Speaking to her physician, LM, a 35-year-old female migraineur, reports:

“We live in Phoenix, and our summers extend well into October. This Fall my husband and I are planning to take two weeks off in September to go to Mallorca, but instead of looking forward to our vacation I’m dreading it. We went to Paris a few years ago for what was supposed to be a second honeymoon, and I just fell apart. I was exhausted the whole time, but I couldn’t sleep. Despite the great food everywhere around me, I had no appetite. And my migraines went ballistic! To my husband’s disgust, I wound up spending most of the so-called vacation in bed (alone) trying to deal with my headache and wishing I was home. He barely spoke to me on the flight back to Arizona. We’ve been saving up all year for this big trip to Spain, but because of my migraine I’m afraid it’s just going to be a big waste of money.”

Extended travel can exact a physical toll on anyone, but long flights and a sudden introduction to an unfamiliar environment may make the experience particularly challenging for the migraineur. No sane migraine sufferer wants to experience an extended flare-up of headache, and that such misery could occur in the midst of a long-anticipated vacation is, to say the least, discouraging.

To make matters worse, the acutely suffering migraineur often must bear an additional burden: the disappointment experienced by one’s traveling companion. Especially if they have no personal experience with migraine, even the most compassionate spouse, significant other, relative or friend may find it difficult to deal gracefully with the unappealing behavior provoked by your acute migraine. After all, you don’t have a fever. You don’t look that sick. Why can’t you … go sailing; walk with me on the beach; stop for a poolside cocktail; have a romantic tryst in our room before dinner at the restaurant our friends told us about? In short, why can’t you do all those things we spent so much time planning to enjoy? Why are you ruining our vacation!

One needn’t travel thousands of miles to the Balearic islands of Spain; even far less ambitious vacations have the potential to unhinge migraine. The alterations in one’s usual eating, drinking and sleeping habits can wreak havoc, leading the poor migraineur to wonder why he or she didn’t opt instead to spend that hard-earned money on a bathroom renovation.

Try following the advice offered here, and you will increase your chances of enjoying a pleasant, headache-free vacation.

Airline Travel

Travel Stress: The circumstances of extended air travel possess a multitude of potential migraine triggers. Whatever the setting, migraineurs inevitably report stress to be the most common stimulus for migraine activation, and events of the last two decades have exponentially amplified the stress associated with air travel. While there’s nothing you can do to eliminate this stress entirely, there are actions you can take to reduce the inevitable annoyances you must endure.

Try to avoid flight itineraries that involve horrifically early or late departures, impossibly tight connections, “red eyes” or stand-bys. When possible, minimize the need to make connections. If one of your flights is cancelled or so hopelessly delayed as to endanger a connection, look immediately to your smart phone rather than stew and fret in an endless line. Anticipate complications by packing a carry-on that contains what you need to get through a 24 hour detour wherein you and your luggage have parted ways: a change of clean clothes, basic toiletries, contraception (if applicable) and-most definitely-medications from the arsenal of therapies you typically use for acute migraine treatment.

Thanks to the dry air within the pressurized cabin, air travel is dehydrating. So are alcoholic beverages and caffeine. Migraine thrives on dehydration. Give yourself a break: save the vodka tonics and diet Cokes for later. While in flight, take pains to over hydrate with water.

Insomnia

Sleep Disruption: Insomnia is a common complication of travel. Disruption of one’s normal sleep pattern is notorious for triggering migraine, and it’s consequently wise for the migraineur to plan in advance for this complication and head it off at the pass.

When traveling across multiple time zones, try to match your internal clock to that of your travel destination; as inviting as that hotel bed may look after an extended flight from Boston to Budapest, resist the urge to give in to your weariness and climb between the sheets at noon. Give your hypothalamus a chance to recalibrate. Take your brain for a walk, eat dinner at a time appropriate to your new locale and try to avoid giving in to sleep until well after sunset.

Benzodiazepines (eg, clonazepam) and non-benzodiazepine sleep promoters (eg, zolpidem=Ambien)) may reduce the insomnia associated with jet lag, but their use can negatively affect next-day physical and mental performance (even to the extent of causing amnesia!). For simple “travel fatigue”, however, as opposed to jet lag insomnia resulting from disruption of your circadian rhythm, use of a “prn” (ie, taken as needed) sleep promoter such as zolpidem, eszopiclone (Lunesta), or temazepam (Restoril) these can make an enormous difference, allowing you to feel well-rested and headache-free.

Migraine Treatment

Medications: When it comes to your usual medications (including contraceptives), don’t get caught short while on vacation. Well before you leave, make sure you have enough of those medications to last for the time you’re away…especially whatever you normally take for acute migraine treatment. And if in the recent past you’ve had attacks of severe migraine that failed to respond to your usual self-administered therapy and required a trip to the doctor’s office or an emergency room, it’s a good idea to bring with you a written statement by your physician that briefly summarizes your medical history, your migraine history in particular and the medications that have been required to treat your migraine. Any migraineur who has suffered through the experience will tell you that to seek treatment for acute headache at an unfamiliar medical facility can be frustrating and even humiliating. To do so bearing a statement from your regular physician may go a long ways towards lessening the hassle.

Relax

Don’t Overdo: Flushed with the excitement of having shed the routine demands of home and work, one’s natural temptation is to kick off the vacation with too much too soon. The beach, ocean, lake, museums, galleries, restaurants and clubs aren’t going anywhere, and to knock yourself out of action for the duration of the trip by overindulging on your first day and night makes no sense. This is supposed to be fun . . . not an endurance test.

Go easy on the caffeine and alcohol, and, once again, don’t forget to hydrate with water throughout the day and evening. Go to bed at a decent hour, and use your medication if you feel a headache coming on. Enjoy your vacation. Avoid transforming what could be an idyllic period of rejuvenation into just another bout of prolonged migraine.

Jet Lag

The circadian rhythm refers to our brain’s inclination to bring various biologic functions into synchrony with the earth’s daily rotation. The misery we term “jet lag” is a symptom complex that results when this internal clock remains stubbornly set to the time back home over the days that immediately follow the brain’s sudden transport to its new destination.

How much one is affected depends in part on the biologic characteristics of the individual traveler’s brain, and this (unfortunately) is where migraine and jet lag intersect. The same genetically derived sensitivity of the migrainous brain that can produce visual aura or attacks of inescapable head pain also increases the predisposition to jet lag. Migraine thrives on change, be it the monthly change in levels of sex hormones experienced by menstruating females, a change in barometric pressure…or a sudden change in time zones.

The symptoms of jet lag occur one to two days after travel across at least two time zones, and jet lag tends to be more severe with travel eastward compared with westward. The most common symptoms are insomnia (coupled with daytime sleepiness), a pervasive sense of fatigue, loss of appetite, constipation, mental “fogginess” and and impaired physical performance.

Great, you say. Jet lag may be a major buzz-kill, but I really want to go to Spain, and I don’t have the time to cruise slowly across the ocean to get there. What can I do?

Without any specific treatment, your circadian rhythm will adjust to your destination time at the rate of about one time zone per day for eastward travel and 1.5 time zones per day for westward travel. Along with the total distance traveled, the severity of jet lag is influenced by:

• The direction of travel (again, eastward travel is more difficult to adapt to than westward travel)
• Your ability to sleep during travel
• Individual differences in the internal “biologic clock” (migraineurs having increased susceptibility)
• The conditions of the travel itself (enforced immobility, air quality, cabin pressure and intake of alcohol or caffeine all tend to worsen jet lag)

For those who are sufficiently motivated, treatment of jet lag involves accelerating one’s adjustment to the new time zone with strategically timed exposure to bright light and the use of melatonin. Put simply, you are trying to help synchronize your biological clock with that of your destination. Making this effort, along with symptomatic measures intended to help alleviate symptoms such as insomnia and daytime sleepiness, can go a long ways towards easing the transition from home to vacation.

Tips for Managing Jet Lag

Traveling Eastward

Before Travel

• Starting 3 days before departure, move your bedtime and wake time 30 minutes earlier each day
• During this shift, avoid light in the evenings (including electronic light) and seek bright light for the 1st 2-3 hours in the mornings

During Travel

• Set your watch to your destination’s time
• With watch set to destination’s time, avoid early morning exposure to bright light (eg, use sunglasses if cabin lights are on; keep windows covered)
• With watch set to destination’s time, maximize late morning and early afternoon exposure to bright light
• Try to sleep during destination nighttime; if unable to sleep, wear dark glasses or sleep mask to reduce light exposure (especially during the second half of the night)
• Do not use sedative medication during your flight

Upon Arrival

• Avoid early morning bright light
• Get lots of late morning and early afternoon bright light
• On day of arrival and for up to 5 days thereafter, take melatonin 3 milligrams at desired destination bedtime
• For daytime sleepiness: short naps (<45 mins) at least 8 hours before desired bedtime

Traveling Westward

Before Travel

• Starting 3 days before departure, move your bedtime and wake time 30 minutes later each day
• During this shift, avoid bright light the first few hours after awakening and seek light in the evenings

During Travel

• Set your watch to your destination’s time
• With watch set to your destination’s time, avoid bright light (including electronics) during your destination’s nighttime.
• Use dark glasses if cabin lights are on
• Try to stay awake until desired destination bedtime
• Try to sleep during destination nighttime; if unable to sleep, wear dark glasses or sleep mask to minimize light exposure
• Do not use sedative medication during your flight
   

Upon Arrival

• Get lots of late afternoon and evening bright light
• Avoid exposure to bright lights during your destination’s nighttime
• Melatonin is not likely to be helpful
• Try to stay up to desired destination bedtime.
• Avoid nodding off early in the eveninge
• Staying asleep may be difficult for the first few days; avoid electronics during nighttime awakenings
• For daytime sleepiness: short naps (<45 mins) at least 8 hours before desired bedtime