FOR THOSE WHO CHOOSE TO LIVE WELL DESPITE

MAGAZINE Issue 02 | Fall 2017 TAKING YOUR MIGRAINE ON VACATION PLUS

MIGRAINE 101 WHAT IS IT WHAT CAUSES IT HOW TO TREAT IT APRILFALL 2017 2012 CONTENTS

REGULAR FEATURES 02 01 Letter from the Editor

01 Migraineur Editorial Board Profile.

2 So You Want to Take Your Migraine On a Vacation!

05 Migraine 101

09 Celebrity Migraine

05 09

SPECIAL FEATURES 11

11 Managing Your Migraine: 01 Tip of the Month 02 Treatment of the Month: Caffeine! 03 Myth of the Month

13 DOCTOR ON CALL

NEXT ISSUE Copyright © John F. Rothrock, 2017. All rights reserved. No part of this publication may be reproduced, stored Sex and Migraine: “Not tonight, honey” or “Bring it on!”? in or introduced into a retrieval system or transmitted • by any means (electronic, mechanical, photocopying, • Migraine and Pregnancy recording or otherwise) without the prior written per- mission of the copyright owner or his formal designate. • “The Big 5”: What Your Doctor Doesn’t Want to Hear

Migraineur Magazine • www.migraineurmagazine.com 1 LETTER FROM Migraineur Editorial Board Profile

THE EDITOR Dr. Rothrock received his medical degree from the University of Virginia and completed his intern- ship and residency training in Neurology at the In this and subsequent issues we will University of Arizona. attempt to dispel the many myths that In 1983 he joined the Neurosciences faculty at surround migraine… the University of California, San Diego (UCSD), where he established and directed the UCSD Welcome to the second issue of a magazine Stroke Center and, subsequently, the UCSD Head- that is intended to both educate and ache Center. He and his UCSD colleagues assisted entertain the many millions of Americans in the development of such medications as in- who suffer from migraine. As a physician and jectable sumatriptan (Imitrex) for acute migraine fellow migraineur who has treated thousands treatment and divalproex sodium (Depakote) and of migraine patients, conducted research in topiramate (Topamax) for migraine prophylaxis. the field and assisted in the development of From 2006 to 2012 he served as professor, vice virtually every new treatment for chair and medical director of Neurology at the since the emergence of sumatriptan (Imitrex) University of Alabama/Birmingham (UAB). At UAB, in the late ‘80s, I have a particular allegiance Dr. Rothrock continued his clinical research in the to our readership. area of migraine, assisting in the development of onabotulinumtoxinA (BotoxA) as a treatment for Migraine is a decidedly odd malady. Although rarely life-threatening, chronic migraine. it is frequently life-altering. Migraine imposes a tremendous physical, financial and psychosocial burden upon our society, and for those of Since July 2015 he has served as professor and us afflicted it may persist, throughout most of our lives. vice chair for the department of Neurology at the George Washington University School of While common, the disorder is poorly understood both by the public Medicine. With his colleagues locally, nationally and by healthcare providers, a situation that results all too often and internationally he is working to develop new in a failure to seek medical care or medical mismanagement and treatments for migraine and other headache consequent patient frustration when such care is sought. disorders.

In this and subsequent issues we will attempt to dispel the many Dr. Rothrock has been listed in America’s Top Doc- myths that surround migraine, acquaint you with the tremendous tors and Best Doctors in America in each of the strides that have been made in understanding and treating the past 15 years. He has been cited in Men’s Health disorder and, most important, offer some guidance as to how we and Women’s Health magazines as one of the 20 migraineurs may enjoy life more fully and control our headache top neurologists in America. disorder more effectively. John F. Rothrock, MD Editor in Chief Editor-in-chief: John F. Rothrock, M.D. Associate editor: Amanda Michael, M.D. Managing editor: Diane Andress-Rothrock ON THE Production editor: Bradley Bawek COVER Director of marketing: Benjamin Lankford Cynthia Andress pauses on the Design: BAWEK creative services / bawekcreative.com Shirley Lake Summit Shirley Lake Trail. She is a mother, Printing: Minuteman Press Bethesda / mmbethesda.com Squaw Valley, CA a full time student, an active Published by: Celeray Press triathlete and a migraineur.

2 Migraineur Magazine • www.migraineurmagazine.com SO YOU WANT TO TAKE YOUR MIGRAINE… ON VACATION! Follow this advice and you will increase your chances of enjoying a pleasant and headache-free vacation

peaking to her physician, LM, a 35-year-old female migraineur, reports: compassionate spouse, significant other, relative or friend may find it difficult to “We live in Phoenix, and our summers extend well into October. This Fall deal gracefully with the unappealing my husband and I are planning to take two weeks off in September to go to behavior provoked by your acute migraine. S Mallorca, but instead of looking forward to our vacation I’m dreading it. We After all, you don’t have a fever. You don’t went to Paris a few years ago for what was supposed to be a second honeymoon, and look that sick. Why can’t you … go sailing; I just fell apart. I was exhausted the whole time, but I couldn’t sleep. Despite the great walk with me on the beach; stop for a food everywhere around me, I had no appetite. And my went ballistic! To my poolside cocktail; have a romantic tryst in husband’s disgust, I wound up spending most of the so-called vacation in bed (alone) our room before dinner at the restaurant trying to deal with my headache and wishing I was home. He barely spoke to me on the our friends told us about? In short, why flight back to Arizona. can’t you do all those things we spent so We’ve been saving up all year for this big trip to Spain, but because of my migraine I’m much time planning to enjoy? Why are you afraid it’s just going to be a big waste of money.” ruining our vacation! Extended travel can exact a One needn’t travel thousands of miles to physical toll on anyone, but the Balearic islands of Spain; even far less long flights and a sudden ambitious vacations have the potential ENJOY A introduction to an unfamiliar to unhinge migraine. The alterations in environment may make the HEADACHE-FREE one’s usual eating, drinking and sleep- experience particularly chal- ing habits can wreak havoc, leading the lenging for the migraineur. No VACATION poor migraineur to wonder why he or she sane migraine sufferer wants didn’t opt instead to spend that hard- to experience an extended earned money on a bathroom renovation. flare-up of headache, and that such misery could occur in the Try following the advice offered here, and midst of a long-anticipated you will increase your chances of enjoy- vacation is, to say the least, ing a pleasant, headache-free vacation. discouraging.

To make matters worse, the acutely suffering migraineur AIRLINE TRAVEL often must bear an additional burden: the disappointment Travel Stress: The circumstances of experienced by one’s traveling extended air travel possess a multitude companion. Especially if they of potential migraine triggers. Whatever have no personal experience the setting, migraineurs inevitably report with migraine, even the most stress to be the most common stimulus

Migraineur Magazine • www.migraineurmagazine.com 3 MIGRAINE THRIVES ON that of your travel destination; as invit- at an unfamiliar medical facility can be DEHYDRATION…OVER- ing as that hotel bed may look after an frustrating and even humiliating. To do extended flight from Boston to Budapest, so bearing a statement from your regular HYDRATE WITH WATER resist the urge to give in to your weari- physician may go a long ways towards ness and climb between the sheets at lessening the hassle. for migraine activation, and events of noon. Give your hypothalamus a chance the last two decades have exponentially to recalibrate. Take your brain for a walk, amplified the stress associated with air eat dinner at a time appropriate to your travel. While there’s nothing you can do new locale and try to avoid giving in to RELAX! to eliminate this stress entirely, there are sleep until well after sunset. Don’t Overdo: Flushed with the actions you can take to reduce the inevi- Benzodiazepines (eg, clonazepam) and excitement of having shed the routine table annoyances you must endure. non-benzodiazepine sleep promoters demands of home and work, one’s natu- Try to avoid flight itineraries that involve (eg, zolpidem=Ambien)) may reduce the ral temptation is to kick off the vacation horrifically early or late departures, insomnia associated with jet lag, but with too much too soon. The beach, impossibly tight connections, “red eyes” their use can negatively affect next- ocean, lake, museums, galleries, restau- or stand-bys. When possible, minimize day physical and mental performance rants and clubs aren’t going anywhere, the need to make connections. If one of (even to the extent of causing amnesia!). and to knock yourself out of action for your flights is cancelled or so hopelessly For simple “travel fatigue”, however, as the duration of the trip by overindulg- delayed as to endanger a connection, opposed to jet lag insomnia resulting ing on your first day and night makes no look immediately to your smart phone from disruption of your circadian rhythm, sense. This is supposed to be fun . . . not rather than stew and fret in an endless use of a “prn” (ie, taken as needed) sleep promoter such as zolpidem, eszopi- an endurance test. line. Anticipate complications by packing clone (Lunesta), or temazepam (Restoril) Go easy on the caffeine and , and, a carry-on that contains what you need thesecan make an enormous difference, once again, don’t forget to hydrate with to get through a 24 hour detour wherein allowing you to feel well-rested and water throughout the day and evening. you and your luggage have parted ways: headache-free. Go to bed at a decent hour, and use your a change of clean clothes, basic toilet- medication if you feel a headache coming ries, contraception (if applicable) and- on. Enjoy your vacation. Avoid transform- most definitely-medications from the ing what could be an idyllic period of arsenal of therapies you typically use for MIGRAINE TREATMENT rejuvenation into just another bout of acute migraine treatment. prolonged migraine. Thanks to the dry air within the pres- Medications: When it comes to your surized cabin, air travel is dehydrating. usual medications (including contracep- So are alcoholic beverages and caffeine. tives), don’t get caught short while on Migraine thrives on dehydration. Give vacation. Well before you leave, make JET LAG yourself a break: save the vodka tonics sure you have enough of those medica- and diet Cokes for later. While in flight, tions to last for the time you’re away… The circadium rhythm refers to our take pains to overhydrate with water. especially whatever you normally take brain’s inclination to bring various bio- for acute migraine treatment. And if in logic functions into synchrony with the the recent past you’ve had attacks of earth’s daily rotation. The misery we severe migraine that failed to respond to INSOMNIA term “jet lag” is a symptom complex that your usual self-administered therapy and results when this internal clock remains required a trip to the doctor’s office or an Sleep Distruption: Insomnia stubbornly set to the time back home emergency room, it’s a good idea to bring is a common complication of travel. over the days that immediately follow with you a written statement by your Disruption of one’s normal sleep pattern the brain’s sudden transport to its new physician that briefly summarizes your is notorious for triggering migraine, and destination. medical history, your migraine history in it’s consequently wise for the migraineur particular and the medications that have How much one is affected depends in to plan in advance for this complication been required to treat your migraine. part on the biologic characteristics of the and head it off at the pass. Any migraineur who has suffered individual traveler’s brain, and this (unfor- When traveling across multiple time through the experience will tell you that tunately) is where migraine and jet lag zones, try to match your internal clock to to seek treatment for acute headache intersect. The same genetically derived

4 Migraineur Magazine • www.migraineurmagazine.com SYNCHRONIZE YOUR loss of appetite, constipation, mental • individual differences in the internal BIOLOGIC CLOCK WITH “fogginess” and and impaired physical “biologic clock” (migraineurs having performance. increased susceptibility) YOUR DESTINATION Great, you say. Jet lag may be a major • the conditions of the travel itself buzz-kill, but I really want to go to Spain, (enforced immobility, air quality, cabin sensitivity of the migrainous brain that and I don’t have the time to cruise slowly pressure and intake of alcohol or can produce visual aura or attacks of across the ocean to get there. What can caffeine all tend to worsen jet lag) inescapable head pain also increases the I do? For those who are sufficiently motivated, predisposition to jet lag. Migraine thrives Without any specific treatment, your cir- treatment of jet lag involves accelerating on change, be it the monthly change in cadian rhythm will adjust to your desti- one’s adjustment to the new time zone levels of sex hormones experienced by nation time at the rate of about one time with strategically timed exposure to menstruating females, a change in baro- zone per day for eastward travel and 1.5 bright light and the use of melatonin. Put metric pressure…or a sudden change in time zones per day for westward travel. simply, you are trying to help synchro- time zones. Along with the total distance traveled, nize your biologic clock with that of your The symptoms of jet lag occur one to the severity of jet lag is influenced by: destination. Making this effort, along two days after travel across at least two • the direction of travel (again, eastward with symptomatic measures intended to time zones, and jet lag tends to be more travel is more difficult to adapt to than help alleviate symptoms such as insom- severe with travel eastward compared westward travel) nia and daytime sleepiness, can go a with westward. The most common symp- long ways towards easing the transition • your ability to sleep during travel toms are insomnia (coupled with daytime from home to vacation. sleepiness), a pervasive sense of fatigue,

TIPS FOR MANAGING JET LAG

Traveling Eastward Traveling Westward Before Travel Before Travel • Starting 3 days before departure, move your bedtime and • Starting 3 days before departure, move your bedtime and wake time 30 minutes earlier each day wake time 30 minutes later each day • During this shift, avoid light in the evenings • During this shift, avoid bright light the first few hours after (including electronic light) and seek bright light for the awakening and seek light in the evenings 1st 2-3 hours in the mornings During Travel During Travel • Set your watch to your destination’s time • Set your watch to your destination’s time • With watch set to your destination’s time, avoid bright light • With watch set to destination’s time, avoid early morning (including electronics) during your destination’s nighttime. exposure to bright light (eg, use sunglasses if cabin lights Use dark glasses if cabin lights are on are on; keep windows covered) • Try to stay awake until desired destination bedtime • With watch set to destination’s time, maximize late morning • Try to sleep during destination nighttime; if unable to sleep, and early afternoon exposure to bright light wear dark glasses or sleep mask to minimize light exposure • Try to sleep during destination nighttime; if unable to sleep, • Do not use sedative medication during your flight wear dark glasses or sleep mask to reduce light exposure (especially during the second half of the night) Upon Arrival • Do not use sedative medication during your flight • Get lots of late afternoon and evening bright light • Avoid exposure to bright lights during your destination’s Upon Arrival nighttime • Avoid early morning bright light • Melatonin is not likely to be helpful • Get lots of late morning and early afternoon bright light • Try to stay up to desired destination bedtime. • On day of arrival and for up to 5 days thereafter, take melatonin Avoid nodding off early in the eveninge 3 milligrams at desired destination bedtime • Staying asleep may be difficult for the first few days; • For daytime sleepiness: short naps (<45 mins) at least 8 hours avoid electronics during nighttime awakenings before desired bedtime • For daytime sleepiness: short naps (<45 mins) at least 8 hours before desired bedtime

Migraineur Magazine • www.migraineurmagazine.com 5 MIGRAINE 101 WHAT IS MIGRAINE?

Migraine actively afflicts over 10% of the general population-surprisingly few can offer an accurate answer to the simple question: What is migraine?

lthough migraine actively afflicts approximately associated nausea or light/sound sensitivity and symptomatically 38 million Americans-well over 10% of the gen- resemble tension-type headache more than what we usually think eral population-and every day is the subject of of as migraine. A countless conversations, publications, web sites, This tendency to characterize only severe as “migraine” advertisements and jokes, surprisingly few people (including can complicate the medical provider’s attempt to accurately deter- medical providers) can offer an accurate answer to the simple mine a migraine patient’s total headache burden, the key to devel- question: What is migraine? oping an appropriate treatment strategy. When questioned regard- The term “migraine” is easy enough to define. If you’ve had 5 ing their headache frequency, migraine patients often base their or more attacks of unprovoked headache (not the headache estimate only on those headaches that are severe and incapacitat- of a tequila ) that lasted 4 to 72 hours, was severe ing. In doing so they may fail to include headaches that are non- enough to inhibit or even prohibit your routine daily activi- disabling but nonetheless decrease work productivity and quality of ties, was accompanied by nausea or light/sound sensitivity and life. Reluctant to overstate the impact migraine is having on their could not be attributed to another medical disorder…you are a lives, patients discount those days when they manage to “carry on” migraineur. despite a headache…but can neither work at full-speed nor take any real pleasure in a social event they otherwise would enjoy. The headache of migraine is not always Again, when migraine patients underestimate their headache bur- severe, throbbing or one-sided den, this works against the provider’s effort to provide them with an effective management plan. However severe the headaches Note that this definition does not require the headache to be involved, a migraine patient who is experiencing only 3 “headache throbbing or lateralized to one side of the head. Although such days” per month requires a very different treatment approach than clinical features are common in migraine, they are far from the patient who not only averages 3 days of incapacitating head- invariable. Plenty of migraineurs have headache pain that is “all ache each month but also is experiencing daily or near daily head over the head”, constant/non-throbbing or both. pain of mild to moderate intensity. Nor does the diagnosis of migraine require the occurrence of aura symptoms (eg, visual “stars”, “flashes”, “zig-zags” or blind WHAT CAUSES MIGRAINE? spots). Only 20-25% of migraineurs ever experience aura, and in that subgroup there are relatively few who experience aura For many years it was believed that migraine attacks arose from with each and every migraine attack. changes in the blood vessels which supply the head and brain. Aura Finally, the headache of migraine is not always severe, and (when it occurred) was attributed to constriction of arteries, with the some migraine attacks may involve no headache whatsoever neurologic symptoms of aura reflecting decreased blood flow to reti- (eg, migrainous aura without headache). With many episodes nal or brain tissue. The throbbing, sickening pain of migraine in turn of migraine the headache may be mild in intensity, lack any was attributed to a compensatory dilation of those and other vessels.

6 Migraineur Magazine • www.migraineurmagazine.com We now believe that migraine is genetic in origin and that the conduction: downward to the TNC in the brain stem and out disorder represents a genetically-induced hypersensitivity involv- the trigeminal nerve to the blood vessels within the dura. When ing neurons (brain cells) located within the central nervous the signal reaches the junction between the nerve and blood system. If a genetically primed neuron is triggered by a change vessel, it stimulates the release of proteins (2) such as CGRP in the external environment (eg, a sudden drop in barometric (calcitonin gene related peptide) that in turn cause the vessel to pressure) or internal environment (eg, a sudden drop in estrogen dilate and to leak other proteins that promote inflammation. That level), that neuron may depolarize (discharge electrically) and, inflammatory response further stimulates the already sensitized by triggering its neighboring neurons to join in, induce the path- trigeminal nerve endings, producing another pain signal that ways in the brain that normally conduct head pain to awaken bounces back (B) to the brain in the normal direction of sensory and produce the familiar symptoms of a migraine attack. flow (dura>brain).

The biologic circuitry of migraine is illustrated below. Under Thus a migraine attack can be thought of as a physiologic “ping normal conditions, a painful stimulus produced by, say, trauma or pong match”, with pain signal flowing simultaneously in opposite meningitis, activates head pain receptors located on blood ves- directions, “inside>out” (brain>dura) and “outside>in” (dura>brain). sels (A) within a membrane (the dura) that lines the brain. Those Each signal reinforces the other, with the signal amplifying as receptors generate a pain signal that is transmitted by the tri- the transmission pathway becomes increasingly sensitized. The geminal nerve (B) to the trigeminal nucleus caudalis (C), a cluster individual suffering the acute migraine attack correspondingly of neurons located within the brain stem. The trigeminal nucleus experiences a progressively more severe headache. This biologic caudalis (TNC), acting as a relay station, passes the pain signal and clinical process will persist until the underlying pain signal- upward to the brain itself, and at that point there is conscious ing system spontaneously becomes inactive or the afflicted indi- awareness of headache. vidual takes action to terminate the attack (eg, goes to sleep or takes a medication such as a triptan). MIGRAINE’S BIOLOGIC If this system of migrainous head pain transmission becomes chronically sensitized, the migraineur will begin to experience WIRING DIAGRAM more frequent episodes of head pain. In the worse case scenario, episodic migraine may “transform” into chronic migraine, and In migraine, the normal flow of head pain signaling is reversed. the migraineur may suffer a constant headache of relatively low In response to a change in the internal or external environment, intensity with superimposed attacks of more severe head pain. genetically hypersensitive neurons located in the visual cortex In such cases a course of preventive (prophylactic) therapy may of the brain (1) fire off electrically, generating a pain signal be required to stabilize the transmission system (see How can that travels brain-to-dura, against the normal flow of head pain migraine be treated? later in this article). In their physiologic origins and their treat- ment, migraine and epilepsy are biologic 1st cousins. Both conditions involve brains that contain abnormally sensitive neurons, and in both the source of this sensitivity may be genetic. Migraine and epilepsy are “bi-directionally co-morbid” (ie, if one has migraine, he or she is more likely to have epilepsy than normally would be expect- ed…and vice versa). Further cementing this relationship is the fact that several of our best medications for migraine prevention were first developed to treat epilepsy (egs, divalproex sodium/Depakote and topira- mate/Topamax, Trokendi).

In short, while changes in the caliber and permeability of cranial blood vessels may play an important secondary role in gener- ating migrainous symptoms, migraine is a primary brain disorder.

Migraineur Magazine • www.migraineurmagazine.com 7 HOW TO TREAT MIGRAINE ACUTE MIGRAINE TREATMENT

Given what we now know about its cause, If medication is used to treat acute inconsistency many individuals experience effective treatment of migraine must migraine headache, several important cave- with their use. necessarily involve stabilization of this ats should be considered. To some extent the problem with gastropa- resis/impaired GI absorption may be circum- genetically primed brain and nervous sys- • Match medication(s) to headache intensity vented by administering the oral medication tem pathway for head pain transmission For example, oral triptans generally work with a caffeinated beverage or by taking a that has become acutely or chronically best for headaches of mild to moderate compound medication that contains caffeine sensitized. intensity, but injectable sumatriptan is more (eg, Excedrin). Some prescription medica- effective for “rescue” from a severe migrain- When we speak of acute (or symptomatic) tions for acute migraine (eg, Treximet) are ous headache. You probably need to keep migraine treatment, we are referring to formulated so as to speed up their exit from multiple pharmacologic “weapons” on hand measures one may take at the time of a the stomach and subsequent absorption to treat the varying intensities of migraine headache that are intended to terminate into the bloodstream. headache you experience. that headache and associated symptoms If your migraine headache is accompanied such as nausea and light sensitivity. • Treat early by nausea and vomiting, then an orally Preventive (or prophylactic) treatment 2-3 aspirin taken with a caffeinated bever- administered medication obviously is a refers to measures used on a chronic basis age early in an attack may be more effective loser. At such times you can resort to acute to reduce headache burden. than a narcotic taken when the headache migraine medication that is administered has become well-established and severe. intranasally or by subcutaneous injection. Reducing chronic stres, good • Administer an adequate dose • Avoid chronic overuse of any given sleep hygiene and avoidance For example, OTC is available in a medication (or class of medications) 200 milligram (mg) strength and naproxen for acute migraine of obvious migraine triggers sodium in a 220 mg strength. Both drugs Virtually all of the medications used to treat may do as much as any pre- can be quite effective for early treatment acute migraine headache, OTC or prescrip- scription therapy to reduce of acute migraine headache, but “migraine tion, may actually promote headache if migraine attack frequency doses” are generally 600-800 mg for ibu- used too often on a chronic basis. Patients profen and at least 440 mg for naproxen often refer to this clinical phenomenon as sodium; with either, co-administer caffeine “rebound” headache, but it is more accu- There are many ways to skin the migraine (see below) rately characterized as medication overuse cat, both for acute/symptomatic treatment headache (MOH). Ironically, the first class • Consider the route of drug administration and for chronic/prophylactic therapy. While of medications synthesized specifically for Acute migraine attacks are accompanied by non-prescription (OTC=”over the counter”) acute migraine treatment, the triptans (eg, gastroparesis, meaning that the stomach’s and prescription medications are often Imitrex=sumatriptan), are especially prone to of great value in controlling migraine, usual motility is reduced to the point that it causing MOH if chronically overused. Others, there are other ways to treat the disorder may not pass orally administered medica- such as “narcotics” (opiates and opioids) that do not involve administering a pill, tions that “drop in” on to the small intestine and butalbital-containing compounds (egs, where they would otherwise be absorbed, nasal spray or injection. Regular aerobic Fiorinal, Fioricet, Esgic) not only cause MOH enter the blood stream and speed their way exercise, other measures taken to reduce may but also block the therapeutic effect to their intended targets to relieve your chronic stress (egs, yoga, meditation), good of migraine prevention therapies. As a rule acute migraine head pain. Erratic gastroin- sleep hygiene and avoidance of obvious of thumb, to avoid making a bad problem testinal (GI) absorption of oral medications migraine triggers may do as much as any worse, use no one acute migraine medica- for the treatment of acute migraine may at tion or class of medications more than 9 prescription therapy to reduce migraine least partially account for the therapeutic days per month on a chronic basis. attack frequency and overall headache burden. Especially when utilized early, PREVENTIVE (PROPHYLACTIC) MIGRAINE THERAPY aerobic exercise, application of heat or cold to the head and neck areas, drinking There are also important caveats to keep in • Take your preventive medication as a caffeinated beverage or just briefly tak- mind if preventive therapy is prescribed to prescribed ing a break and relaxing may terminate an chronically stabilize the biologic migraine Skipping doses of an orally administered acute attack. pathway and thus reduce headache burden. medication for migraine prevention or

8 Migraineur Magazine • www.migraineurmagazine.com taking a lower (or higher) dose than pre- an optimal therapeutic response, a process scribed may work against you, preventing that may take weeks to accomplish. Even if any positive treatment response, encour- such escalation is unnecessary and you get aging side effects and even serving to take a therapeutic dose from the get-go, increase your headache burden. If you are it may take a month or more to determine receiving Botox injections for suppression whether the medication is going to be of chronic migraine, the intervals between effective for you. treatments typically should not exceed 12 Unfortunately, it’s during those first few weeks; extending those intervals beyond weeks of treatment with an oral preven- 12 weeks may give the migraine pathways tion therapy that side effects from the a chance to “recover” and become re-sen- drug tend to be most prominent. It’s dis- sitized, and before you know it you’ll be couraging to be experiencing side effects back to your miserable pre-Botox baseline. but no benefit, but stick with the treatment if possible. Talk it over with your provider. • There’s no guarantee of success. Sometimes a temporary reduction in dose No one preventive therapy is effective will help you through the rough patch. for all migraineurs, and your friend’s or If you are receiving Botox injections for relative’s remarkably positive response migraine prevention, remember that to a given therapy does not ensure you many patients with chronic migraine do will have the same experience. In addi- not begin to experience any reduction in tion, all allopathic therapies for migraine headache burden until after the second set prevention have potential side effects, den that is eroding your quality of life… of injections. Don’t give up after only one and one patient may enjoy a wonder- do something! Perhaps you need a higher treatment. ful therapeutic response to a particular dose. Perhaps a different dosing regimen treatment whereas the next will suffer a • Treat break-through headaches aggressively (say, twice daily rather than at bedtime bag-full of annoying side effects and abso- Seldom is a migraine prevention therapy only). Perhaps a different therapy altogeth- lutely no reduction in headache burden. so effective that it will completely pre- er. Whatever. If you’re not making progress, Unfortunately, medical providers currently vent all headaches from occurring. If you it’s time for a change. lack much in the way of a means to pre- have an acute headache despite preven- dict which patient will respond well versus tion therapy, treat that headache! Use the SUMMARY poorly to a particular therapy, and both same strategy outlined earlier under Acute acute and preventive migraine treatment migraine treatment. This, then, is the essence of migraine: thus remains a process of educated “trial • Don’t stick with a loser its clinical definition, its underlying bio- and error”. If you’ve given the prevention therapy a logic cause and its treatment. Study this • Continue treatment for an real chance; if you’ve taken an adequate migraine primer, take away from your adequate duration dose for an adequate duration or, in the reading the major points made, and you Don’t expect immediate success. Some case of Botox, if you’ve received at least will know more about your disorder than oral medications for migraine prevention two treatments separated in time by no 90% of health care providers. More impor- require a gradual upward escalation of more than 12 weeks; and if you still are tant, you will be prepared to take an active their doses to reach what is required for stuck with a substantial headache bur- role in effectively managing your migraine.

Calcitonin Gene-Related Peptide (CGRP), a protein which is the most potent natu- CGRP: WHY ALL THE FUSS? rally occurring dilator of blood vessels in the human body, plays a vital role in the circuitry which produces migraine headache. Point-to-point communication within our nervous systems relies on electrochemical transmission: a electrical signal passes down a conducting “wire” (ie, a nerve), and when that signal reaches its target at the nerve ending, a chemical neurotransmitter is released to connect with a receptor located on the nerve’s target. In the case of migraine, the “wire” is the trigeminal nerve, the chemical neurotransmitter is CGRP and the target is a head pain receptor located on a dural blood vessel. The CGRP antagonists are experimental large molecule monoclonal antibodies or small molecules that either block CGRP directly or block its receptor. Now under investigation for their safety and effectiveness in treating acute migraine and preventing headache in episodic or chronic migraine, they are highly selective agents that prevent closure of the migraine circuit at a key point in the path- way that generates head pain. Five different pharmaceutical companies (Alder, Allergan, Amgen, Lilly and Teva) are racing to bring their CGRP antagonists to mar- ket for general clinical use. According to the antagonist involved, administration may be oral, subcutaneous or intravenous. The results from research conducted to date have been highly promising, and the CGRP antagonists may well represent the next great breakthrough in migraine therapeutics.

Migraineur Magazine • www.migraineurmagazine.com 9 CELEBRITY MIGRAINE MARGARET REED Stress, Migraine and Cannibalism in the Sierra Nevada

o matter the individual’s race, gender, ethnicity or culture, stress is the most common N trigger for acute headache reported by migraineurs. Paradoxically, a sudden release from stress also may pro- duce an acute attack of migraine (eg, the comes from Margaret Reed, a survivor of for the children. Age 70, Sarah would be dreaded “vacation migraine”), whereas a the infamous “Donner party”. the first of the party to die on the emi- chronic reduction in stress may result in a grant trail…but far from the last. dramatic decline in one’s migraine burden. In 1846, desiring a better life for his family and specifically concerned by the Margaret’s migraine flared near the north- In the Winter 2016-17 issue of Migraineur eastern border of present-day Utah, as the we presented the case of Ulysses S. frequent, debilitating migraines suf- company’s wagons lumbered down a sec- Grant, military hero, 18th U.S. President fered by his wife, James Reed used what tion of trail lined by 300 Sioux warriors on and “celebrity migraineur”. In April remained to him after declaring bank- 1865, despite having cornered Robert ruptcy to obtain the wagon, oxen and horseback. Attracted by the Reed’s 13-year- E. Lee’s dwindling Confederate army at supplies required for the long emigration old daughter, Virginia, the Sioux offered Appomattox, Grant feared Lee would once to California. On April 14, accompanied buffalo robes, “pretty beaded moccasins” again conjure up the trickery required to by eight wagons belonging to a number and ropes made of grass in exchange for elude his grasp. Racked by anxiety, Grant of other families (the large Donner clan the young girl and her pony. Only after her developed an acute migraine headache amongst them), James, Margaret and their husband tactfully managed to convey that that by April 8 was peaking in intensity. In four children began the exodus from Virginia was not available did Margaret’s his memoirs he wrote, “I was suffering very Illinois. Passing through Springfield on the “crippling migraine” subside. severely with a sick headache...I spent the 15th, James was unable to persuade his Delayed by a variety of circumstances, near night in bathing my feet in hot water and old and trusted friend, Abraham Lincoln, to what is now Wyoming the large band that mustard, and putting mustard plasters on join them. had traveled so far together divided into two my wrists and the back part of my neck.” separate groups. Fearing that they might Despite these efforts, his “sick headache Margaret’s migraine flared otherwise fail to clear the Sierra Nevada was still present on the morning of the near the northeastern border range before winter’s onset, one group opted 9th. of present-day Utah, as the to take “Hasting’s Cutoff”, a little-used new detour that led south of Salt Lake and across Then arrived a note from Lee indicating company’s wagons lumbered his willingness to surrender. Decades later the great salt desert before rejoining the Grant recalled that “the instant I saw the down a section of trail lined standard California Trail. The other group contents of the note, I was cured.” by 300 Sioux warriors on opted for the longer but proven route that arced northward far above the Lake and Other “celebrity migraineurs” less well horseback. then southwest into Nevada. known to history than Grant have experi- enced this same stress/release migraine Margaret, 32, was “migraine-prone”, and James Reed spoke strongly in favor of phenomenon. One particularly vivid exam- her mother, Sarah, consequently joined the detour and the time it would save. ple of the effect of stress on migraine the Reed household to help Margaret care Ironically, those who traveled with him

10 Migraineur Magazine • www.migraineurmagazine.com on this shorter route-those known to his- OR ID WY SD MN Donner Party Camps WI tory as the “Donner Party”- would become 9/25/1846 30/30/1846 to 4/21/1847 trapped in the mountain snow. Many Fort Laramie Fort Bridger IA would perish. NV NE UT 6/31/1846 IL Sutter’s Fort The detour proved to be a bust. Time was California Trail Springfield San Independence Francisco Hastings Cuttoff CO Mother Died passing, autumn was approaching and Migraine Attack 4/14/1846 KS 5/12/1846 the Donner Party grew ever more aware CA Margaret Reed’s Ordeal MO of their slow progress. Nerves frayed, AZ April 14, 1846, to April 21, 1847 tempers erupted and Margaret’s migraine 0 1250125 250 500 miles NM TX OK AR MS blossomed. In a bizarre incident along the alkaline waters of the Humboldt River, and slaughtered them in the snow. When And yet all the Reeds survived. Margaret James was banished from the Party after that meat was gone, she deftly slit the and James were reunited on February 28, killing a young teamster. Knowing how throat of the family’s beloved pet dog and as a rescue party heading westward with inadequate was the emigrants’ remaining wept as she cut up his body. Determined the wife in tow met an eastward-bound store of provisions, he set out for Sutter’s that her children not starve, on January 4 rescue party led by the husband. On March Fort on the far side of the Sierras to seek she set out to cross the mountains, orga- 1 Margaret suffered an especially severe much-needed supplies. nize a relief party and bring back food. migraine attack, and the relief party bear- With James Reed now exiled, the Party After 5 days and 4 nights in the snow and ing her consequently stopped for a day continued on, and after 68 excruciating freezing cold she was forced to turn back. of rest. After so much stress for so long, days on the Cutoff they finally rejoined the the sudden release must have been over- established California Trail. They rested Even in her desperation, however, Margaret whelming. (too long) in a large meadow near present- Reed did not resort to cannibalization. day Reno before moving into the moun- While written accounts of the emigrants’ Of the 87 members of the Donner Party, 41 tains. On October 30 they made camp in a camp at the lake describe “hair, bones, perished. Of the 35 who died in the camp “pretty little valley” in the High Sierras just skulls and the fragments of half-consumed by the lake or attempting to cross the five miles from Truckee (now Donner) Lake. limbs”, children with blood-stained faces mountains, 18 were cannibalized. As for That night it snowed 8 inches. devouring human liver and heart, and the Reeds, James Reed subsequently made human flesh boiling in a large iron kettle, his fortune and eventually became one With her mother buried by the Reeds are considered to be the only of California’s leading citizens. His wife, the trail back in Kansas and family of the Donner Party not to have Margaret, is said to have led a peaceful consumed other humans. life. Peaceful…and migraine-free. her husband absent and quite possibly dead, Margaret Reed fought alone to keep her children alive.

It was only the beginning. By the follow- ing afternoon the snow was axle-deep and the wagons useless. For eight consecutive days the snow continued to fall, and by Projected the time the weather briefly cleared it was Snow Depth obvious to all that the pass was closed. 10-12 ft They would be waiting out the winter by the frozen lake. Without rescue, starvation seemed a certainty. The weeks passed. With her mother bur- ied by the trail back in Kansas and her husband absent and quite possibly dead, Stumps of trees cut by the Margaret Reed fought alone to keep her Donner Party in Summit Valley, CA children alive. Despite her growing weak- • Photo published 1866 ness and incessant migraine, she pur- • Courtesy Library of Congress chased four oxen from the other emigrants

Migraineur Magazine • www.migraineurmagazine.com 11 MANAGING YOUR MIGRAINE

Here is information that may help you on your journey towards “headache free or nearly so”

Migraine a migraine attack. This is unfortunate. a journey of a If you are a particular fan of red , Tip of the Month: aged scotch or bourbon, liqueurs/aper- thousand miles Beverage Awareness tifs (egs, amaretto, ouzo) or dark beer: 1 watch out! , too, can be a begins with a If you enjoy an occasional glass of killer. For better or worse, the odorless wine, beer or cocktail and have found or near–odorless alcoholic beverages single step that ingestion of an alcoholic beverage tend to be less potent triggers. There frequently will precipitate a migraine is an old saying amongst those who amount of alcohol intake (another unfor- attack…well, I’m sorry. Having this ten- seem to know: “Vodka is the drink of tunate fact of life for many migraineurs). dency myself, I can empathize. migraineurs.” Finally, as if the “alcohol as migraine trig- Short of absolute what can Whatever alcoholic beverage you ger” issue weren’t bad enough, remem- one do to overcome this unfortunate choose to drink, be sure to chase it ber that migraineurs tend to be more stimulus>response relationship? with copious amounts of water. This prone to than those with- First, recognize that as a general rule it is will help you avoid both a migraine out migraine who drink an equivalent the aromatic alcoholic beverages that pos- and the embarrassing tendency to amount of alcohol. Take pains to hydrate sess the greatest potential for triggering become inebriated after even a modest well both while you are imbibing your of choice and during the hours afterwards.

THE FIRST STEP OF YOUR JOURNEY BEGINS HERE Migraine Treatment of the Month: 2 Caffiene! Chronic over-consumption of caffeine can aggravate chronic migraine by predispos- ing to yet more headache, and for some relatively few and unlucky migraineurs

12 Migraineur Magazine • www.migraineurmagazine.com ingestion of caffeine may trigger an Migraine Myth migraine trigger reported by migraineurs acute migraine attack. For the majority of is stress (Andress-Rothrock D, King migraine sufferers, however, caffeine can of the Month W, Rothrock J. An analysis of migraine serve as a surprisingly effective thera- triggers in a clinic-based population. 3 Myth: Migraine is caused by… peutic weapon for dealing with acute Headache 2010;50:1366). Ironically, a sud- stress, hormones, weather changes, sinus migrainous headache. den release from stress also can precipi- disease, problems with the temporoman- tate a migraine attack, a fact of migraine Why? For one thing, acute migraine dibular joint (TMJ), “evil” humors, etc. induces gastroparesis (paralysis of the life that puzzles and frustrates many stomach”). If the stomach’s typical motil- Reality: Migraine results from a geneti- of those thus afflicted. The genetically cally sensitized brain whose “primed” neu- ity is absent, any oral medication that migrainous brain is highly reactive to rons may respond to a variety of external “drops in” may simply lie there instead of change, be it “bad” change (a nasty run-in environmental stimili (egs, barometric moving on to the small intestine to be with your boss) or “good” (sleeping in on pressure changes, bright sunshine) or absorbed into the bloodstream and trans- Saturday morning after a sleep-deprived internal stimuli (fluctuations in the levels ported to target receptors. week). [See “Celebrity Migraine” p9] of sex hormones) by discharging elec- trically and igniting an attack of acute Wait a minute, you say. If migraine is …wash down oral medication migraine. The stimulus is the match, the genetic, why is it that no one else in my intended for acute migraine genetically sensitive brain is the fuse and family but me has ever had a problem treatment with your favorite the head pain signaling pathway of the with migraine? nervous system is the stick of dynamite. caffeinated beverage. One possibility: you’re mistaken. If provid- Not infrequently a patient will assure ers ask patients with migraine whether a To circumvent this gastroparesis problem her provider that she has “ 1st degree relative (mother, father, sister, one can use a drug that rapidly exits headaches, rainy weather headaches, brother) has migraine, about 50% respond the stomach despite its immobility headaches with my periods and stress “yes”. If clinical investigators directly (eg, Treximet), co-administer an oral headaches…but not migraine”. What this interview those family members, about medication that promotes stomach patient in fact is saying is that she has 90% respond “yes”. motility (eg, metoclopramide) or simply a migrainous brain that responds to a Another possibility: in the generation pre- give up on the oral route and administer variety of common triggers by produc- ceding yours, there was very little clinical the acute migraine therapy intranasally ing a migraine attack. It is her genes expression of the genetic predisposition or via injection. A cheap and simple and her brain that cause her to have the to migraine in the affected individual(s). alternative to these options: wash down disorder we identify as “migraine”. It is A red wine headache here. A menstrual oral medication intended for acute the stress, red wine, menses, etc that trig- headache there. Not much. migraine treatment with your favorite gers migraine. Similarly, migraine may caffeinated beverage. be aggravated by pain elsewhere in the A final possibility: during your own body (especially in structures supplied by embryogenesis, within your mother’s uter- Aside from its effect of speeding up the nerves that are part of the migraine cir- us, your DNA underwent a subtle muta- absorption of whatever oral medication cuitry: the neck,jaw, sinuses). is taken with it, caffeine also may have a tion, and-voila!-you, like an Abraham of direct effect on reducing acute migraine No matter the gender, race, ethnicity headache, created your very own new line headache. In migraine’s circuitry caffeine or country of origin, the most common of migraine. Congratulations? inhibits a key step in head pain signaling, and many migraineurs have discovered that a timely cup of coffee or can of soda will terminate acute migraine. For the majority of migraineurs, then, here is your “caffeine prescription”: 1) Avoid chronic overuse of caffeine, but… 2) In the setting of acute migraine head- ache, administer your oral “rescue” medica- tion with a caffeinated beverage. 3) Eliminate caffeine from your diet if you wish, but do so knowing that the value of any “food elimination diet” for migraine treatment remains an object of consider- able controversy.

Migraineur Magazine • www.migraineurmagazine.com 13 DOCTOR ON CALL

cycling females with menstrually-related migraine (MRM) have attacks temporally related to menses and also at other times arilyn, a thirty-seven year of the month. old journalist living in A majority of actively cycling female Alexandria, Virginia writes: migraineurs-up to 70%-report worsen- M ing of their migraine in association with “I’ve had it! While I’ve had migraines here menses. As a general rule, the headaches and there at other times, since 8th grade I’ve of MRM tend to be longer in duration and had a severe migraine, lasting for days, every less responsive to acute treatment than month when I have my period. For years, at headaches that occur at other times of the least a fifth of my life has been consumed by month; for some women, the menstrual these menstrual headaches. My mother had week is marked by one long, continuous the same problem, and her migraines ended migraine. Once the MRM boulder starts completely after menopause. Same thing rolling down the hill, its biologic momen- effective for MRM as well. Any of the 7 with her mother. And my older sister. tum accelerates, making it hard to stop. Key currently available oral triptans, Treximet (an oral compound containing brand I say, enough is enough. Why put up with to optimal treatment of MRM is stopping Imitrex and naproxen sodium), intranasal this for another 10 year? I’ve had my chil- the migraine before it gets a chance to zolmitriptan (Zomig), “exhalant” sumatiptan dren. I’m ready for a hysterectomy…and an start. (Onzetra), various of the oral non-steroidal end to these monthly migraines.” Effective management of MRM typically anti-inflammatory drugs (NSAIDs: egs, aspi- involves the use of a calendar and head- rin, naproxen sodium, ibuprofen, Cambia) ache diary. Tracking your migraine and THE and subcutaneously injected sumatriptan menstrual cycle will help you identify are reasonable options. DOCTOR’S REPLY when migraine occurs in relation to onset of flow. If there is a distinct pattern-say, While elimination of menses may also migraine attacks usually begin the day eliminate MRM, DO NOT seek surgical Prior to puberty migraine is slightly more prior to flow onset-and your cycles are menopause simply as a treatment for MRM. common in males, but from puberty regular and predictable, then anticipatory To their dismay, many women with MRM onward the headache disorder is notable “mini-prophylaxis” can be utilized. A day or find that even following removal of their for its preponderance in females. By two prior to the anticipated onset of your ovaries (and a consequent end to the cyclic young adulthood the female:male ratio for MRM you can begin any one of a num- fluctuations in levels of sex hormones) they migraine prevalence is 3:1, and only with ber of medications intended to prevent continue to experience monthly episodes the onset of menopause does this gender- menstrual headache and continue that of week-long migraine that mimic their related difference begin to diminish. medication for the next 5 to 7 days, your pre-surgical menstrual headaches. It’s as if Migraine’s tendency to affect women more “high risk” (for migraine) time. Medications the brain has become “hard-wired” to MRM, than men has been attributed primarily to commonly used for MRM mini-prophylaxis and the “hard disc” will continue to signal the influence that female sex hormones include magnesium oxide (400 milligrams cyclical periods of migraine headache even exert upon the biologic circuitry that gen- (mg) once or twice daily-no prescription in the absence of peripheral stimuli (ie, erates migrainous symptoms. Put simply, required), naproxen sodium (550-660 mg estrogen shifts). one of the key contributors to migraine’s twice daily-available via prescription or There are ways to suppress menses that preponderance in females is the fluctua- over-the-counter) and frovatriptan (Frova; are reversible and far less invasive than tions in estrogen levels that occur through- 2.5 mg twice daily-prescription only). surgical resection of the ovaries. You can out much of a woman’s lifetime. Strangely, some women find that success- take an active oral contraceptive through- One of the most common clinical mani- ful prevention of MRM with their mini- out the month, skipping the week of differ- festations of this hormonal influence is prophylaxis therapy may simply shift the ently-colored inactive pills. You can use an migraine’s tendency to worsen just before prolonged migraine they avoided to the estrogen-secreting IUD for contraception. and during menses. In “pure” menstrual week following the end of menses. You can become pregnant! Any of these migraine attacks occur only in conjunction The same acute migraine treatments you may lead to cessation of MRM (definitely with the menses. More commonly, actively use at other times of the month may be so in the case of pregnancy).

14 Migraineur Magazine • www.migraineurmagazine.com Don't let frequent headaches interfere with your child's daily life.

Children’s National Interdisciplinary

Intractable Headache Clinic utilizes

lifestyle modification and healthy habits,

alternative medicine, pain-focused

cognitive behavioral therapy, biofeedback,

nerve blocks and infusions to provide

additional treatment options for kids.

Our team works together to identify the cause of headaches in children and find effective ways to help manage them. For urgent appointments, call: 202-476-HEAD (4323)

www.childrensnational.org/departments/headache-program

14 Migraineur Magazine • www.Migraineur.com

CN Migrane Ad-V4.indd 1 8/4/17 10:15 AM IN 1991, WILDLANDS NETWORK EMBARKED ON A BOLD MISSION: to reconnect, restore, and rewild North America so that life in all its diversity can thrive. Our work has since catalyzed a dramatic shift in conservation, with parks and other protected areas serving as the building blocks for networks of wildlands across the continent and around the globe. These wildlands networks give refuge and safe passage to large carnivores and other animals that need “room to roam” to find food, mates and to flourish, so that they can fulfill their ecological roles. Investments in nature also earn significant returns in the form of healthier communities, healthier economies and healthier people. More and more research is showing that outdoor recreation delivers real health benefits that in many cases are on par with pharmaceutical treatments. Protecting and connecting wildlands requires the cooperation of wildlife agencies, elected officials, private landowners, outdoor recreationists, conservation groups, and all of us who care about the future of North America’s great natural heritage and the well-being of our communities. In sum, Wildlands Network helps to protect our planet and sustain the diversity of life—including us. Wildlands Network is pleased to invite Migraineur magazine readers to join our Wildlands Stewards giving society. You’ll receive a complimentary copy of For the Wild, a beautiful and inspirational compilation of essays and photographs that highlight the impassioned union of science and activism and the dedicated community of people working to heal broken landscapes and rewild our hearts. Visit www.wildlandsnetwork.org/donate or contact [email protected] to learn more about Wildlands Stewards or for more information on Wildlands Network’s bold vision of a reconnected, restored and rewilded North America.

Migraineur Magazine • www.Migraineur.com 15 Your special moments should never be ruined by a migraine. We have your back, no matter where the trail leads you.

GW-MFA Headache Center 2150 Pennsylvania Avenue, NW 7th Floor Washington, DC 20037 202-741-2700 www.gwdocs.com/neurology/headache-center

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