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December 20, 2000
Migraines: A Model for Relief

first letter I often found Lisa in my office on Mondays or after a short vacation. I can still picture her lying on the exam table, her face mournful and her eyes filled with tears. Her letdown headaches were the worst. But she also had migraines before her period, and sometimes they were triggered by stress, bright lights, or strong odors -- especially bleach.

Ounce of Prevention


By Elizabeth Smoots, M.D.

Just before one of Lisa's intense, throbbing headaches and vomiting would begin, she typically saw an aura with shimmering spots. I used to tell her this was caused by the constriction of blood vessels in the brain followed by dilation. Over the past several years, however, a better explanation has evolved. For nearly 30 million migraine sufferers -- three-fourths of whom are women -- the current view may foster some helpful ways of warding off these debilitating headaches.

The body electric

Using imaging advances to visualize patients' brains during an attack, scientists have devised a new theory of migraine genesis. Doctors now know that patients like Lisa are susceptible to severe headaches because their brain cells are hypersensitive to changes in or outside the body. Any migraine trigger -- such as certain foods, stress, or hormone variations -- may stimulate nerve cells to start firing. The smallest spark ignites an explosion of activity that surges across the brain. In this way, a migraine is much like a seizure, I explain to patients, since both begin with a tiny, spreading electrical discharge.


Any migraine trigger -- such as foods, stress, or hormone variations -- may stimulate nerve cells to start firing.


That's where the similarities end. A seizure usually produces convulsions, while most migraines culminate in a severe headache. This happens when the electrical storm reaches a remote part of the brain called the trigeminal nerve. Here substances called neuropeptides are released that cause blood vessels to swell and leak, spurring the inflammation and ungodly pain of a migraine headache.

Fresh insights, novel ideas

An improved understanding of migraines has opened the door to new approaches for prevention. Recently, the U.S. Headache Consortium, formed by seven organizations led by the American Academy of Neurology, released migraine guidelines that emphasize prevention and self-care. The guidelines recommend keeping a diary to help identify and control factors that trigger headaches. They also advocate taking steps to reduce the frequency of migraines if, despite treatment, the disorder significantly interferes with your daily routine or is difficult to control.

In situations like these, the guidelines say, you should strongly consider using preventive medication. Some of the treatments take advantage of the recently proven similarity between migraines and seizures. Antiseizure pills like valproic acid and gabapentin work by dampening excessive nerve activity that can instigate migraine symptoms. In addition, a whole host of traditional drugs can effectively head off migraines, including blood pressure medicine such as calcium-channel blockers and beta-blockers, or antidepressants like amitriptyline.

For those reluctant to take medicine, several alternative therapies are available to help forestall migraines. The herb feverfew, the mineral magnesium, and the B vitamin riboflavin all had some efficacy when scientifically reviewed by the consortium. Moreover, stress management, relaxation training, and biofeedback may benefit some migraine sufferers, says the report, especially in combination with other preventive measures.

There's still no magic cure for migraines. But today, thanks to research breakthroughs, patients like Lisa can choose from a greater variety of options.

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Elizabeth Smoots, M.D., F.A.A.F.P., is a board-certified family physician in Seattle, Washington. A fellow of the American Academy of Family Physicians, Dr. Smoots specializes in prevention and primary care medicine.