1. Migraine Tip of the Month: Beverage Awareness

If you enjoy an occasional glass of wine, beer or cocktail and have found that ingestion of an alcoholic beverage frequently will precipitate a migraine attack…well, I’m sorry. Having this tendency myself, I can empathize.

Short of absolute sobriety, what can one do to overcome this unfortunate stimulus>response relationship?

First, recognize that as a general rule it is the aromatic alcoholic beverages that possess the greatest potential for triggering a migraine attack. This is unfortunate. If you are a particular fan of red wine, aged scotch or bourbon, liqueurs/apertifs (egs, amaretto, ouzo) or dark beer: watch out! Champagne, too, can be a killer. For better or worse, the odorless or near–odorless alcoholic beverages tend to be less potent triggers. There is an old saying amongst those who seem to know: “Vodka is the drink of migraineurs.”

Whatever alcoholic beverage you choose to drink, be sure to chase it with copious amounts of water. This will help you avoid both a migraine and the embarrassing tendency to become inebriated after even a modest amount of alcohol intake (another unfortunate fact of life for many migraineurs).

Finally, as if the “alcohol as migraine trigger” issue weren’t bad enough, remember that migraineurs tend to be more prone to hangovers than those without migraine who drink an equivalent amount of alcohol. Take pains to hydrate well both while you are imbibing your alcoholic drink of choice and during the hours afterwards.

2. Migraine Treatment of the Month: Caffeine!

Chronic over-consumption of caffeine can aggravate chronic migraine by predisposing to yet more headache, and for some relatively few and unlucky migraineurs ingestion of caffeine may trigger an acute migraine attack. For the majority of migraine sufferers, however, caffeine can serve as a surprisingly effective therapeutic weapon for dealing with acute migrainous headache.

Why? For one thing, acute migraine induces gastroparesis (paralysis of the stomach”). If the stomach’s typical motility is absent, any oral medication that “drops in” may simply lie there instead of moving on to the small intestine to be absorbed into the bloodstream and transported to target receptors.

To circumvent this gastroparesis problem one can use a drug that rapidly exits the stomach despite its immobility (eg, Treximet), co-administer an oral medication that promotes stomach motility (eg, metoclopramide) or simply give up on the oral route and administer the acute migraine therapy intranasally or via injection. A cheap and simple alternative to these options: wash down oral medication intended for acute migraine treatment with your favorite caffeinated beverage.

Aside from its effect of speeding up the absorption of whatever oral medication is taken with it, caffeine also may have a direct effect on reducing acute migraine headache. In migraine’s circuitry caffeine 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 headache, administer your oral “rescue” medication 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 considerable controversy.

3. Migraine Myth of the Month

Myth: Migraine is caused by… stress, hormones, weather changes, sinus disease, problems with the temporomandibular joint (TMJ), “evil” humors, etc.

Reality: Migraine results from a genetically sensitized brain whose “primed” neurons may respond to a variety of external environmental stimili (e.g.s, barometric pressure changes, bright sunshine) or internal stimuli (fluctuations in the levels of sex hormones) by discharging electrically and igniting an attack of acute migraine. The stimulus is the match, the genetically sensitive brain is the fuse and the head pain signaling pathway of the nervous system is the stick of dynamite.

Not infrequently a patient will assure her provider that she has “red wine headaches, rainy weather headaches, headaches with my periods and stress headaches…but not migraine”. What this patient in fact is saying is that she has a migrainous brain that responds to a variety of common triggers by producing a migraine attack. It is her genes and her brain that cause her to have the disorder we identify as “migraine”. It is the stress, red wine, menses, etc that triggers migraine. Similarly, migraine may be aggravated by pain elsewhere in the body (especially in structures supplied by nerves that are part of the migraine circuitry: the neck,jaw, sinuses).

No matter the gender, race, ethnicity or country of origin, the most common migraine trigger reported by migraineurs is stress (Andress-Rothrock D, King W, Rothrock J. An analysis of migraine triggers in a clinic-based population. Headache 2010;50:1366). Ironically, a sudden release from stress also can precipitate a migraine attack, a fact of migraine life that puzzles and frustrates many of those thus afflicted. The genetically migrainous brain is highly reactive to change, be it “bad” change (a nasty run-in with your boss) or “good” (sleeping in on Saturday morning after a sleep-deprived week). See “Celebrity Migraine”

Wait a minute, you say. If migraine is genetic, why is it that no one else in my family but me has ever had a problem with migraine?

One possibility: you’re mistaken. If providers ask patients with migraine whether a 1st degree relative (mother, father, sister, brother) has migraine, about 50% respond “yes”. If clinical investigators directly interview those family members, about 90% respond “yes”.

Another possibility: in the generation preceding yours, there was very little clinical expression of the genetic predisposition to migraine in the affected individual(s). A red wine headache here. A menstrual headache there. Not much.

A final possibility: during your own embryogenesis, within your mother’s uterus, your DNA underwent a subtle mutation, and-voila!-you, like an Abraham of headache, created your very own new line of migraine. Congratulations?