Hear a Patient Power interview with Peter Goadsby, director of the UCSF Headache Center, discussing headache issues. More than 25 million Americans have migraine headaches. What is a migraine headache? What treatments are available? How is it diagnosed? What triggers it?
Hello and welcome once again to Patient Power sponsored by UCSF Medical Center. I'm Andrew Schorr, and once again we're going to connect you with a leading UCSF specialist to talk about an important health concern. You know, 26 million Americans, and maybe even 27, who knows exactly, but it's a big number, are affected by migraine headache. What is migraine headache? What are the treatments available now? How is it diagnosed? What triggers it?
Thank you for asking me.
So help us understand sir, migraine is so common, what is migraine?
Well as you say, migraine is very common. It affects probably about 15 percent of the American population, much more common in women than in men. It's an inherited disorder of the brain essentially.
Now when women would go to the doctor over many years and they'd say they get these terrible headaches — sometimes with their period, sometimes at other times — and it can be very disabling. They were often just told well, it's in your head. You're a little crazy, you know, maybe even Valium or things like that were prescribed.
Now it's recognized as a condition, and I understand even with some imaging modalities you can see it, right?
Precisely. Migraine is an inherited condition substantially. Most migraine sufferers have an affected mother, father, brother or sister, and with the latest brain scanning technology, you can see the disorder, so to speak, during an attack. It's a very exciting time for migraine sufferers as we're able to understand the disorder and have some clarity about its biology.
Now what are the typical symptoms? For my assistant producer, it can happen any time in the month, maybe when she's under stress, and then she can't even open her eyes. She has to go in a dark room and may feel nauseous. I know that's typical, and there are other symptoms as well.
Yes. You've outlined a pretty typical case. A typical migraine attack will have pain that's very often on one side of the head that very often pounds or throbs that's made worse when the patient moves about, runs up a flight of stairs or shakes his or her head about. It's typically associated with nausea, sensitivity to light and sensitivity to sound, and will last from hours to days. The overriding message of the attack is that it's associated with disability, significant disability. Patients can't do the things that they want to do.
There are some other symptoms that we're only starting to study and appreciate now, the so-called promontory symptoms — things such as tiredness, neck stiffness, yawning, passing more urine, mood change, that can occur in a day or so before the attack comes on.
It a rich thing, a migraine attack, in terms of the features.
So there you are with migraine. Now how do we understand what triggers it, and does it vary for different people?
Well as we discussed, migraine is fundamentally an inherited disorder. If you want to say it this way, you picked your parents poorly from a headache point of view, and you have a tendency to have the attacks that's expressed during life. Now part of that expression is being female in the sense of probably female hormones, and one of the triggers that revolves around that is the menstrual cycle. Very often, women will find that just prior to the menstrual bleeding or in the first day or two, they will have one of their worst attacks.
The other sorts of triggers that are well recognized are essentially triggers of change, and that's the big lifestyle message about change. So changing sleeping habits, not getting enough sleep or sleeping in and having too much sleep; changing eating habits, skipping meals for example; change in stress, so having too much or paradoxically when you relax perhaps for the weekend or on a holiday and have too little stress if you like, that change triggers headache; weather change, change in the barometric pressure is an established thing to trigger migraines. So it's all about change.
My wife has that. She can feel bad weather coming on, my wife can.
It's actually quite a reasonably well-established phenomenon. The Canadians did a good job with a study of the Chinook winds. We don't understand how this change plays into activating migraine biology, but the advice then very clearly is that regularity — regular sleep, regular meals, regular exercise. A bit of regular stress, not too much and not too little, is helpful for migraineurs.
Having said that, controlling all of that, the migrainous brain seems to be able to get around that from time to time, and a migraine sufferer will tell you that on some days they can skip lunch and on other days if they just don't have morning tea they have their attack, and that's one of the great frustrations that we don't understand sufficiently about that biology yet.
Now I understand that coffee and caffeine can be a bad guy, and it seems like as we try to get along with less sleep, do more, have more in our busy schedules, we're guzzling coffee, that can be a bad guy, right?
Precisely. Excess caffeine intake can promote it and in fact in some respects make headache treatments more difficult, so some care with that is a good thing. Typically once you get over more than two cups of coffee in a day, you can start to run into problems, and patients will recognize that as a caffeine withdrawal headache, which can be problematic.
Dr. Goadsby, so when someone wants to see a headache specialist such as you have with yourself and others, your colleagues at the UCSF Headache Center, you're trying to figure out what causes it or what changes people have had. Do you ask them to keep a journal or a diary to try to see the correlation between what's going on and what they're eating with when this occurs?
Yes, I think a headache diary is an extremely useful thing, and it doesn't have to be more complex than a diary that records what day every day that the headache is present and particularly the menstrual cycle around it and what medicines are being taken and other things that are occurring on a, if you want, on a regular basis. That enables the clinician to see the patterns. It enables the clinician and the patient to see what the load of the headache is in the terms of the disability that's being built up, and helps a great deal in planning treatment.
Let's talk about treatment. So we have been in really an incredible era of new medications and new understanding of migraine. Where are we now with the tools you have to help someone who's a sufferer?
Yes you're right. We've gone through quite a significant revolution in the last decade or so with treatments and combined with the biology that we were talking about earlier with the brain imaging for example, the whole scope for the migraineur, the migraine sufferer, has changed, so we have explored better preventives, and most recently there have been developments in acute treatments, and actually further developments around the corner.
The most recent development just actually released in the last week or so has been a combination of one of the well-recognized now treatments, sumatriptan, combined with the so-called nonsteroidal anti-inflammatory naproxen in a combination tablet, which is very effective at providing pain relief, indeed pain-free rates at two hours, and has the particular advantage of reducing the number of patients who have so-called headache recurrence. Many of the listeners would recognize that that when they take their medicine the attack goes away but then they have it come back in 8, 10, or 12 hours. Headache recurrence, it's a bit of a drag because not only does the attack come back, but you have to re-treat it, and this new combination medicine has a substantial reduction in headache recurrence.
And just around the corner we saw published, again in the last couple of weeks, the next step, which will be an even completely new class of treatments, the so-called calcitonin gene-related peptide, or CGRP receptor antagonist, a whole group of new words to learn so to speak, that will provide further benefits, again probably in this headache recurrence area and important improvements in safety. It's a very bright time for the migraineur.
So, we've come a long way now. Let's say you try medicine "A" on someone, and it just doesn't quite cut it. Is there still a chance that medicine "B" could work for them?
Absolutely. The one thing not to do in migraine is for both either the doctor or the patient to get despondent. There are many things that can be done. There are many options for treatment and for the patient for whom medicine "A" doesn't work, there's medicine "B" and when medicine "B" doesn't work, there's medicine "C" and when medicine "C" doesn't work, there'll be medicine "D," and the place of headache centers and headache specialists is to explore with the patient who's having a difficult time getting the therapy or having a difficult time understanding what's going on to explore their headache and their treatment in an appropriate way. There are very, very, very few people in my experience that you can't do something for.
Well that was my question to you as a headache specialist. So at the UCSF Headache Center, it sounds like you are headache detectives in that understanding the individual biology of that person and their lifestyle and then seeing what are the tools that can be brought to bear for them.
If you like, I see my role as making sure that the individual with a headache problem has the right diagnosis, that's important, has a really good understanding of the disease as best as I can give it to them, and then knows what the options are because if people understand things better and they know what their options are, they start to get control of the problem, and instead of being a slave to their migraine or a slave to the tablet that they're now reaching for and that they're disturbed that they don't have in their bag, they're in control. The thing that migraine does is take away control of their life, and our goal is to do two things; one, give them back control of their life, and the other thing crucially for us is to conduct research to advance our understanding of the disorder because if we don't leave something better for our kids, we haven't been much of a research group.
You know, I'm going to make a weird analogy maybe, but in what's happened in dentistry, nobody wants a toothache, and so over many decades now the dentists have been committed to preventative dentistry to try to have you not get to that point. For people who are at risk of having migraines, do we have preventative strategies now so that they just avoid them, but there are certain things they need to do to maintain that status?
Well we have, that's an interesting analogy, we have preventive treatments that will reduce frequency and severity of headache or of migraine when you've already got the established problem, so to speak. There hasn't been enough done I think on the biological side to understand how to stop it getting to that stage.
We know from very good work that's been done by the epidemiology people, particularly Professor Lipton in New York, that if you have more headache this year, you're more likely to have more headache than that in the following year, so that's certainly true. So it seems clearly a good thing to try and reduce headache frequency.
What we don't understand is how to take a cohort of children or adolescents if you want and prevent it coming altogether. It's one of the challenges that face us, but at least the challenges trackable. Migraine is a disorder that can be really changed if we apply good sensible research techniques and put some resource behind it. If we can make change, then the disorder will be just unrecognizable in 15 years.
That would be a wonderful goal to achieve. Now everybody wonders what can I do myself? So they can see a headache specialist and certainly understand what you're dealing with and if appropriate certain medications may come to bear. Are there other strategies that can also be used that might help people? Like I think of when it comes to pain can something like acupuncture have benefit for some people?
Yes, no one has all the answers to the headache problems as you say. If a patient is well informed, if they understand their own triggers a little bit, they can do a lot for themselves in terms of lifestyle modification; it gives them a better control of their disorder. There are non-pharmaceutical, non-drug approaches to the treatment of migraine. We're quite interested in them. You mention acupuncture, it has some role, and there are some non-drug treatments such as riboflavin that's a well established vitamin B2. There are ways of dealing with some patients, not all, but a significant number of patients where drug therapies are not needed.
The important thing I think is to have the range of options and not to be just locked into one paradigm. The crucial thing is to want to aim to improve the patient in a way that's congruent with their lifestyle and which they're comfortable with.
Now, I understand that your migraine problem for someone who's affected by this can change over time, and we mentioned hormones in women, and some women get menstrual migraines. After you go through menopause can you expect that to subside?
Yes, in large part you can. In the main, about 80% of female migraine sufferers will have their attacks abate almost completely after menopause is finished, so there's much that's positive in that.
It is important that if you induce a menopause, particularly surgical induction of a menopause, that abatement, you don't improve with that generally speaking, and in fact inducing an early menopause will very often make the process of stopping the attacks slower, so at the moment we can give people the good news that things will improve, but there's no way of taking advantage of that, and doing anything about it actually seems to make things worse.
I just want to make sure I understand that. That's new information for me. So certainly one of the more common surgeries is hysterectomy, which women might have for a variety of reasons, so if they have that, that may not help them with their migraine problem if I've got that right.
Precisely. Hysterectomies and taking the ovaries out, a so-called oophorectomy, that doesn't help with migraine. That's perfectly clear, and it's also perfectly clear that a good proportion of women who have the oophorectomy will actually go on to have more problems for a longer period with their migraine. We don't recommend that at all.
Whoa, okay. And also as we talk about diagnosis earlier, we talked about the classic symptoms of migraine, but people can certainly, even migraineurs could also have other types of headache. You can still get a tension headache, right?
Yes, migraine is a word that's used in two ways in English; that's the beauty of the language. It refers to the attacks, which we described, which are typical, but it also refers to the disorder, and the disorder migraine is an inherited tendency to have headache triggered under particular circumstances of change, which very often manifests as typical migraine, but I think it's reasonably well accepted that on some days the migraine sufferer will have less obvious migraine if you want and less severe headache, which looks for all the world like a tension-type headache. The underlying message of migraine is not the detail of every attack but the general pitch of the helicopter view of what the migraine sufferer is, and that's a person who is prone to headache very often in a family of people who are prone to headache.
Well, you've certainly given us a lot of information today, and I also loved what you said that you really feel there's a brighter future and also a lot you can do now, so I would certainly urge people listening if you have this problem, if you think you do, if it runs in your family, to really consult with the UCSF Headache Center, and Dr. Peter Goadsby. Thank you so much and welcome as the new program director there. I'm sure you can help a lot of people.
Well we hope to do so, and thank you very much for listening.
Thank you sir and I want to mention to our listeners, if you want to contact the UCSF Headache Center, here's the number 415-353-8393. For more information about the physicians and services at UCSF more generally, you can call the referral service, and that's 888-689-UCSF (8273).
Recorded May 2008
Reviewed by health care specialists at UCSF Medical Center.
This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.
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