Headache triggers. Helping patients to recognize headache triggers and aggravating factors is an important element in treating and preventing migraines. Identifying these factors in the patient history can help you establish a diagnosis and implement steps to avoid or reduce attack severity.
Table 4
TREATMENT OPTIONS FOR PREVENTING MIGRAINE ATTACKS
| Drug | Efficacy* | Side effects* | Indications | Contraindications |
|---|---|---|---|---|
| β blockers | 4+ | 2+ | Hypertension | Depression, asthma, diabetes, hypotension, congestive heart failure, peripheral vascular disease |
| Ca channel blockers | 2+ | 1+ | Hypertension, angina, asthma, migraine aura | Constipation, hypotension |
| Tricyclic antidepressants | 4+ | 2+ | Depression, anxiety disorders, insomnia | Heart block, urinary retention, mania |
| Selective serotonin reuptake inhibitors | 2+ | 1+ | Depression, obsessive-compulsive disorder | Mania |
| Monoamine oxidase inhibitors | 4+ | 4+ | Depression | Dietary restrictions |
| Divalproex/valproate | 4+ | 2+ | Epilepsy, anxiety disorders, mania | Liver disease, bleeding disorders, hair loss |
| Naproxen | 2+ | 2+ | Arthritis, other pain disorders | Gastritis, peptic ulcer |
| * Ratings on a scale from 1+ (lowest) to 4+ (highest). Table partially derived from data in: Silberstein SD, Lipton RB, Goadsby PJ, Smith, R (eds). Headache in primary care. Oxford, UK: Isis Medical Media, 1999. | ||||
Common migraine headache triggers include menstruation, stress, relaxation after stress, fatigue, too much or too little sleep, skipping meals, weather changes, high humidity, glare and flickering lights, loud or high-pitched noises, smoke or dust, strong perfumes or cooking aromas. Food triggers cause 10% of migraine cases. Chocolate, strong cheeses, red wine, beer, citrus fruits, and foods with monosodium glutamate and nitrate preservatives are common food triggers.
Tension-type headaches are triggered by stress or the end of a stress-filled day. Triggers for cluster-type headaches include alcohol, smoking during the cluster phase, and lying down during an attack.
Case 2: Flying the unfriendly skies
Ms. B, 38, is a mother of three who works as a flight attendant. She is separated from her husband and had filed for divorce because of repeated spousal abuse. She has visited her primary care physician multiple times for migraine, sinus problems, backache, and coccygodynia. Orthopedic and rectal examinations revealed no abnormalities.
Her headaches met the IHS diagnostic criteria for migraine with aura, and these responded well to zolmitriptan, 5 mg. The headaches usually occurred during days off from work, but her sinus problems also led to headaches and nasal stuffiness when she flew. Her headaches eventually occurred almost daily.
Her supervisor was unsympathetic. An otolaryngologist had prescribed decongestants and a course of desensitization, both of which brought only transient relief.
A counselor at work recommended that Ms. B go on sick leave and accept a transfer to a non-flying job. The patient was tearful and felt overwhelmed by her problems. She felt that life was no longer worth living. She agreed to see a psychiatrist, who diagnosed depression and anxiety disorder. The psychiatrist prescribed citalopram, 20 mg/d, and agreed to see her regularly to monitor progress.
Discussion. As a migraineur, Ms. B was at increased risk for depression and anxiety disorders.19 Migraine with aura is associated with an increased lifetime prevalence of suicidal ideation and suicide attempts.20
The exact mechanisms by which migraine and depression are related are unknown. Each disorder increases the risk for developing the other. The specificity of this relationship is strengthened by the fact that depression is not associated with a greater risk of severe nonmigrainous headache, even though a severe nonmigrainous headache may cause depression.21
The patient in case 1 responded well when an antidepressant was added to her treatment. In her case, the diagnosis of a depressive disorder remained an open question. Migraine attacks are known to be associated with mood change, lethargy, and cognitive changes. The picture may be further confounded because migraine without depression responds well to prophylaxis with antidepressants.
The patient in case 2, however, presented with a complex of interrelated headache and psychiatric problems of potentially dangerous proportions. Psychiatric problems in migraineurs may be deep-seated, and these patients may require urgent, specialized attention to avoid further serious disability and a possible tragic outcome.
Related resources
- Silberstein SD, Lipton RB, Goadsby PJ, Smith, R, eds. Headache in primary care. Oxford, UK: Isis Medical Media, 1999.
- Silberstein SD, Lipton RB, Dalessio DJ. Wolff’s headache and other head pain (7th ed). New York: Oxford University Press, 2001.
- Davidoff RA. Migraine. Manifestations, pathogenesis and management (2nd ed). New York: Oxford University Press, 2002.
- International Headache Society. http://www.i-h-s.org
Drug brand names
- Citalopram • Celexa
- Dihydroergotamine • Migranal
- Eletriptan • Relpax
- Rizatriptan • Maxalt
- Sumatriptan • Imitrex
- Valproate sodium • Depakote
- Zolmitriptan • Zomig
Disclosure
Dr. Smith reports that he serves as a consultant to and is on the speakers’ bureau of AstraZeneca Pharmaceuticals.
Dr. Hasse reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.