Migraine and Coexisting Conditions

What is migraine?

Migraine is one of the more common types of headache. Approximately 17 to 18% of all women and 6% of all men suffer from migraine headaches. This type of headache is partly due to expansion (dilation) and inflammation of brain blood vessels, causing pain messages to travel to the brain. Although these affected blood vessels are located in the scalp, skull, and surface of the brain, the pain feels like it is coming from inside the head. The pain associated with a migraine attack usually lasts 4 to 72 hours.

Migraine headaches are often localized to one side of the head, and the pain can be pounding or throbbing in nature. Some people feel nauseated, and others actually vomit. Noises and light can make the headache worse. Up to 25% of migraine sufferers have an "aura" prior to the onset of pain. An aura is recognized by seeing flashing lights or curved lines, arm or leg numbness or tingling, or rarely, one-sided weakness.

What are coexisting conditions?

Coexisting medical conditions are multiple illnesses or health conditions that can occur at the same time. For example, some children with seizures also may have headaches. Headache sufferers may have coexisting health conditions or illnesses, such as depression, anxiety, high blood pressure, or a sleep disorder. Nearly half of the patients with chronic tension-type headache also suffer from mood or anxiety disorders.Sometimes these coexisting conditions are related biologically to each other, and sometimes they are independent from each other. One person with migraine may suffer from depression, while another migraine sufferer may have asthma. Both asthma and depression are coexisting conditions with migraine, but it is likely that only depression and migraine are related. Some researchers believe that changes in brain chemicals, such as serotonin, may be a common underlying factor related to specific coexisting conditions and migraine.

Why diagnose coexisting conditions?

Diagnosing and acknowledging the presence of migraine and coexisting conditions are steps to successful migraine management. For the migraine sufferer, it is important to:

• Recognize that there are two or more conditions.
• Accept the need for treatment of these conditions.
• Work with the physician to develop a treatment plan that fits with lifestyle issues.
• Understand that treating more than one condition at a time is complex, and requires added medical attention and long-term, follow-up care.

Can coexisting conditions make migraine worse?

There are at least two critical reasons to diagnose and appropriately manage migraine along with coexisting conditions.

• Cause
  Some health conditions may increase the frequency or severity of migraine attacks. By gaining control of the coexisting condition, the migraine attacks may become less frequent or less severe and, in some cases, completely go away.
• Treatment
  Some medications used to treat coexisting conditions can make migraines worse. Fortunately, other medications used to treat specific medical conditions also will treat migraine successfully.

Can modification of lifestyle help?

Feeling good about "life" is an important part of successful migraine management and also may help with managing coexisting conditions. Some lifestyle changes are simple and easily incorporated into a daily routine, while others may require a little more effort. Here are a few ways migraine sufferers can gain control of their headaches - and their lives:

• Diet - avoid foods that may trigger migraine (red wine, food additives [MSG, nitrates], chocolate, caffeine, peanuts, aged cheeses). Remember that the best way to identify a food trigger is to keep a calendar/diary.
• Exercise - exercise regularly with moderation; too much or too little exercise may trigger migraine.Meals - eat regularly; fasting and hypoglycemia may trigger migraine.Sleep - engage in a normal sleeping routine; sleep deprivation and changes in sleeping patterns may cause migraine. This is often seen with long-distance travelers that suffer from "jet-lag."
• Stress - reduce work and personal stress. High stress may cause anxiety, depression, panic, and other emotional fluctuations that may trigger migraine.
• Hormones (women) - be aware of monthly biological changes. Fluctuations in hormones during menstruation, ovulation, and while using birth control pills may trigger migraine. Talk with a health care provider about how to incorporate lifestyle changes that may prevent or relieve both migraine AND other coexisting conditions.

Are some medical conditions more common? For reasons that are not well understood, some medical conditions are more commonly associated with migraine. Some of these include:

• Asthma - Inflammation of the airways leading to breathing difficulty and shortness of breath
• Fatigue (chronic fatigue syndrome) - A combination of unexplained fatigue (lack of energy) with memory or concentration problems, sleep difficulty, muscle or joint pain, or headaches
• Hypertension - High blood pressure; long-term effects include kidney disease, vision loss, heart attack, and stroke
• Raynaud's Phenomena - Spasms in the arteries in the fingers leading to numbness or decreased blood flow to the fingers
• Stroke - Sudden neurological condition usually related to blocking of the blood supply to an area of the brain

While many of these conditions are associated with headache and are more common in individuals with migraine, most migraine is not caused by one of the above medical conditions. Individuals who think that they may have migraine along with at least one of these coexisting conditions should discuss this with the doctor.

What psychological conditions are associated with migraine?

Many conditions that affect behavior and mood are more frequent in migraine sufferers. This is likely due to changes in the brain chemical serotonin. Certain brain cells that use serotonin as a messenger are involved in controlling mood, attention, sleep, and pain. If serotonin levels suddenly drop, a migraine may develop. Chronic changes in serotonin levels may also lead to psychological conditions.

People with anxiety or panic disorder develop an overwhelming sense of fear or nervousness without any clear reason. This may be so severe that they are unable to function at work or at home. An actual attack can last for several days.

Depression is a change in a person's mood that lasts for an extended period of time. People with depression often feel sad, alone, or isolated. They also have decreased energy and do not enjoy activities that they would enjoy normally. Some people with depression have decreased appetite and lose weight; others will eat continuously even though they are not hungry. Sleep problems-including difficulty falling asleep, waking up during the night or early in the morning, and not feeling rested in the morning-are also part of depression.

Stress is the human body's response to outside factors that a person perceives as dangerous, damaging, painful, or which may have a negative impact on the person. Thousands of years ago, human stresses were mostly physical. Today, many stresses are directed toward a person's emotional and psychological well-being. These stresses can come from work and family responsibilities, changing relationships, and financial difficulties. Stress may be triggered by positive changes as well, such as taking on a new job, buying a house, getting married, or having a child. While everyone is exposed to daily stresses, the migraine sufferer's nervous system may respond in such a way that it causes greater negative effects on the body.

Talking to your doctor

Headache sufferers should make a specific appointment to talk to their doctor about headaches. This way both the doctor and the headache sufferer will plan enough time to discuss all aspects of the headaches and possible coexisting conditions. The doctor will want to discuss other symptoms that may not appear to be related directly to headaches. These symptoms may be a clue that one or more coexisting conditions are present. During the office visit, it is critical to establish an open and honest dialogue with the doctor. Specific characteristics of migraine and coexisting conditions will influence the treatment plan. For example, issues to discuss honestly with a doctor might include:

• Ability to cope with stress
• Severity of pain
• Degree of disability
• Rate of pain onset
• Treatment preferences
• Lifestyle preferences

Here are steps that will help prepare headache sufferers for an office visit:

1. Keep track of headaches and associated symptoms (use a headache diary).
2. Make a list of questions to discuss with the doctor or nurse; during the course of the office visit, it can be difficult to remember all the questions or concerns that most migraine sufferers have.
3. Bring all the medicines taken daily or on a routine basis (including successful and unsuccessful headache medications, allergy medicines, vitamins, and others).

During the office visit, it is important that the doctor and migraine sufferer review each condition and its relationship to migraine. Understanding why each medicine is used will help ensure their appropriate use. Furthermore, it is critical to review lifestyle issues during the office visit. Sometimessimple modifications in lifestyle will dramatically improve the frequency and severity of migraines.

Treatment of migraine with coexisting conditions

Headache characteristics and the presence of coexisting conditions CLEARLY will affect the specific treatment plan designed for each migraine sufferer. For example, treatment of a coexisting condition alone may make migraine less frequent and less severe. And, treatment of migraine also could decrease the disability caused by coexisting conditions. An individually designed headache treatment plan should:

• Alleviate the pain from migraine,
• Reduce the disability from migraine attack,
• Allow the sufferer to return to normal activities as quickly as possible, and
• Reduce the impact of coexisting conditions on activities.

Two general approaches are used to treat migraine:

• Acute Treatment
  Everyone requires medication that is taken when the migraine begins or during the course of the headache. The goal of acute treatment is to allow the migraine sufferer to be pain-free and to return to normal functioning as quickly as possible.
• Preventive Treatment
  Some migraine sufferers require medication to prevent migraine from developing. These medications are used by patients with relatively frequent or severely disabling migraines. Many of these medications also can be beneficial for treating coexisting conditions.

The doctor must screen carefully for coexisting conditions because some migraine medications may not be appropriate to use in the presence of such conditions as heart disease, high blood pressure, depression, asthma, pregnancy, seizure disorder, or risk of stroke.

Migraine sufferers may be able to decrease the impact of migraine as well as certain coexisting conditions by using nonpharmacologic (nondrug) approaches. Some patients may benefit from certain behavioral treatments and physical therapies.

Behavioral treatments may include biofeedback training, relaxation training, stress-management training, and even hypnosis. Physical therapies include massage, acupuncture, and cervical manipulation. These techniques have not been rigorously tested in clinical trials for migraine patients, but many patients have found them useful.The goals of nonpharmacological therapies are to:

• Improve the overall management of migraine and possible coexisting conditions,
• Reduce the need for multiple medications to treat migraine and coexisting conditions over a long period of time, and
• Provide the migraine sufferer with alternate tools to gain control of their migraine attacks.

It is important to make the doctor aware of nonpharmacological treatments or alternative therapy approaches used for managing migraine or other coexisting conditions.

Taking control

The burden of dealing with migraine can be shared by the patient, family, loved ones, coworkers, and doctor. Health care providers and doctors will guide migraine sufferers through treatment regimens and lifestyle changes, but ONLY the sufferer can be fully responsible for gaining control of migraine. How can sufferers gain control of their migraines? Here are a few steps to begin with:

Step 1: Learn about each condition.

Doctors and other health care providers are prepared to answer questions and explain what migraine is and why the various medications are needed.

Remember: The only silly question is the one not asked.

Step 2: Follow the treatment plan established with the doctor.

• Be sure to understand what to do when the next migraine attack comes.
• Take medications EXACTLY as recommended by the doctor.
• Take only medications recommended by the doctor.
• Take acute medications as soon as it is clear that the headache is a migraine.
• Carry medications at all times.
• If preventive therapies are prescribed, follow the treatment plan EXACTLY as agreed upon. If the treatment plan is too hard to follow, contact the doctor.
• Do not increase or decrease the amount of medication without talking to the doctor FIRST.

Step 3: Monitor headaches.

One important part of migraine management is being able to accurately recognize improvement or deterioration in migraines. A headache calendar will help identify headache patterns, triggers, and responses to treatments.

Important tips

• Acute medication may not work every time, therefore, rescue medication prescribed by the doctor may be necessary.
• Preventive medication may take a few weeks to show improvement.
• Call the doctor if side effects occur from medication.
• Record headache activity on a daily basis using a headache diary.
• Make and keep follow-up appointments with the doctor.Migraine can be effectively managed. If a treatment plan is not as effective as expected, it might be possible to modify it. Establishment of a successful treatment plan may require several changes. Medications should be adjusted after considering coexisting conditions and lifestyle needs. Changes in the treatment plan must be discussed with the doctor.

Source: American Council for Headache Education, 2000