "tryptans". Examples (brand name in brackets) are: almotriptan (Axert), frovatriptan (Frova), rizatriptan (Maxalt), sumatriptan (Imitrex), zolmitriptan (Zomig). In my practice, Imitrex and Zomig are the most commonly used. This class of medicine can work literally "at the last minute". If a patient has convenient access to the medicine, one can stop what can be a severe headache by taking the medicine as soon as one senses the attack is coming. Tryptans are not sedating or constipating like the painkillers. More importantly, there is a much lower chance of addiction. Naturally I would not consider it a "new drug" since I have been prescribing the injectable form since the 1990's. However, manufacturers have made one new development after another ever since, and this class of medicine is now available in many forms - nose spray and pills for example. I suspect this is what my cousin is asking about.

Despite the benefits of the tryptans, I need to give one word of warning about this type of drugs, however. Even though I have not seen it, one serious complication has always been mentioned in the label of this class of drugs -- STROKE!  Theoretically, this class of drugs works by stopping those blood vessels inside your brain from dilating, and so it should not be surprising if it may constrict the same blood vessels excessively. If that happens, naturally a stroke can be the result. In practice, however, I have never seen this happening, and it probably is very, very rare. Trouble is overdosing. If one dose does not work, sometimes patients can be miserable enough to keep repeating the treatment, which can be dangerous. Each patient should discuss with the physician beforehand, as to how frequently they can take this medicine and what is the maximum allowed in a 24-hour period. Generally speaking, it is most effective before the headache starts. It is not very effective once the headache is in full swing.

Writing this article in Chinese, for her friend who may only understand Chinese, will slow me down substantially. So with my apology to her for procrastination I would also ask for her help in translation, if her friend needs it. However, I would write a shorter but special article in Chinese, as a make-up bonus to her friend on the same subject. Given my unique expertise and strong interest in traditional Chinese medicine (TCM), I cannot resist the temptation to write about this subject from a TCM perspective -- and in my opinion, this subject as discussed in the TCM literature is actually quite interesting. It will be posted shortly after this column... promise.