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UNDERSTANDING AND CHANGING THE IMPACT OF THE MIGRAINE HEADACHE CYCLE ON PATIENT LIFESTYLE

Migraine is a chronic neurological condition that is a significant public and personal health problem worldwide. In recent years, migraine headache has finally been recognized as a major cause of disability and lost productivity in all phases of a patient’s life cycle, starting as early as childhood. In the United States, the monetary value of productivity lost because of migraine headache amounts to $13 billion per year. Recent research indicates not only that this disorder affects the entire life cycle of a patient but also that migraine characteristics and effective treatment strategies can change as a patient ages.

Migraine impairs function in all aspects of life, including family, social, work, and education. However, a communication gap exists with regard to migraine-related disability. On one hand, patients underreport such disability; on the other hand, physicians tend to focus on diagnosis and treatment but not disability. In addition, patients with migraine may have other debilitating comorbidities, including anxiety and depression. The most conspicuous precipitating factors of migraine headaches are stress and mental tension, which are often integrally linked to lifestyle and personality. Other reported precipitants include alcohol, lack of sleep, cold or fever, smoking, weather changes, food, and menstruation. Successful migraine management means a readjustment in all aspects of a patient’s daily routine.

MIGRAINE IN CHILDREN

The prevalence of migraine headache in children is about 5-10%. In boys, the incidence of migraine with aura peaks when patients are aged 5 years, and migraine without aura peaks when patients are aged approximately 10-11 years. In girls, the incidence of migraine with aura peaks when patients are aged 12-13 years, and migraine without aura peaks when patients are aged 14-17 years. Thus, migraine begins earlier in boys than girls. Contrary to popular thinking, an equal number of girls and boys are affected in childhood.

Characteristics of migraine

The characteristics of migraine are different in a child than in an adult. In children, the headaches are shorter (can last 30 min vs the 4 hours required to qualify as migraine in adults), have a more rapid onset, are accompanied by particular symptoms other than headache (eg, cyclical vomiting, benign paroxysmal vertigo), and are often accompanied by additional symptoms (eg, photosensitivity) that need to be ascertained by adults observing the child’s behavior.

Treatment approaches

The treatment approach is also different for a child; the parents and the school of a child with migraine headaches must be educated about the disorder and involved in its management. If a child starts to have a migraine headache during school, the importance of immediately administering acute abortive treatment is not always understood. The child’s academic performance should be monitored because it may help discern how well the disorder is being managed or whether the disorder is a stressor for the child. Understanding the psychosocial dynamics (ie, relationships between the patient and his or her parents and siblings) and treating psychological stressors is also very important. Treatment planning should include discussions regarding alcohol use, drug use, and birth control pills, since these substances can impact migraine disability and treatment.

Pharmacologic and nonpharmacologic therapy

Triptans, which are acute abortive agents often used for treatment of migraine in adults, have not been approved by the US Food and Drug Administration (FDA) for migraine treatment in children. Practice guidelines put forth by the American Academy of Neurology state that the first line of therapy for acute treatment of migraines should be simple analgesics or a combination approach with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). Therefore, the treatment approach with children tends to be conservative. However, in children whose migraine headaches have failed to respond to such therapy, triptans have been found to be generally safe and well tolerated.

Pharmacologic prevention is necessary when treating severe and disabling migraines. Medication choices are the same in adults and children (ie, antiepileptics, antihypertensives, antidepressants). However, long-term adverse effects should be carefully considered when prescribing medications such as valproic acid, which has been described in the literature to lead to various endocrine, metabolic, gastrointestinal, and other adverse reactions when prescribed to children. Adolescents are also at higher risk of having anxiety or suicidal or homicidal thoughts after starting therapy with certain antidepressants. Therefore, a clear discussion of a potential medication’s adverse effect profile should take place in the presence of the patient’s parents or guardians.

Behavioral treatment (eg, biofeedback, cognitive behavioral therapy, relaxation therapy) is known to be very effective in preventing migraine headaches and should be a first-line approach when choosing preventive therapies. Lifestyle modification is an integral part of managing pediatric migraine. Such modifications include regular daily routines, sleep hygiene, and proper diet and hydration, with special attention paid to avoidance of environmental and internal triggers.

MIGRAINE IN ADULTS

The prevalence of migraine in Western countries is 12-16% and is highest in persons aged 25-55 years. Prevalence varies with income and race. An association between higher incidence of migraine and lower socioeconomic status has been observed. Two hypotheses may explain this observation. One states that the poor diet, lack of medical care, and high levels of stress that result from having a lower income may trigger more migraines, and the other states that migraine headaches interfere with education and work and lead to a lower income status. On average, a person with migraine misses work 1 day every 3 months and is bedridden for 4-8 days every year from migraine. In a subgroup of patients, migraine is a progressive disorder that leads to chronic daily headaches, which is an even more disabling condition. Some of the modifiable risk factors for migraine progression include higher attack frequency, medication overuse, and stressful life events. The key to preventing disability and progression of migraine is, therefore, early and aggressive treatment.

Treatment guidelines

The US Headache Consortium has developed multispeciality consensus guidelines to manage migraine. These guidelines include the following:

1. Establish the diagnosis. Migraine headache is diagnosed by careful history and physical examination alone. Complicated testing is not required to make the diagnosis.
2. Assess disability. Clinicians and patients should use a standardized, simple questionnaire on each visit to assess migraine disability, and one of the goals of treatment should be reducing disability. One example of a standardized measure is the Migraine Disability Assessment Questionnaire (MIDAS), which takes just a few minutes to complete.
3. Educate patients and establish realistic expectations. Patients are more compliant with treatment if they understand the pathophysiology of migraine and that it is a chronic and incurable condition.
4. Encourage patients to participate in their own treatment. Migraine cannot be managed by medication alone. The patient has to take ownership of the treatment plan, which should, ideally, take into account all aspects of life, including personal, social, work, and school. One of the key aspects of migraine management is lifestyle modification to eliminate as many triggers or precipitating factors as possible.
5. Individualize care. Each patient has a unique set of precipitating factors and circumstances and should be treated in the framework and context of his or her lifestyle.
6. Follow up with patients to assess and optimize care.

Menstrual migraine

The decline in estrogen that results from menstruation is one of the strongest and most well-known migraine triggers in women. Menstrual migraines can be more intense and can last longer than a patient’s usual migraines. The treatment strategies for acute and preventive therapy are similar to those used in the general population. Menstrual migraine occurs during a well-defined and, often, predictable period of about a week (ie, starting 2-3 days prior to menstruation up to 3 days after). Short-term preventive treatment is often used during this period. Recently, a trend has developed of using certain long-acting triptans like frovatriptan and naratriptan for “mini-prophylaxis” perimenstrually. The longer-acting triptans, when given twice a day prior to the onset of menstruation until 2-3 days after menstruation ends, can significantly decrease the intensity, duration, and disability of menstrual migraine.

Preventive treatment with oral contraceptives or hormonal therapy is another option for women. However, the relationship of oral contraceptives and migraine is not linear; some patients’ migraine symptoms can dramatically improve, and others actually experience worsening of their headaches. Several options are available, all of which aim to offset the decline in estradiol associated with the onset of migraine. A transdermal estrogen patch can be used for short-term prophylaxis. Another approach would be to use oral contraceptives for 3 weeks, supplemented by estrogen only during the fourth week of the menstrual cycle. Oral contraceptive use in migraine with aura can, however, increase the patient’s risk of stroke, especially if the patient smokes.

Pregnancy

Fortunately, women do not have many migraines during pregnancy. During this period, migraine headaches should be managed jointly with the patient’s obstetrician. For acute abortive treatment, the choices during pregnancy are limited to acetaminophen and narcotics. NSAIDs should not generally be used during pregnancy and should especially be avoided during the last trimester. Triptans are category C, which means they have been demonstrated as harmful to pregnant animals, but not enough data are available in humans to determine the level of harm. Ergots are category X, which means they are absolutely contraindicated in pregnancy. Steroids can be safely used as rescue treatment during pregnancy. Daily preventive treatment for migraine is best avoided, especially during the first trimester, when most of the organogenesis occurs. For women who experience migraines, planning pregnancy is important. If the fetus has been exposed to teratogenic medications, the fetus should be monit! ored carefully during the pregnancy for abnormal organogenesis.

Sports migraine

Athletes with predisposition to migraine may experience prolonged exertion as a trigger for a typical migraine. For a headache to occur with prolonged exertion, additional triggers may be required. Such triggers include heat, altitude, bright light, dehydration, and low blood sugar levels. Migraines can also be triggered after the use of certain types of athletic equipment. Poorly fitting mouth guards and tight helmets and goggles have been noted as potential triggers for athletes with migraine. The headache may occur minutes or hours into the activity or after cessation of activity and does not typically resolve when the activity is discontinued.

The evaluation of an athlete with exertion as a trigger for migraine is the same as that of any patient who presents with headache. Special attention should be given to triggers related to the environment. These might include the use of equipment, environmental factors (eg, sunlight, altitude), or diet. The treatment for exercise-induced migraines should include proper warm-up before exercise and minimization of environmental risks. Other important aspects, which are important for all patients with migraine, are consistency in daily routines, sleep hygiene, good nutrition, and proper hydration. Some athletes with prolonged exertion as a trigger for migraine respond to pretreatment with triptans or indomethacin.

Leisure headaches

Patients with migraine often report having leisure headaches or migraines during weekends or vacations. These patients report having a heavy workload, difficulties with the transition from work to nonwork situations, and stress associated with travel and vacation. Certain personality characteristics, such as an inability to adapt to nonwork situations, a high need for achievement, and a high sense of responsibility with respect to work, have been seen with such patients. Notwithstanding these personality traits, the threat of migraine during vacation and weekends looms large over these patients and causes much anticipation anxiety. These patients need to have an acute abortive treatment that provides rapid and complete relief. When planning a vacation, patients should consider potential vacation-related migraine triggers, including air travel and high altitude. Having to carry migraine medications at all times can be limiting and curtail the sense of spontaneity for adventur! ous individuals.

MIGRAINE IN ELDERLY PATIENTS

Migraines do not commonly start in elderly patients. When treating an elderly patient with migraine, the patient more commonly has a long history of migraines and may start having more migraines or migraines that transform into chronic daily headache. In this age group, consider secondary causes (eg, malignancy) and perform neuroimaging (eg, MRI of the brain) when patients describe a change in headache pattern. Certain types of migraine are specific to this age group and present with stroke-like symptoms (late life migraine equivalents). Acute abortive treatment with a triptan is usually contraindicated in elderly patients because of potential complications from comorbidities such as high blood pressure and coronary artery disease and the potential for medication interactions. Therefore, the choice of abortive treatment is limited to regular analgesics, and good preventive treatment becomes the cornerstone of treatment. Preventive treatment includes placing patients on a dai! ly regimen for 3-6 months; the usual choices are antihypertensives, antiepileptics, or antidepressants. Since elderly patients generally have lower tolerance to adverse effects of medications, dosage can also be limited.

Elderly patients are often dealing with loneliness and depression, which tend to create a chronic pain cycle. For long-term successful treatment of migraine, these psychosocial issues need to be addressed and treated. The importance of behavioral treatment in this age group cannot be overstated. Elderly patients may also have other headache types, like cervicogenic headache and occipital neuralgia. Treating these other headache types is key to breaking the chronic headache and pain cycle. Another problem in this age group is deconditioning due to a sedentary lifestyle, which encourages musculoskeletal-based pain. Physical therapy helps improve musculoskeletal pain with range of motion exercises, conditioning, and posture education.

CONCLUSION

Migraine disability and impact on the patient’s entire life span is underestimated and underrecognized. Successful treatment throughout the life span depends on recognizing the changes in characteristics of migraine headache and the differences in the pharmacokinetics and dynamics for different age groups. A multidisciplinary approach with the key concept of sustained lifestyle modification helps limit the pain cycle and the disability that arises from it.

REFERENCES

Breslau N, Rasmussen BK. The impact of migraine: Epidemiology, risk factors, and co-morbidities. Neurology. 2001;56(Suppl 1):S4-12.

Landy S. Migraine throughout the life cycle: treatment through the ages. Neurology. 2004; 62(Suppl 2):S2-8.

Lane JC. Migraine in the athlete. Semin Neurol. 2000;20(2):195-200.

McKenna J, Peters M. The problem of sustaining a healthy active lifestyle among migraine sufferers: a qualitative study. Medicine & Science in Sports & Exercise. 1999. Available at: www.acsm-msse.org.

Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain. 1993;53(1):65-72.