“People with migraines are vulnerable to overreacting physiologically to a variety of triggers,” says Saper. The triggers can be generated externally (by a stressful event, for example) or internally (by hormones—migraines tend to strike around menstruation and during perimenopause). “It’s not the presence of estrogen that acts as a trigger but the fluctuation of it,” Saper notes. That explains why migraines often diminish or even abate after menopause, when sex hormone levels take a dive.
Dilated blood vessels, long suspected to be the cause of migraine pain, are now seen as just part of a cascade of events that include, among other changes, inflammation of brain tissue and shifts in levels of the pain-regulating neurotransmitter serotonin. “Pulsating blood vessels irritate the inflamed tissue around them, and this contributes to the pain,” says Saper.
A variety of drugs are available to relieve this misery. Most, including narcotics and barbiturates, are taken on an as-needed basis to stop a headache that has already begun. Triptans, which have been heralded as a migraine breakthrough, work best at the onset of an attack; they provide relief by reducing blood vessel inflammation. Other drugs are preventives that are prescribed for daily use. For instance, older tricyclic antidepressants that affect levels of serotonin and norepinephrine, such as amitriptyline, may lower the frequency of migraine episodes. Antiseizure drugs like Topamax also reduce recurrences for some sufferers. Last year the FDA approved a novel treatment: Botox injections around the head and neck. These have been shown to help with certain types of migraines, possibly because they block pain receptors or reduce inflammation.
WHEN MOST REMEDIES DON’T WORK
Many patients are able to effectively reduce pain through these conventional therapies. But about 10 to 25 percent of chronic-headache sufferers (of all kinds) don’t find relief. Overwhelming migraine pain is responsible for more than a million patient visits to hospital emergency rooms each year.
Recurring migraines can take a huge toll on sufferers’ lives. “I have never known what it is like not to have a headache,” says Jeanne Stebbins of DeForest, Wisconsin. Decades on painkillers and ever-worsening attacks led her to leave her longtime job as a legal secretary and file for disability. Shawn King believes that her use of migraine painkillers endangered her life. By the time she entered treatment in 2008, she was taking up to 20 Vicodin a day, and a physician sometimes went to King’s home to inject her with morphine. “I could easily have died,” the singer says.
Kathleen Cresong, who works for a payroll company near Philadelphia, believes that brutal migraines prevented her from attending college and contributed to the dissolution of her first marriage. “I was and am still willing to do anything to stop the pain,” she says. Now 50, Cresong had her ovaries and uterus removed at 33 in an unsuccessful attempt to stop her headaches by ending her production of sex hormones. She finally found relief last summer after undergoing an experimental procedure that involved implanting an electronic device at the base of her skull.
THE PAINKILLER PARADOX
Compared with such extreme measures, swallowing a Vicodin or Percocet can seem like a relatively tame way for migraine sufferers to escape the hell of an attack. “Patients essentially trade debilitating sedation for debilitating pain, but it’s not a ridiculous choice to make, considering how severe the pain can be,” says Richard B. Lipton, MD, director of the Montefiore Headache Center in New York City.
For people who experience only a few episodes a year and get insufficient relief from other pain medications, powerful opioids and barbiturates can be a relatively low-risk and effective treatment option. The problem is that a significant proportion of sufferers experience attacks far more often: 37 percent endure episodes one to three times a month; 14 percent have them two to six times a week; and 11 percent, once a week. A patient downing opioids or barbiturates that often is likely to build up a tolerance that will lead her to crave progressively larger amounts of medication, creating a real risk of physical dependence.