It was June, 1996 and Dr. Michael Cutrer, head of the headache unit at Massachusetts General Hospital, was hard at work as usual in his sixth floor lab in Charlestown.
Suddenly, he’d look at somebody “and part of the face wouldn’t be there, just a shimmering blind spot” that grew “until half of the vision in both eyes was sparkling and shimmering,” he recalls.It was, as Cutrer knew all too well from both personal and professional experience, a classic “aura,” often the first sign of a crippling migraine headache.
But this time, Cutrer, 41, dashed down to a special MRI (magnetic resonance imaging) scanner on the first floor and jumped into position – as the patient.
For the next 45 minutes, as he lay watching the blind spot creep to the periphery of his vision, technicians tracked sharp changes in blood flow to the visual cortex of his brain. It was one of the first times scientists had been able to catch a spontaneous aura in progress, and it yielded an important clue to the underlying dynamics of migraines, which plague 16 to 18 million Americans.
In the nick of time, just as the aura turned into a throbbing headache, Cutrer gave himself a shot of a drug called Imitrex, or sumatriptan. Within minutes, the pain and vomiting he had come to expect with migraines since age 14 were gone.
In the not-so-old days – before Imitrex reached the market in 1993 – the main remedies for migraine were addictive painkilling drugs or ergotamine, either in a pill form that could make you “sicker than when you started,” as Cutrer puts it, or a less nauseating injectable form called DHE-45.
But today, migraine sufferers can often abort attacks in an hour or less with injectable Imitrex, and since last year, with a slower-acting pill form as well. And next month, a just-approved, fast-acting Imitrex nasal spray will become available.
That’s just the beginning. A nasal spray form of DHE-45 is also expected to be approved soon. A number of other remedies – an herb called feverfew, biofeedback, new Imitrex-like drugs – are showing some promise in preventing or aborting migraines.
And scientists, among them the MGH brain scanners who have recorded seven auras and 15 migraines in progress, are beginning to understand what goes wrong in a migraine headache, including identifying alterations in genes on chromosomes 1 and 19 that seem to put some people at risk.
Chronic headaches plague 45 million Americans. Most are “tension headaches,” with vise-like pain that can be severe – and frequent – but that often responds to antidepressants or over-the-counter remedies like ibuprofen and caffeine.
A tiny share of headaches – about 2 percent – are caused by brain tumors, aneurysms (weakened blood vessels in the brain) or infections in or near the brain.
Most of the rest are vascular headaches – migraines, which affect 18 percent of women and 6 percent of men, and cluster headaches, which are more rare and occur mainly in men.
While migraines cause a horrible, throbbing pain, cluster headaches cause a severe “cutting” type of pain, says Dr. Seymour Diamond, head of the Diamond Headache Clinic in Chicago and executive chairman of the National Headache Foundation.
In both types, some scientists believe, the pain, usually on just one side, comes from activation of nerve fibers in blood vessels in and around the brain.
While migraines, which often run in families, are often accompanied by nausea, vomiting and severe sensitivity to light and sound, cluster headaches are not. Migraines typically last from several hours to three days; cluster headaches last several hours but can strike two or three times a day for months.
At the onset of a migraine, some believe, the level of serotonin, a natural chemical in the brain, drops suddenly, allowing blood vessels in the brain and the meninges (the fibrous tissue surrounding the brain) to dilate, which can cause surrounding tissues to swell painfully.
But blood vessel dilation is only part of the story, says neurologist Cutrer. Whatever the initial trigger of a migraine – a particular food, alcohol, missing meals, changes in sleep patterns, menstruation, bright lights, loud noises – nerve cells in the meninges and in the meningeal blood vessels release chemicals called pain peptides.
Signals from the meninges are then transmitted deeper into the brain, causing exquisite pain – as millions can attest.
Ellen Blau, for instance, a 47-year-old Michigan woman who now coordinates support groups for the National Headache Foundation, has had migraines since she was 17.
“I was in bed half the week for many years,” she says. Her son often “came home to notes saying, ‘Quiet, I’m sick.’ ” At one point, she was so sick – and so sick of being sick – that she was “ready to commit suicide, to not live anymore.”
What finally brought Blau’s migraines under control was a course of Nardil (a type of antidepressant).
Now, to prevent attacks, she takes the antidepressant Prozac (although Prozac’s effectiveness for migraine prevention is controversial), another drug that combines a muscle relaxant with the antidepressant Elavil, and an anti-inflammatory drug. (Antidepressants often help people with migraine because they not only elevate mood but combat pain.)
Like Blau, Valerie Socha, a 38-year-old Revere computer programmer, has also suffered migraines since she was 17 – in her case, every time she got her period.
Now, she says, her attacks have been reduced, thanks in part to an herbal remedy, feverfew, which she takes daily – three 380 milligram capsules morning and night.
For many people with migraine, however, among them Patricia Poisson, 56, a self-employed Wayland businesswoman, finding relief means trekking from doctor to doctor.
Many women find their migraines get better after menopause, but Poisson says hers got worse: “I had seven headaches a week – I either woke up with one or got one as the day went on.”
She now swears by atenolol, a beta-blocker drug used to treat high blood pressure. She still gets two migraines a week, but says, “This is nothing compared to what I have had to live with for the last eight years.”
The options may keep expanding for Poisson and others.
Encouraged by data suggesting that Imitrex aborts migraines by constricting blood vessels and blocking release of pain peptides, researchers are now working on a number of Imitrex “clones.”
About six months ago, researchers also reported that Lidocaine nose drops can help abort a migraine attack. This summer, at an international conference in Amsterdam, Belgian researchers reported that 400 milligrams a day of riboflavin (vitamin B-2) seemed to cut migraines by more than 50 percent.
And at the New York Headache Center, researchers have found that half of people with migraines and cluster headaches may have low levels of the mineral magnesium, and that intravenous injections of magnesium may help.
But Dr. Dhirendra Bana, director of the headache and pain center at Faulkner Hospital, cautions that in practice some remedies fall short.
“We haven’t had much luck with magnesium,” he says, or with melatonin, the sleeping aid sold as a dietary supplement. While some data suggest high (10 mg) doses of melatonin may prevent cluster headaches, Bana says it hasn’t worked well in his patients.
Another drug, Stadol, a nasal spray used for pain, has also come under attack – after numerous reports of adverse reactions.
Still, there is a powerful sense among both migraine specialists and patients that “all of a sudden, because of the success of sumatriptan Imitrex, there has been created an awareness of migraine and that treatments are available,” says Diamond of Chicago.
Cutrer agrees, noting that many patients now prevent attacks with beta-blockers, calcium channel blockers, nonsteroidal anti-inflammatory drugs like Naprosyn, the antidepresssant Elavil, or Depakote, an anti-epileptic drug that also fights pain.
Increasingly, nondrug therapies are also an option, especially biofeedback, which can teach patients to increase blood flow to their hands, perhaps causing blood vessels in the head to become less swollen and painful.
Once you find something that works, says Patricia Poisson, life can be utterly transformed: “It’s like having that faucet shut off from Chinese torture. . . I don’t know how I stood it all those years.”
To learn more
For more information on migraines, call:
-
1-800-843-2256 begin_of_the_skype_highlighting 1-800-843-2256 end_of_the_skype_highlighting, the National Headache Foundation.
-
1-800-372-7742 begin_of_the_skype_highlighting 1-800-372-7742 end_of_the_skype_highlighting, to find or start a headache support group in your area.
If you have migraines with auras that occur after you eat a certain food or another “trigger” and would like to participate in the brain scan study at Massachusetts General Hospital, call 617-726-6939 begin_of_the_skype_highlighting 617-726-6939 end_of_the_skype_highlighting.