As a medical student on neurology rotations, Frederick G. Freitag noticed that headaches were rarely taken seriously by attending doctors.
"The response among my teachers was a prescription for Valium, a pat on the shoulder, and a 'You'll be OK, Sweetie,'" he remembers. While the pathology of migraines remains somewhat mysterious, Freitag, now director of headache medicine at Baylor University Medical Center, Dallas, TX, recently reported in The Lancet Neurology that more effective treatments are finally on the way, no patronizing required.
For decades, researchers suspected that the root of migraine pain, which afflicts about 45 million Americans, was vascular. While the circulatory system is likely involved (a class of drugs called triptans can reduce migraine pain by constricting blood vessels), improved imaging tools and a 2008 study in Brain have shown that the vascular hypothesis was misguided. Blood vessels do not, in fact, dilate at the start of a migraine.
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In a recent paper in Neuron, psychiatrist David Borsook emphasizes that migraine is a stress-related brain disease, not just a recurrent acute pain syndrome. Indeed, most experts now believe that treatments should target the brain and nervous system without interfering with circulation--good news for patients at risk for heart disease.
Blocking the receptors of calcitonin gene-related peptide, a neurotransmitter, halts migraine pain as effectively as triptans, with fewer side effects. While further testing is needed, several blockers have proven effective in early trials.
Other nonvascular treatments include a prescription-strength ibuprofen-type drug that can be dissolved in water (for fast relief of inflammation around the brain, which exacerbates migraine pain) and direct stimulation of a spinal nerve--a procedure that unfortunately costs $50,000. But because of migraine's complex constellation of symptoms, any new therapy should be just one part of a treatment plan that also includes stress-reducing lifestyle changes.
"We have to be holistic in our approach," says Freitag. "People forget that pain is a state of mind, as well as a state of body."
GOOD MUTATIONS MIGRAINE OR HEADACHE?
The Greeks described a migraine as a "sick headache"--not just a very bad pain in the head. In fact, it's a triad of symptoms: head pain, neurological effects (light and noise sensitivity, paralysis, visual auras), and gastrointestinal problems (loss of appetite, nausea, vomiting, diarrhea). A run-of-the-mill tension headache, meanwhile, is one thing only: an aching noggin.
"It can be a heck of a headache," Freitag notes, "but without any of those other symptoms, it's not a migraine."
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