How serious are migraines? A doctor discusses.

Jul 21, 2011

Talk of Michele Bachmann's migraines and if they would hamper her ability to serve as president has brought up an interesting question: Just how serious are migraines? Dr. Elizabeth Loder will answer your questions about migraines. Questions aobut symptoms, treatment, what they feel like, and any other related topics are all fair game. Post science reporter David Brown joined her.

Welcome chatters! This is a chance for you to ask questions of Elizabeth Loder, MD, a headache specialist with a particular interest in migraines, which have been in the news because of Rep. Michelle Bachmann suffers from them. Dr. Loder works at Brigham and Women's Hospital, which is a hospital in Boston affiliated with Harvard Medical School. She wrote a review of migraine treatment with triptan drugs in the New England Journal of Medicine last year. Triptans are a family of commonly used prescription drugs for migraines.  Ms. Bachmann takes sumatriptan for her headaches. So let's begin.

Hello. Dr. Elizabeth Loder here from the Brigham and Women's Hospital in Boston. I'm on line now and ready to answer questions about migraine and its treatment. 

I know that there are preventive medicines for migraines, and that avoiding triggers can also help. But are there any surgical options that are more permanent?

There are a few published reports suggesting that some surgical procedures might help for migraine. For example, several small studies have suggested that weight loss surgery might improve migraine headaches in obese people who experience the headaches. 

There is also some interest in a technique developed by a plastic surgeon that supposedly "deactivates" peripheral triggers for headache in the muscles of the head. 

In my view the evidence for these two things is not currently substantial enough to recommend them. For one thing, the published studies are too small to identify potentially serious harms and longer term followup is needed to see whether any benefits are lasting. In my experience surgery of any kind often produces temporary improvement in migraine headaches. 

Good Afternoon, Sometimes I get Migraines at work when I am under stress. The migraines that I receive are not painful but my vision is impared with calidiascope type figures in my sight. What type of migraine am I receiving and should I be consulting with a physician?

I haven't examined you, but what you are describing certainly sounds like what is called migraine with aura. About 20-30% of people who have migraine will sometimes or always experience neurologic events in association with their headache. You don't say when yours occur, but typically these come before the headache itself begins and do not last longer than an hour. The headache that follows may be a severe migraine but sometimes is milder. Occasionally people can have the aura without any headache. 

 

Visual aura is by far the most common sort of aura, but it is also possible to have weakness or sensory changes. 

 

Aura is thought to be the result of early changes in brain function that occur in migraine. These changes are particularly likely to happen in the area of the brain responsible for vision, which is why visual auras are most common. 

 

If your auras and headaches are relatively infrequent and not causing you problems, you may not need any treatment for them. It would be a good idea, though, to mention this to your physician. It isn't common but sometimes other eye problems can mimic visual aura. 

I suffer from migraines and know how debilitating they can be. But can we really be sure that it would cause a negative impact on Bachmann's ability to serve? As much as we may not like her politics, I'm not sure that we can rule her out because of massive headaches. Your thoughts?

My thoughts are similar to yours. Migraine is extremely common and the majority of people who have it function at a very high level. I don't have any special knowledge of Ms. Bachmann's case, but from what I have read she is being treated appropriately with effective medications that work well for her. It seems unlikely to me that this would have any material impact on her ability to carry out her duties, presidential or otherwise.

Hi, I have been dealing with migraines for about 10 years now (I'm 29). At first, I was able to link certain foods with causing them and so avoided those foods. Lately though, I have been getting them for no apparent reason. I have migraines with aura, so I do know when they are coming and I take sumatriptan which seems to work pretty well. My regular doctor doesn't seem too concerned, but I'm wondering- is there a benefit to seeing a neurologist? Thanks!

If you are taking medication that works well for you and your headaches are not disabling, you may not need additional treatment. If, however, you are experiencing headaches that require medication more than 2-3 times a week, or if you frequently find that medication doesn't work for you, you might benefit from a consultation with a neurologist or headache specialist. 

 

Your comment about food triggers reminds me that most people with migraine do notice things in the environment that can affect the chance they will have a headache. Most of the time, however, even if they are careful to avoid these things, they will still get some headaches. I think that is because for most people who are susceptible to migraine there are usually many different things that can trigger a headache -- not just a single thing -- and some of those things are not obvious or avoidable. 

Hello Dr. Elizabeth. I am so glad to have found this chat, because I suffer from severe migraines. I unfortunately have run out of all of my meds and can't get in to see a new neurologist for 2 weeks. Do you have any suggestions for non-pharm. treatments that could help me over that time? Sleeping is not an option really, because I can't miss work. Although that is the one thing I've found to help the most.

Most people with severe migraine find that they need medication to treat at least some of their headaches, but nondrug techniques may still work well for milder headaches. They may also help medication work more effectively for severe attacks. This is an area that has not been well studied, but in my experience nondrug approaches to headache control that work well (in addition to sleep) include making sure to eat regular meals, avoiding dehydration and practicing some sort of regular daily relaxation technique.

This is David Brown, the host:  Some people believe that exercise also has a preventive effect, although what the mechanism might be--whether it's because of the cardiovascular fitness or because of the relaxation it produces--isn't known.

 

Hi there -- Within the past year, I've gotten maybe 5 occular migraines (where you see the flashing lights that usually indicate that a migraine is coming, yet pain never starts). I've never had migraines before and my doctor didn't seem to think these were serious. Should I be concerned? Will these ever begin graduating to full-blown migraines? What causes this? Thanks!

I haven't seen and examined you, but what you describe does sound like typical visual aura without a subsequent headache. As I mentioned in answering a previous question, 20-30% of people with migraine do experience aura, most commonly visual disturbance, usually before a headache. Aura can also occur without a headache, as you are describing. 

 

The main thing in evaluating a situation like yours is to make sure you don't have one of the rare other eye problems (like retinal problems) that might produce similar symptoms. It sounds like your doctor has assessed that possibility and is not worried. 

 

Assuming this is typical visual aura without migraine, it is possible that you will occasionally experience the headache in addition to the aura. As far as developing "full-blown migraines," that would depend on your age and sex and family history. 

 

Aura is thought to result from early changes in brain function that precede a migraine headache. As for why it can occur without a headache following it, I will say that the most likely explanation is that the brain has mechanisms to try to shut down headaches and in some cases these are successful, so that the process does not finish. 

I don't suffer from migraines myself, but of all the people who I know that do, none seem to have any trouble holding down a job. Are these concerns about Michele Bachmann overblown? I am a Democrat, but I want every candidate to be treated fairly.

The vast majority of people with migraine have no trouble holding down a job. In fact, I would say that in my experience migraine sufferers tend to be overachievers. I don't have any special knowledge of Ms. Bachmann's case, but from what I have read she is using treatment only for individual headaches and reports it works well.  To me, that does suggest that the speculation about the effect of her headaches on her ability to function is somewhat overblown and possibly unfair. 

D. Brown here, the the host:  The speculation about possibly disabling health conditions of candidates has become a fixture of presidential campaigns.  No matter how successful a treatment for a disease has been--I am thinking of Sen. John McCain's various operations for melanoma--there is always a lot of speculation about the chance of recurrence or that the condition is actually more serious than it appears. It almost doesn't matter what the illness is, it will be kicked around in the news for a while and probably longer than it needs to be. We're on the third day of Michelle Bachmann's headaches!  I suspect this won't be the last discussion of candidate health this season.

As a lifetime migraine sufferer I sympathize with Rep. Bachmann's condition. But I've never been hospitalized for them and to me, that takes her episodes to a completely different level. Aren't her multiple hospitalizations a serious red flag?

I haven't scrutinized the reports of her "hospitalizations" but I wonder if in fact what occurred is that she had a particularly bad headache that took her to an emergency department. That's quite a different thing from being "hospitalized" and isn't a red flag in my mind.

 

Over a lifetime of having migraine it's not at all uncommon for people to have an attack here or there that doesn't respond to their typical outpatient treatment. In those cases we often advise them to go to an emergency department. 

 

A common scenario is someone with migraine who, let's say, has a stomach upset with vomiting. Perhaps they then aren't able to keep down their usual migraine pill. It's perfectly reasonable for them to go to an emergency department to get some intravenous fluids and to get their migraine medication given as an injection. 

 

I'm no fan of Michele Bachman, but I think this migraine thing is a red herring. I have had severe migraines since college (I'm 60 now), and, although I sometimes choose to go lie down in a dark room, if I were President and had to handle a crisis, I could ALWAYS do it. I just tell myself, nobody ever died of a migraine, and you can always 'just do it'. Now, if she's using her migraines as a excuse for missing important events, then that's a legitimate reason she shouldn't be president. So I don't think it's the simple fact of having migraines, it's how the individual manages her life with migraines. Do you agree? IS there any danger in 'toughing it out'?

Migraines aren't fatal and so no, I don't think there's any danger in "toughing it out"  for an individual headache. But given all the helpful medications we have, I'm not sure there's any good reason to do that!

 

I agree with you it's how people handle the headaches that matters. What you say about having migraine and being quite certain you could ALWAYS handle a crisis strikes me as quite true. Even my very severely affected migraine patients do very well during serious situations and crises. In fact, a hallmark of migraine is what we call "let down" headache, where the person sails through a stressful event or crisis but tends to get a headache afterwards. 

Hello, I suffer from migraines associated with my menstrual period. I have severe pain behind one eye that is aggravated by movement, sitting, standing, etc. I usually get sick to my stomach also. Sometimes I treat the migraine with Treximet, sometimes not because I don't like the side effects. Does not treating the migraines cause any internal damage that I should be aware of? Thanks.

Interesting question and one that many patients ask. We don't have any evidence that not treating migraine attacks causes permanent damage of any sort.

 

There are a few studies suggesting brain differences in people who have migraine compared with those who don't, but there's no evidence these changes are due to untreated attacks -- rather, they may reflect underlying processes that are related to having migraine in the first place. 

I grew up taking the terrible migraines and accompanying vomiting etc. for granted because everyone on my mother's side of the family had them. It was sort of grit your teeth and bear it because that's life. My sister and I seemed to get them worse than the other cousins and my dad always said that was because he'd suffered from them as a child but had outgrown them. I recently read about some genes they say may be associated with migraine and am wondering about these and what they might mean for migraine treatment as well as how could I find out what the chances of any children I might have suffering from these headaches.

Several genes that are associated with an uncommon inherited type of migraine with aura -- familial hemiplegic migraine -- have been identified. Recently a gene associated with more common types of migraine also has been identified. It's too soon, though, unfortunately, for these to have any impact on diagnosis or treatment. They are mainly of interest to scientists who will now work on identifying potential targets for the development of drug treatments for migraine -- so the treatment benefits of these discoveries are in the future and not here yet!

 

As for the chances that your children will have headaches, based on twin and other population studies, a broad brush estimate that is commonly given is that if both parents have migraine there is a better than even chance that a child will as well. 

Hello doctor, I have been suffering from migraines from past 2 years and have found no link between any kind of diet and my headaches. However, mostly I get them when I am stressed. I am hyper sensitive to any kind of medication. Are there any exercises that can be done once we feel that the headache is starting? P.S. I do not get any kind of flashes before my headache starts.

I am not aware of any physical exercises that have been shown helpful early in a migraine attack, but many of my patients who have learned meditation or biofeedback techniques tell me that if they practice these early in a headache they are sometimes successful in stopping the headache in its tracks. Other tricks that patients report are sometimes successful early in a headache include having a cup of coffee or some other sort of caffeinated drink, or having something to eat. 

 

If stress is the biggest trigger for you, you might benefit from some sort of technique that would address this on a daily level and help preempt attacks. This could be something like yoga or meditation. Most studies show that the biggest benefit comes when these things are practiced daily -- even when you don't have a headache -- rather than saved for the attacks themselves. 

When I was younger (before menopause) I experienced debilitating migraines sometimes as many as three times per week, with visual symptoms as well as vomitting. Thankfully, I don't get them much any more. What I would like to know is do they cause permanent damage? Do they signal other problems, stroke, alzheimers, etc.?

Migraines do often improve with age and I am so glad that has happened for you. There is no evidence that the migraine attacks themselves cause damage to the brain, although that can't be entirely ruled out. The question of whether migraine sufferers are more likely to develop dementia has been looked at and so far they don't seem to have any increased risk there. 

 

People who have migraine with aura have a very small increased risk of stroke compared with people who do not have migraine or who have migraine without aura. This risk seems to be greatest in women during their childbearing years and for unclear reasons does not persist into older age. There is some evidence that perhaps people who have had migraine with aura when younger might be more likely to have cardiovascular problems later in life, but the evidence is not firm right now. 

 

What I tell patients is that these increases in risk are very small for an individual patient. The increased risk from migraine, for example, is not nearly as large as the risk from smoking or having high blood pressure. The best advice is to focus on those other risk factors that you do have under your control and not fret about the tiny increased risk that comes from having migraine, something over which you do not have control. 

Do you know, in states where medical marijuana is legal, if marijuana can help with some kinds of migraines?

With some other doctors I recently looked at the published evidence about marijuana or synthetic cannabinoid drugs and headache. There is really not much good evidence. One worry I have is that there is some evidence that marijuana may (rarely) cause constriction of some of the arteries in the brain, leading to a severe sudden onset of headache. This "reversible cerebral vasoconstriction" can be serious. So I do not feel comfortable recommending marijuana to treat headaches. 

I used to get severe dizzy spells - head floating above my body type things - I see a neurologist now who tested me for lots of things - and never figured out why I would get these with my migraines - any thoughts?

Hmm. It's difficult to say without talking with you in more depth, but there certainly are people who experience unusual forms of aura. That's where I would focus my attention. 

I've had migraines for years and years, and I was one of those showing up at the ER late at night with a bowl and sunglasses for a shot of Demerol until I discovered Midrin, which worked wonders for me. But now it is unavailable. Sumatriptan works OK, but it is so very very more expensive than Midrin and my insurance company will cover only NINE tabs a month. What happened to Midrin?

It's a long story, but unfortunately midrin (which contained isometheptene, dichloralphenazone and acetaminophen) seems to be gone for good. I miss it, too, and so do many of my patients! It was not widely used and my understanding is that the manufacturer simply stopped producing it. There's a good discussion of the details on Teri Robert's blog, which you should be able to find by googling midrin and her name.

We already had President George H.W. Bush throwing up all over the Japanese Prime Minister's shoes, humiliating our nation. The US cannot afford a President with a chronic condition that could cause an embarrassing scene again, when the condition is known in advance. And, just to be fair, I wouldn't want a Democrat for President with the same predilection either.

Some people with migraine do vomit with their attacks, but if Ms. Bachmann were prone to that I think we'd already know it. Sorry, but I just don't agree with you that this particular chronic condition is relevant in the context of her ability to function. 

Dr. Loder, have you ever heard of a migraine sufferer having such a painful migraine that they have a psychotic break that resolves after being sedated?

No, I can't say I have heard of that, but certainly in someone with a predisposition to psychosis it's not hard to imagine that a severe stress like a migraine might provoke symptoms. 

Hi Dr. Loder. I suffer from bad headaches always on the right side of my head. I went to a neurologist yesterday and she said it is a result of TMJ and bad posture. I suffer from headaches every day and all the time. Do you recommend any treatment? Thank you.

Without examining you it's not possible to comment on the diagnosis or recommend specific treatment. It does sound like the doctor does not suspect a dangerous underlying explanation for your daily headaches. In most cases, though, having headache every day is difficult to cope with. There are daily medicines that can help reduce the number of headaches you have and also medicine and nondrug techniques that might help for individual severe attacks of pain. It may be worth keeping a log of your daily headaches and pain and returning to the doctor with a request to discuss such treatments. 

When do you make the jump from a neurologist to a headache specialist or even a headache treatment facility? I've been working with a highly regarded neurologist who sees many migraine patients but I seem to be one of her tougher cases. We've been unsuccessful at finding significant or even moderate relief for my chronic migraines over the six years I've been seeing her. What could a headache specialist or specialized treatment center provide?

I always appreciate another opinion on tough cases where a number of treatments haven't been helpful, and most of the doctors I work with feel the same way. While there are people whose headaches simply don't respond to currently available treatments, it's also the case that sometimes a fresh look can help identify new treatment angles. So I'd talk with your doctor to see how she feels about getting another opinion on things. 

D. Brown here:  And I would add that if you want a second opinion after six years of less-than-optimal outcomes from your current treatment, I would not hesitate to get it. I know it is difficult to tell a doctor that you are consulting someone else but my reporting suggests that this is not viewed by most physicians as a criticism and that many, in fact, welcome what might emerge from such a consultation, either a better idea or confirmation of the quality of the treatment that has already been given.  In any case, it's your feelings that are most important, not the doctor's.

 

Since my family all had migraines, it was a shock when I got married and my husband had no idea how to respond when I got a migraine. In fact, I suspect the whole migraine thing is part of what caused our eventual divorce. As a medical doctor, most people he saw in the ER who claimed they had migraines were actually drug seekers who refused sumatriptans and other migraine medications seeking pain killers instead. He seemed to think my migraines were malingering or attempts to avoid special events. Have there been any studies done on families which mix those with migraines and those who don't get them? What kind of family support should a migraine sufferer expect? How do the migraines affect families?

I am glad you brought this up. I am always surprised how many of my patients bring family members along for their appointments. I think it is often an attempt to help the family member see that the problem they have is "real." I generally like having family members at appointments because it helps me understand how things are going at home. 

It's hard to generalize about the kind of family support a migraine sufferer should expect, because all families are different. That said, I think it's sometimes difficult for family members to know how to respond. It's probably best to discuss the subject when you are not having a headache, and let your family know what would be helpful. For example, "When I have a bad headache, it would help me if you could keep the kids quiet and do the dishes."

 

D. Brown:  There is a long, stand-up-comic history of headaches as convenient excuses for not doing things, which is unfortunate and may, as you suggest, subconsciously color how a lot of people feel about headaches, even these very severe ones. 

I don't have a question. But I suffered with migraines for decades. Last fall I began using transdermal magnesium chloride in lotion form developed by Dr. Norm Shealy, MD, a neurosurgeon. I no longer get migraines. Dr. Shealy is an advocate of transdermal magnesium chloride to prevent migraine headaches.

I am glad that works for you. To see whether this is a good and safe choice for other people, though, as a scientist I would want to see properly conducted double blind randomized studies to evaluate the drug -- the sort of thing the FDA rightly requires before a drug can be promoted for any purpose. In general, any drug strong enough to effectively treat migraine is also likely to be strong enough to have side effects, and needs careful study. 

I have suffered from migraines for the past 30 years, and now, in my early 50's they still occur often and severely and last from seven to ten days. Are there any new drug on the market beside the triptins? Even Migranal has become ineffective for me. Thank you.

There are not any new drugs on the market that are meant to be used to treat individual attacks of headache, which is what the triptans and migranal are used for. In your case, though, I wonder if that is the best approach. The seven to ten day headaches you describe might be better treated with a combination of daily medicine to try to reduce the number (and length) of headaches, in addition to drugs aimed just at the attack itself. So you might want to discuss with your doctor whether a preventive approach might be needed in addition to just treating the headaches when they come. Good luck!

Why does imitrex, sumatriptan succinate, work for some migraine sufferers and not others?

No drug works for everyone, and sumatriptan is no exception. That said, sometimes it (or any other triptan) may appear ineffective if the dose used is too low, if it's taken too late in a migraine after the headache has had a chance to really get going, or if it's not absorbed. 

 

For all of these reasons my mantra is that "You haven't failed sumatriptan until you have failed to respond to a full dose of injectable sumatriptan given early in an attack!" 

There is also evidence that combining a triptan with an anti-inflammatory drug might improve the likelihood it will be effective. 

 

D. Brown:  It should be noted that high-dose non-steroidal antiinflammatory drugs (such as 800 mg of ibuprofen or 3 full dose (325 mg) aspirin) are extremely good pain killers and are often adequate to stop the pain of migraine headaches. There have been some studies, not all of them published, showing they work as well as triptans for many patients.  That said, there are unquestionably migraines that are too severe to be relieved by high-dose aspirin or ibuprofen.

Hi Doctor. Where does the line cross between headaches and migraines? I get bad headaches, so that there's pain and sometimes I can't concentrate, but I don't think that crosses the line to migraines. But whenever I have to bow out of something because of the headaches (especially when that something would involve traveling somewhere on a bus or Metro, which would aggravate the situation), I feel like a wimp because it's not a "migraine."

To determine whether an individual headache is a migraine or not we look at more than just how severe the headache is.  We also look at whether it is associated with nausea, vomiting, sensitivity to light or noise, and a number of other things. As a general rule, though, if you are prone to migraine, my guess is that headaches that interfere with your ability to function are in fact migraine attacks. You might find that treating them accordingly helps! 

I've had a handful of terrible migraines with aura over the course of my life (fewer than 20) and they seem to have been clustered around and associated with hormonal changes (puberty, periods, menopause). Can you explain the connection between migraines and hormones? I've heard that they do increase for some during menopause. As far as a president having migraines I'd like to think he or she would be taking medication to control them. However, I must say that my worst migraines completely incapacitated me for hours at a time because of the severity of the pain.

Good question! About 2/3 of women who have migraine say that they notice a connection between their menstrual cycle and headaches. And a lot of women do report changes in the frequency or severity of headaches in association with events like pregnancy or menopause. 

 

The connection between hormones and migraine is complex and not all that well understood. As a broad generalization, though, stable levels of estrogen seem to reduce migraine activity (so that many women are better during pregnancy or after menopause when hormone levels don't fluctuate a lot). A decline in estrogen levels, particularly when it comes after a period of relatively high estrogen levels, in contrast can often provoke an attack. This is probably the explanation for a migraine flare that occurs after delivery or at the beginning of the menstrual flow. 

Thanks for all of the questions. Best of luck to all of you struggling with headaches! Elizabeth Loder, MD, MPH

And let me add my thanks both to all of you who wrote in questions and followed the chat.  And especially thanks to Dr. Loder.  We're closed.

In This Chat
Elizabeth Loder
Elizabeth Loder received an undergraduate biology degree from Harvard College, studied Medicine at the University of North Dakota and received a Masters degree in Public Health from the University of Massachusetts. She has worked as a clinician and researcher in the headache field since completing a fellowship in headache medicine in 1990. She currently divides her time between her position as a senior research editor at the British Medical Journal and duties as the Chief of the Division of Headache and Pain in the Department of Neurology at the Brigham and Women’s/Faulkner Hospitals in Boston. She is an Associate Professor of Neurology at Harvard Medical School. Dr. Loder served on the board of directors of the International Headache Society from 2005-2009, is the Winter Meeting Director for the Headache Cooperative of New England, and is the President-Elect of the American Headache Society.
David Brown
Washington Post science reporter
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