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This section of the Sinus411 site will discuss Migraine Headaches, which are frequently labelled "sinus headaches". There are several sections of this discussion, which include the following topics:

How common are migraines?

How disabling are migraines?

How is a diagnosis of migraines made?

The main types of migraines (migraines with aura and migraines without aura)

What are the phases of a migraine?

In the subsequent few pages, the following topics will be covered.

Treating migraine headaches.

Some factors that may provoke migraines.

Foods that can trigger migraines.

Drug therapy for migraines.

Who is a candidate for prophylactic or preventative medications for migraines?

Practical issues in prophylactic drug therapy for migraine.

You can click on any of the topics above to skip to them, or read one page to the next.

How common are migraines?

In the United States, studies have shown that a proximally 6% of men and 18% of women have migraines, which is approximately 20 to 25 million Americans.  How prevalent migraine is in the American population is to pended upon the age and sex of the person.  And women under 20 the prevalence of migraine is about five to 7%, but by 40 years of age, about 25 to 30% of women have migraines.  In men, children and young adults under 20 have a prevalence of less than 5% and the prevalence peeks at about 8% at age 40.  The prevalence of migraines is higher in homes with the lowest income.  Migrants are more common among Caucasians then among blacks.  Most studies show that migraines are underdiagnosed and undertreated.  That is many patients with migraines are not aware that there headaches and symptoms are migraine this in nature.

How disabling are migraines?

The majority of patients with migraines will report that they are migraines prevent them from performing their daily activities.  More than half of the patients with migraines will also report extreme impairment in their ability to perform daily activities and report that their migraines have required bed rest.  One to two days of restricted activity during a migraine attack is not uncommon among a migraine sufferers.  About one third of migraineurs will miss more than a day of work or school because of a migraine and three months.  Time most migraineurs will report that their home oral work-related activity is reduced by more than 50% during a migraine attack..  Between attacks, migraineurs are often fearful that another attack will occur, interrupt their work, family, or social schedules.

How is a diagnosis of migraines made?

 a diagnosis of migraine is typically made based on information about the migraine attack, the triggers that precipitate the attacks, and the history of symptoms that accompany the attacks.  The patient's headache history, our country by the family history and they've physical examination provide most of the information necessary to make a diagnosis of migraines.

Are there different types of migraines?

 There are two major types of migraines: migraines without aura and migraines without aura.

Migraines without aura are the most common type of migraine, accounting for about 70 to 80% of people with migraines.  When these people with migraines without aura do get headaches, the headaches occur more often as well.  The frequent headaches are treated with more frequent medications, which unfortunately causes rebound headaches, complicating matters further.

Migraines with aura are recurring headache attacks that occur with neurologic symptoms, the the most common of which are visual symptoms and or speech symptoms.

By the way, a single person can have both types of migraines, migraine with aura and migraine without aura, at different times.  In fact, sometimes most of the migraine symptoms are present but the headache does not develop.  So the symptoms can be variable.  The international headache Society scratch that the International Headache Society have developed diagnostic criteria for the different types of migraines.

What is a migraine without aura?

In order to meet the diagnostic criteria for migraine without aura, patients must have the following:

1. At least five attacks fulfilling criteria B-D.
2. Headache attacks lasting 4-74 hours
3. Headaches have a least two of the following characteristics:
1. Pulsating quality
2. unilateral location
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
4. During headache at least one of the following:
1. Nausea and/or vomiting
2. Photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

5. Not attributed to another disorder (meaning that a clinician has not found evidence of some other cause of headaches or some other neurologic disease) on

The phases of a migraine headache

There are four phases to a migraine headache: the prodrome, the aura, the headache, and the resolution phases. 

The prodrome phase, which is experienced by many patients, consists of a feeling that occurs hours to days before the aura or headache occurs.  The proto-can be vague symptoms such as changes in mood, food cravings, yawning, or changes in digestive activity.  Some patients can use to program as a warning of the headache and intervene with medications, sleep,, or other methods that may delay or prevent the headache.

The headache phase begins in mild intensity and may build slowly over a period of several hours before it reaches its peak.  If the headache is untreated, most migraines will progress to a moderate or severe head pain that makes it difficult to perform normal daily activities or prevents one from daily activities.  They pain can occur anywhere in the head but is described usually as throbbing or pounding, especially if it becomes a severe attack.  However, not all migraine headaches or throbbing in pounding in nature.  Often the headache is made worse by exercise.  The pain may start on one side but can also go to the other side during the same attacked or maybe on different sides in different attacks for the same person.  40 to 45% of patients may have bilateral headaches.  Sometimes patient start with headache so one side before the headache spreads all over the head.  Migraine headaches typically interfere with a person's ability to carry out activities, whereas the majority of muscle tension headaches do not prevent activities.

Migraine headaches are aggravated by movement or exercise or any activity that increases the pressure in the head, including coughing, sneezing, bending, exercise, or straining.  Often a patient with a migraine prefers to lie down because activity or synthetic.

Loss of appetite, nausea, and/or vomiting frequently accompany migraines and are helpful for making a diagnosis.  Nausea occurs in about 85-90% of patients and vomiting may occur in about 30%.

During headache phase, people complain of increase sensations, particularly sensitivity to light(photophobia), sensitivity to sound (phonophobia), and sensitivity smells.  This may be associated with overall irritability, poor concentration, and even some behavioral changes.

During headache phase about 40 to 45% of patients have nasal congestion, rhinnorhea, or tearing.

During headache phase, patients also developed sensitivity of the scalp or skin which may include symptoms of soreness or sensitivity while brushing the hair, roaming the scalp, or lying on one side.  Sensitivity can occur on the trunk or extremities as well.  As many as 50% of migraineurs may experience this sensitivity, which is called allodynia.

The resolution phase of a migraine occurs after the headache, when the patient may feel tired, restless, irritable, or or have difficulty with concentration.

Notice how the migraine without aura does not have neurologic symptoms such as visual symptoms, tingling, numbness, or pins and needles.

What is a migraine with aura?

Migraine with aura is also called a classic migraine.  These are migraine attacks that are associated with on aura, that is a neurologic symptoms or symptoms.  The neurological symptoms develop gradually over about five to 20 minutes and last less than 60 minutes the neurologic symptoms are frequently visual symptoms but can also be sensations such as pins and needles or numbness,or speech changes. The headache typically follows the aura symptoms.

The International Headache Society has also developed criteria for the diagnoses of migraine with aura.  Those criteria are as follows:

1. First, the headache must fulfill the criteria for migraine with aura, noted above. The headache must begin during the aura or follow the aura within 60 minutes. 
2. There must be least two attacks that must meet the criteria A, B, C below

3.  The aura must consist of a lease one of the following, but not have any muscle weakness.
A.  Visual symptoms that completely resolve such as flickering lights, spots,  lines, or loss of vision's in the areas.
B.  Abnormal sensations such as pins and needles or numbness that resolve
C.  Changes in speech that fully resolve.
4.     At least two of the following:
A.  one-sided visual symptoms and/or one-sided abnormal sensations
B.  at least one or a symptom that is developed gradually over>5 minutes and/or different or symptoms occurring one after another for>5 minutes
C.  Each symptom lasts > 5 minutes but< 60 minutes.
5.   The headache cannot be attributed to another disorder by a clinician evaluating the patient.

Treating migraine headaches

There are several points to be made about treating migraine headaches. 

The aim of treating migraines is threefold: (a) to make the patient pain free as soon as possible, (be) to minimize the associated symptoms such as nausea, and vomiting, photophobia, phonophobia, and fatigue, and (see) to minimize disability and improve quality of life.

Several principles have evolved.  These include:

1. Treat the migraines as soon as possible, early in the course, before the head pain is severe and before nausea causes poor absorption of the oral medications

2. 2 Use effective doses of medications to gain control of the migraine faster (for instance, 200 mg of ibuprofen is much less effective than 600 to 800 mg of ibuprofen).

3.  Avoid the frequent use(more than 3 times per week)  of medications with substantial potential for rebound, including aspirin, Tylenol, and caffeine combinations.

4.  Avoiding trigger factors.  Patients at a regular meals, aim to get regular and adequate amounts of sleep, avoid smoke and other noxious fumes if they are triggers, and reduce or eliminate medications that may be triggering headaches.

5. Consideration of behavioral treatments to reduce migraine triggers.  Behavioral therapies may be especially appropriate for patients who have difficulty tolerating medications, who prefer nonpharmacologic treatments, who have contraindications to medications, who don't respond well to medications, who have had a history of excessive medication use, who have substantial psychological stress or difficulties coping with stress, or patients who are pregnant or plan to become pregnant and want to reduce medications.

Behavioral therapies include biofeedback, relaxation therapy, cognitive-behavioral training, and psychotherapy.  Biofeedback entails training so that patients can use imagery or repetition of phrases to decrease activity in the muscles, particularly in head and neck.  Monitors or electrodes on the scanner used to measure the muscle activity and provide feedback to the patient can enhance their ability to relax muscles.  Relax patient therapy entails patients concentrating on major Muss will groups, contracting a relaxing the muscles until they can easily relax all the muscles at will.  Electrician therapy can also entail training the mind using repetition of brief phrases that suggest relaxation and visualizing relaxing settings to produce a relaxed response of the body.  Breathing exercises are also used to reduce muscle rho activation.

Cognitive-behavioral training (stress-coping training) is used to help patients learn to manage their problems, cope with the stressors in their lives, and reduce maladaptive thinking patterns and beliefs (change their " cognitions") by providing a series of problem-solving and coping skills for repeat counseling sessions.  A skilled cognitive-behavioral therapist is critical to teach biofeedback, rely sedation, or behavioral therapy.

Exercise:

Regular aerobic exercise has been reported to be helpful in the reduction of migraine attacks, the intensity, and the duration of the tax.  The exact mechanism by which exercise improves migraines is uncertain.

There are many factors that can provoke a migraine attack, and the provoking factors are different from patient to patient.  About 80% of migraineurs recognize one of their migraine trigger factors, but most patients to recognize all of them, so reviewing a list of potential triggers is worthwhile endeavor for most patients the list of triggers is long enough that many patients find it helpful to keep a migraine diary in order to identify which triggers affect them.  Once they migraineurs can identify the trigger mechanisms, he or she can avoid those triggers potentially reduce the frequency or severity of attacks.
,, sometimes by as much as 50% although it is difficult, patients need to realize that identification and reduction a removal of these factors may be critical in their treatment.

Dietary changes are difficult to perform and difficult to sustain, so keeping a headache diary allows patients to identify foods which are likely to lead to migraine headaches, and then only removed foods that are very suspicious.    Unfortunately, food that trigger migraines are difficult to identify because a particular food may trigger a migraine only when other precipitating factors are present.  A food trigger may need to be ingested at a certain dose, concentration or intensity before an attack can occur. 

Irregular sleep patterns can trigger more frequent migraines.  Migraineurs should avoid oversleeping, under sleeping, or your regular napping schedules.

Smoking can trigger migraines, it is believed.  Either the smoke or the nicotine content of cigarettes may be the trigger.  Secondhand smoke also may trigger migraines.  Cessation of smoking and avoidance of smoke may be a helpful measure.

Some factors that may provoke migraines include:
Missing meals or irregular mealtimes
Stress (an accumulation of minor daily hassles, moreso than major life events)
Hunger:  irregular meals
Irregular sleep patterns (too much or too little sleep and)
Weather changes
Visual stimuli:  exposure to glare, bright,  or flickering lights
Auditory Stimuil:  Loud noises or music
Physical activities :  exertion or fatique
Local Stimuli in head and neck:  eye, teeth, jaw, sinuses , neck , nose
hormonal changes (including oral contraceptives, menstrual periods, or pregnancy)
Certain foods and alcoholic beverages
Stress or anger
Emotional letdown
Exhilaration or anticipation
General body stress (such as infection)
Olfactory Stimuli:  Strong odors or perfumes or chemical smells; Smoking or secondhand smoke
Some medications: 

Foods that can trigger migraines
Foods that contain Tyramine which include
Aged cheeses (Camembert, Brie, cheddar, Parmesan, Roquefort, bleu)
Some beers, ales and chiantis
Died salterd herring
Some sausages
Sauerkraut
Yeast xtracts
Alcohol (especially red wine)
Caffeine or caffeine withdrawal
Chocolat (e
Concentrated sugars
Dairy products Fermented or pickled foods
Fruits
Meets with nitrites
Monosodium glutamate
NutraSweet
Sulfites
Vegetables parentheses peanuts, nuts, Peapod, onions, lima beans)
Yeast products and breads

Chocolate is one of the most frequently cited triggers of migraines in both children and adults.  Some researchers think that a craving for chocolate may be a prodrome rather than a trigger of migraines.  Migraines arising after ingesting chocolate may occur as late as 24 hours after eating chocolate.  Caffeine can trigger migraines in about 10% of patients.  Withdrawal from caffeine, because of the physical dependence that can develop, can trigger migraines as well.  Withdrawal headaches can start start eight to 16 hours after the last dose of caffeine and can last 24 to 48 hours or longer.  Caffeine withdrawal headaches should be considered in the differential diagnosis for patients who have headaches on the weekends when they do not drink caffeine, patients with morning headaches, or patients with headaches before or after surgical procedures, when they are not eating.

Drug therapy for migraines.

 There are many considerations that need to be taken into account in the treatment of patients at migraines, so this review is designed more to serve as a framework to help guide patients as they discuss treatment options with their physicians.  Generally speaking, the aim of treatment is to reduce or eliminate the pain and associated symptoms such as nausea or vomiting as fast as possible in order to return the patient back to daily activities without significant side effects.  Typically, most simple and least expensive medications are tried first.  This would include aspirin, Tylenol, and nonsteroidal anti-inflammatory drugs such as ibuprofen (600 or 800 mg).  If these medications (and avoidance of triggers or behavioral therapies) are adequate, and the patient only has attacks that  require these medications two or fewer times a week, the treatment regimen can be used intermittently, as needed.  If appropriate dose of ibuprofen or other nonsteroidal anti-inflammatory drugs are not successful in stopping an attack, or historically do not abort a typical attack, a second-line drug is used.  The most commonly used drug for second line treatment are of the class entitled "triptans”.
The most commonly prescripted triptans are

Almotriptan (axert)
Eletriptan (relpax)
Frovatriptan (Frova)
Naratriptan (Amerge, Naramig)
Rizatriptan (maxalt)
Sumatriptan (Imitrex, imigran)
Zolmitriptan (Zomig)

There is a class of non-selective triptans, which are less commonly prescribed, but helpful at times.  These include

Cafergot
Dihydroergotamine (DHE), either nasal or injectable. 

Triptans are contraindicated in patients with angina, complicated migraines, uncontrolled high blood pressure, pregnant or lactating, or patients taking drugs called monoamine oxidase inhibitors.

Choice of medications for migraines is dependent on many factors, the most important of which are the following:

1. Frequency of headache attacks.  Because rebound can occur from taking almost any migraine medication, patients who use symptomatic medications more than twice a week require prophylactic medications in order to reduce the probability of these rebound headaches.  The goal of prophylactic medications is to eliminate the need for abortive, symptomatic medications or to reduce the frequency of abortive medications to two times a week or less.
2. The speed of onset of a headache.  Headaches that developed quickly into severe-intensity headaches require medicines that are rapidly absorbed.
3. The severity of headaches.  Tylenol, aspirin, NSAIDs are usually effective for controlling mild to moderate severity migraine attacks.  If they are not successful, triptans are usually prescribed.
4. Types and severity of associated migraine symptoms.  Nausea and vomiting are the most common and troubling associated symptoms for migraineurs.  If nausea occurs early or is a prominent symptom, and antiemetic medication can be given by mouth, injection, nasally, or rectus late to control the nausea.
5. Medical comorbidities or psychiatric diagnoses.  Patients with ischemic heart disease may not be candidates for triptans or erot drugs.  Patients with allergies or asthmatic reactions to aspirin should not take aspirin.  Patients with liver disease should typically avoid Tylenol.  Patients with a history of gastric ulcers, gastritis, impaired kidney function, or pregnancy should typically avoid NSAIDs. 
6. History or of effective or ineffective medication treatments.  Previously administered drugs may or may not have been prescribed an optimal doses or may not have been given adequate trials.
7. Patient's complaints and preferences.  Some patients primary goal is to relieve head pain, while others is relief of nausea and/or vomiting.  Rectal suppositories, injectable medications, and medications with intolerable side effects are not practical.
8. A patient's history of drug or alcohol abuse they weren't concerned about addiction to migrate medications, particularly if any opioids are prescribed.
9. Pregnancy or planned pregnancy.  Medications for aborting or preventing migraines are often limited if the patient is pregnant or attempt to become pregnant, or lactating.  Tylenol or narcotics might be usable, with appropriate consultations.

Medication overuse or rebound headaches

Anti-migraine medication, specifically the abortive medication, should not be used more than two days a week and preferably less frequently.  Any pain medication, if taken in excessive amounts or for prolonged periods of time can cause rebound headaches.  The class of anti-migraine drugs called triptans, when taken more than two times a week, will also frequently cause rebound headaches.  Tylenol, aspirin, Motrin or any of the NSAIDs taken three or more times a week for more than two or three weeks can also cause rebound headaches, particularly in migraineurs.   The rebound headaches can occur on or chronic, daily basis and can be associated with moderate to severe pain.  Although rebound headaches can be severe and intensity, they often lack the associated symptoms of that might occur with a patient's typical migraine.   Therefore, these  rebound headaches are called transformed migraines.   Patients on the abortive medications or than two days a week should be on a preventative medication, that is medication taken regularly to prevent the onset of migraines. 

Who is a candidate for prophylactic or preventative medications for migraines?

Although the standard answer is prophylactic medication should be used for any patient who has three or more problematic migraine attacks a week, in reality, the criteria for a trial of prophylactic drugs needs to be tailored for each patient's individual circumstances.  Prophylactic medications may be indicated for patients with less than three migraines a week if the migraines were severe and incapacitating.  For example, prophylactic medications may be a indicated for patients with headaches that were causing frequent absences from work, headaches that were particularly long-lasting (>48 hours) , headaches that disrupted a patient's work or family life substantially.  Preventive medications may also be indicated for patients who have not adequately spotted to abortive therapy, have intolerable side effects from abortive therapy, are suffering from rebound headaches from abortive therapy, or are likely to develop rebound headaches from abortive therapy.  Patients with complicated migraines, that is migraines with prolonged aura, migraines with weakness on one side of the body, or migraines with other substantial neurologic symptoms, may be candidates for prophylactic medications.

Practical issues in prophylactic drug therapy for migraine.

1. Start low and go slow with the dosage of drug, increasing the dose until symptoms are relieved or side effects occur.
2. Choose a first-line treatment that is the most effective with the fewest side effects, if possible. 
3. Allow a drug one to three months at an adequate dose before assessing effectiveness.
4. Use one drug whenever possible.
5. assess for concomitant medical comorbidities that may guide the choice of anti-migraine prophylaxis.
6. If a drug is ineffective, withdraw the medication slowly before trying a second drug.
7. Consider reevaluating in six months.
8. If headaches are well-controlled, discuss risks and benefits of a slow taper. 
9. Counsel women of childbearing age about adequate contraception and the risks of pregnancy.

What other medical diseases might affect the choice of migraine prophylaxis?