HEADLINES

VOLUME 2, ISSUE 10, OCTOBER 1997

A Publication of the East Bay Headache Support Group

(The text of this newsletter has been simplified with all graphics removed to suit all users' browsers and computer speeds.)

October 14th Meeting:

PREVENTION OF STRESS HEADACHE: A PRACTICAL AND UNIQUE APPROACH

Stress contributes to the death of millions of Americans each year, and is a leading cause of headache. The cumulative effects of seemingly minor upsets are as devastating as life’s major setbacks. Dr. Roger Johnson will present a unique and effective approach to rapidly dissipating the stress of the daily grind.

As a specialist in Veterinary Medicine, the director of a high pressure veterinary hospital for 28 years, and the husband of a migraine sufferer, Dr. Johnson observed the crippling effects of stress and headache in the workplace as well as in his personal life. He has lead numerous workshops on Stress Reduction in the veterinary hospital and has widely written and lectured on scientific subjects.

Past Meetings:

November 11th: Leonard Saputo, M.D. — "Natural Alternatives for the Management of Headaches"

December 9th: Peter Visendi, O.D. — TBD

January 13th: "Talk It Over Night"

Note: Notes from each of the above-listed meetings are available on line by going to the site directory and clicking on the date of the meeting.

HELP FOR HEADACHES IS AVAILABLE

(The following article was written by Judith S. Askew, M.A., for the May/June 1996 issue of Menopause News, and reprinted by permission. Menopause News is published six times per year by Ms. Askew in San Francisco. For information, or to subscribe, phone: (800) 241-MENO, email: mnews@well.com, http://www.well.com/~mnews )

Between puberty and menopause, women suffer 75% more headaches than men. Before and after those milestones, they occur to men and women in equal proportion. This fact gives us a clue about a precipitating headache factor for women: hormones.

We are all old enough to remember the tacky joke about women, sex, and their headaches. Isn’t it wonderful that instead of being the brunt of nervous humor, we are now receiving serious attention for hormonal-related discomforts. PMS is real. So, unfortunately, is menopause. And so are headaches, which even women themselves tend to treat lightly or to feel guilty about.

We still have much to learn about headaches, but know-ledgeable help is available, though we might have to search to find it. Many doctors are just not informed about new understandings or may be too busy to work with you to find healing for your pain, which is not always easy to do. My internist called my perimeno-pausal migraines "sinus" headaches and treated me with a daily Seldane tablet.

Migraine headaches, so painful and debilitating, tend to intensify or increase in frequency with perimenopause. I was recently told of a woman in Silicon Valley who had been unable to find help, and she just could not take her headaches any longer. She committed suicide.

That tipped me into writing this issue, which I had been postponing.

Now I realize I am a migraineur (my mother was, and so was my grandmother), and though I have tried to take better care of myself, I understand that migraine is an on-going condition. Several of the experts I talked to drew comparisons with diabetes. That gave me pause. The mechanism that causes migraine is not fully understood, but migraines—and other types of headaches—are understood to be more than just a little pain in the head or an excuse to take a day off from work. If you suffer from headaches, understand that you are not suffering from a character defect or from an inability to handle stress, but from a particular electrical and biochemical process in the brain.

What is a headache?

A headache is pain that is usually perceived to be inside the head. Even though you may perceive it to be there, it is called referred pain and is actually generated in the face, neck, scalp, or casing of the brain. A migraine is usually felt on one side of the head or the other, and often behind one eye. Migraineurs sometimes see a dentist because they perceive pain in their jaw. They may perceive it in their sinuses or in their eyes. Stubbing your toe is a fact, but it takes interpretation by the brain, through its nerves, to register pain. This is why sometimes a person who has had a limb amputated will still feel pain in the missing arm or leg—the brain has erroneously registered a sensation, or referred pain.

Messages in the body or the brain are sent by transmitters (neurotransmitters) and received by receptors. The absolute level of neurotransmitters in the brain, particularly serotonin, and their rise and fall as well as the condition of the receptors, all affect how sensitive we are to pain, how well we sleep, whether we are depressed, and how we respond to stress. All of these factors seem to be linked. Research shows that migraineurs tend toward depression and sleep problems. And because the processing of stress is linked to serotonin, stress seems to be a factor in headaches. Lower levels of serotonin and endorphins have been shown to correlate with depression.

Dr. Ninan Mathew, director of the Houston Headache Clinic and chairman of the headache section of the American Academy of Neurology, has said that anyone who thinks stress is not a factor in migraine doesn’t see enough patients.

"Stress may not cause migraines immediately, but you can work through a very stressful period and then when it is over, on the weekend or on a vacation, you suddenly come down with a headache. We don’t understand this stress/relaxation cycle, but learning relaxation techniques is very effective. We ask that our patients with this problem practice relaxation techniques every day, sit down and relax. It works," he said.

The picture is complex, which you know if you have tried to understand what caused a recent headache. Other neurotransmitters come into play—dopamine, noradrenaline, substance P, and acetylcholine. Some pain medications will affect these transmitters and will block the pain. They will not cure it; you will just not feel it. And as you know, we have a natural pain reliever, endorphins, which like synthetic morphine, lessens the perception.

Two Types of Headaches are Relevant for Women

Besides migraine, women and men have "tension" headaches. One type of tension headache comes as a specific reaction to a specific event, such as exposure for a long time to bright sunlight or staring too long at a computer screen. Another type, called a "chronic" tension headache, occurs more frequently, as often as four times a week. These headaches usually begin early in the day or can be felt upon waking. Tension headache pain is not as debilitating as migraine pain. Described as being all around the head or feeling like one’s head is caught in a vise, the pain usually starts in the muscles at the back of the head and works its way up to the forehead. While these headaches can also settle in during a stressful event or immediately after one, the appearance of a migraine will be more subtle and may not appear until a relaxing Saturday or even at the beginning of a vacation.

We’ve All Heard of Headache Triggers...

Stress may be an important factor in headache pain, but anyone who suffers headache realizes certain foods or events can provoke a headache.

Stunning Statistics

* Over 45 million Americans get chronic, recurring headaches.

* 16 to 18 million Americans suffer from migraines. 50% of them are not getting treatment.

* 70% of migraine sufferers are women.

* 65% of women who get migraines get them during the days just before, during or after a period.

* Based on several surveys, nearly 1/2 of migraineurs discontinued normal activity (during a headache); nearly 1/3 required bedrest. In one study, 55% said they missed two workdays/month and 88% worked at lower productivity 5.6 days/month.

* If both parents have migraine, a 70% chance exists a child will have migraine. With one parent, there’s a 50% risk. Even with a distant relative, there’s a 20% chance.

* Americans spend over $6 billion annually for over-the-counter painkillers (many of which are ineffective).

Dr. Steve Peroutka, a neurologist and pharmacologist who is currently medical director of Spectra Biomedical, Inc., a firm in Menlo Park, California, where the hunt for the headache gene is racing along, claims that he can give anyone a migraine.

"I told a brother once who had said his sister had more headaches than he that I was going to take him once a month flying at high altitude, because that’s a problem. Then I was going to land on a mountain in Switzerland, keep him up all night drinking red wine, and then tell him he had been fired from his job. I told him to imagine doing that for 400 straight months, 30 years in a row, and he would have some understanding of what his sister, who had regular menstrual migraines, was going through."

Dr. Peroutka believes that when the migraine gene is found that it will change our understanding of migraine, showing it to be a metabolic disease, like diabetes. (One theory holds that migraineurs, unlike diabetics whose pancreas produces too little insulin, may produce too much insulin, which reduces the amount of blood sugar too rapidly and too low.)

"Right now one problem with migraine is that it is entirely subjective. If a diabetic told you she’s so weakened and a glass of orange juice will cure her, and you don’t know anything about diabetes, you would think that was goofy. Migraine has all sorts of things that supposedly work, but there’s no logic behind it. I have prescribed an over-the-counter nonsteroidal drug three days before a predicted migraine and four days afterwards. That seems to work for some people."

Dr. Peroutka’s research confirms that migraine is a genetic susceptibility to headaches. What seems to be the basis is a change in environment, be it internal or external. "What migraine people share is sensitivity to any acute change in things like the weather (windy days or rainy and then clear days), changing sleep patterns (too much or too little), altitude changes, skipping meals. The menstrual cycle is an internal change. Migraine people do not handle shifts in the environment well. They need to be as regular as they can be with various trigger factors. A cup of coffee or tea every morning is OK. What is not OK is three cups, then none on Saturday or Sunday, and then to sleep in late."

"Migraine has to be one of our most mismanaged diseases. We give one dose to everyone. Can you imagine if we gave five units of insulin to every diabetic. We can really manage migraine. We have great drugs, we just don’t use them right."

What About the Vascular Constriction Theory?

Experts see linkages between genetics, low blood sugar, serotonin, and constriction of blood vessels. Migraine headaches were thought to be caused by constriction of blood vessels, which is still believed to be part of the process and may account for classic migraine signs that precede the onset of pain by about one-half hour. (The signs are often visual flashing lights, loss of part of the visual field, depression, numbness in arm or leg, increased sensitivity to light and smell.) Certain neurotransmitters seem to irritate nerve cells and blood vessels causing inflammation in the covering of the brain. The blood vessels first constrict and then dilate.

Another theory holds that low levels of cerebral magnesium followed by electrical charges in the back of the brain set off changing levels of serotonin. Levels of serotonin have been shown to be unusually high before a migraine and then unusually low during a headache. The speculation is that the fluctuations set off vascular problems. Low levels of serotonin might explain the depression that some people experience before a migraine and the feelings of well-being that follow a migraine when serotonin levels are restored.

And How Do Our Hormones Fit In?

Dr. Joel Saper, neurologist and medical director of the Michigan Head Pain and Neurological Institute, says there is a Hormonal connection. He finds the mechanism of a migraine to be connected to the upper brain stem. Within that, there is a zone that is believed to be a migraine generator, or area where migraine excita-bility comes from. There are estrogen receptors in the brain (and other areas of the body, obviously) and, he says, "we know there are intimate connections between the estrogen receptors and pain mechanism not only for migraine, but for other pain. It is almost as though the estrogen receptors alter the threshold of pain or vulnerability to pain in a migraineur."

Dr. Saper finds a direct connection to serotonin more difficult. He says that there seems to be some modulating influence that estrogen has on serotonin mechanisms. "The data show that during all the hormonal milestones of a woman’s life, there are headache-related events if a woman is headache-predisposed. That’s the important feature. Not everybody has headaches and those who do are generally genetically predisposed. For predisposed women in the menopause who do not take estrogen replacement, there is a tendency for the headaches to abate. If the headaches were significant before menopause, they are likely to be worse heading into menopause when there is a lot of fluctuation. Some women for whom headaches were not significant before menopause, begin to have them during menopause when they take estrogen replacement.

Additionally, there seems to be an interplay between estrogen and Provera."

"On the other hand, if a woman is taking no estrogen preparation, or an inadequate level, and her normal levels falls too low, that can also cause a headache. That may sound confusing! What we are finding is that three variables are most important: fluctuation of estrogen, or too high a level or too low a level. What is really ideal for women is some sort of consistent stability that is slightly on the low side, but not too low," he said.

John Arpels, M.D., a San Francisco gynecologist, finds that for migraineurs their headaches often change during menopause, becoming tension headaches. "Women whose headaches occur during the week off using birth control pills or before the menstrual cycle begins or in the middle of it—times when estrogen levels drop—can benefit from an attempt to keep the estrogen level consistent. Women whose headaches are triggered by those events are helped by boosting the estrogen during those days or by using a skin patch, which gives a steadier, smoother course of estrogen. Oral estrogen gives peaks and valleys, with an initial six- to eight-hour peak and a twelve-hour trough."

When discussing the anti-estrogen effect of a progestogen, Dr. Arpels suggests when adding progesterone that estrogen can be increased those days to counteract progesterone’s tendency to decrease blood flow.

Many physicians prefer not to give hormone replacement to women who suffer from headaches or migraines. Certainly the comments from these physicians indicate the migraine mechanism is not completely understood. Again, I encourage a woman to trust the wisdom of her body, and to find a doctor she trusts, one who will work with her to treat her migraines and menopause in a way to ease her pain while fitting her treatment into her life-style. Maybe it will be using the new

Vivelle patch. Maybe it will be an injection one-half hour before an important meeting. Maybe it will be trying to be more regular with sleep and giving up red wine. Certainly detecting headache provocateurs, learning some relaxation techniques, such as biofeedback, or working with an herbalist or homeopathic physician will all be useful. The tried and true—daily exercise, the aerobic variety is usually mentioned in connection with headaches—is also on the list of helpful aids for headache sufferers.

One important caution--do not be too ready just to take painkillers. Aspirin, Tylenol, iboprofen or prescription medications can have a "rebound" effect. The medication may give some relief at first, but as you take more and more, a reaction sets in. As the body becomes accustomed to the medication, it requires more and more to combat the headaches that set in as soon as the medication wears off. Try to work with a doctor who will help you develop a holistic plan to treat your headaches, working with your diet, exercise, and stress management, while limiting your painkillers. €

Melatonin and Migraines

Melatonin helps to reduce the incidence of migraine headaches. In this study, 10 mg of melatonin was administered to half of 20 cluster headache patients in a double blind controlled study that lasted 14 days. Headache frequency was significantly reduced in the melatonin treatment group. Five of ten people in the melatonin group reported that their attack frequency declined after only 30-35 days of treatment. No patient in the placebo group showed this response.

Caphalalgia, 1996;16(7). Excerpted From Colgan Chronicles.

The intention of the East Bay Headache Support Group and Headlines newsletter is to provide information and resources. It does not provide medical advice, which should be obtained directly from a physician.

TAKE A BOW

The East Bay Headache Support Group has had 21 informative monthly meetings since its inception in January 1996. We would like to take this opportunity to thank our speakers who have so generously given their time and expertise to the group. In order of appearance, they are:

Michael Stein, M.D. - January, May, October 1996 and May 1997

Ellen Place, R.N. - February 1996 and June 1997

Steven Peroutka, M.D. - March 1996

Judy Rael, M.S.W. - April 1996

Debbie Stevens, R.D. - June 1996

Craig Weinston, D.C. - July 1996

Darryl Nomura, Pharm.D. - August 1996

Sondra Altman, M.D. - September 1996

Leslie Wenz, P.T. - November 1996

Stephen Sardella, M.F.C.C. - December 1996

Hugh Wang, M.D. - January 1997

Majeed Al-Mateen, M.D. - February 1997

Steven Goldman, D.D.S. - March 1997

Jan Mundo, C.M.T. - April 1997

Robert Horwitz, Pharm.D. - July 1997

Nathan Schultz, M.D. - August 1997

Jerome Goldstein, M.D. - September 1997

Also, this organization could not continue without the support of many individuals and organizations. Your contributions are greatly appreciated:

GlaxoWellcome, Inc.

Merck & Co., Inc.

John Muir Medical Center

Kinko’s Copies

Contra Costa Times

ACHE (American Council for Headache Education)

Individual Donors

The Organizing Committee