Headache: Many myths and misconceptions

By Michael K. Sowell, MD

How common are headaches?  Significant headaches occur in as many as 45 million Americans.  Migraine, the most common, recurrent, disabling form of headache occurs in 28 to 30 million Americans or 12% of the population.  Approximately 6% of men and 18% of women suffer from migraine.   50% of all migraine sufferers begin to have their attacks before the age of 20 years.  About 5% of children suffer from migraine (ranging from 3.2% to 10.6%).  The gender ratio for children is about 1:1 under the age of 12 years, with a slight preponderance of boys.  However, after the age of 12 years, the incidence of migraine in females increases to an approximate 3:1 ratio of females to males in the adult.  This may be related to the cyclical hormonal effects of estrogen and progesterone.

What impact does migraine have on the workplace?  Migraine in the workplace exerts a significant impact on an individual’s productivity.   This may take several forms including:  absenteeism, reduced productivity while at work, individuals working at a level below their capacity (underemployment), and unemployment.  The best estimates suggest that migraine costsU.S. employers $13 billion per year in lost productivity.

When should you see your doctor for headaches?  There are no absolutes, however, some general guidelines are that if the headaches are moderate to severe, recurrent, of new onset, associated with light or sound sensitivity, or resulting in attack-related impairment. This impairment may be defined in a functional sense, meaning that you have to go to a dark room to lie down or miss work, school, or family-related activities.

How is a diagnosis of migraine made?  In the simplest of terms, migraine is headache, gastrointestinal symptoms, Neurologic symptoms and disability, in various combinations.  A physician makes a diagnosis of migraine by applying clinical criteria recently revised by the International Headache Society (ICHD-II)

and applying them to the individual.  Care must be taken to exclude secondary causes of headache.

If a diagnosis a migraine is made by a physician, what are the options for treatment?  Essentially 2 therapeutic strategies are employed, acute treatment and preventive or prophylactic treatment.  Acute treatment options include a number of options, the most common of which is the “triptans”, a class of medications which are thought to be “migraine-specific” in their mechanism of action.  The patient must be assessed for the possibility of any risk factors for coronary artery disease or uncontrolled hypertension.  These would be contraindications to the use of “triptans”.  Prophylactic or preventive treatment is for those patients who have frequent, severe, disabling migraine.  The goal of preventive treatment is to reduce the frequency, severity or disability of the attacks.  Also, when used in combination with an acute treatment strategy, the preventive medication may make the attacks more responsive to the acute treatment.

Are there non-pharmacologic approaches to therapy?  Education is essential to every patient with migraine.  The goal is self-management within parameters established by a physician.  Exercise has important benefits for a wide variety of medical conditions, migraine is included.  Relaxation training has been shown to be of benefit.  Biofeedback has been shown to be of benefit, particularly in frequent, disabling migraine headaches.  Certain dietary triggers can worsen migraine in some situations, perhaps the most notable being chocolate, caffeine, aged cheese, and alcoholic beverages.  The list of potential dietary triggers is quite lengthy, however, largely does not fit all patients with migraine.  Therefore, it is best for the individual with migraine to identify those potential food and drink triggering factors and to avoid them.

Where can I learn more?  The American Council for Headache Education sponsors a patient-oriented website www.achenet.org  A Kentucky support group chapter is needed.

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Michael K. Sowell, MD, Assistant Professor of Neurology and Pediatrics Director, University of Louisville Comprehensive Headache Program. Dr. Sowell joined the faculty full-time in 2002 and currently serves as Director of the University of Louisville Comprehensive Headache Program.  The headache program is the only academic program of its kind in Kentucky to serve the needs of patient care, teaching, and research with headache as a specialty.  Dr. Sowell is Board-certified in Neurology with special qualification in child neurology.  Dr. Sowell completed medical school at the University of Arkansas for Medical Sciences in 1987.  He then completed a residency in Pediatrics at the University of Arkansas/Arkansas Children’s Hospital in 1990.  He then completed a residency-fellowship in Neurology (Child) at Washington University in St. Louis (Barnes Hospital, St. Louis Children’s Hospitals) in 1993.  He came to Louisville in 1993 and became Director of Neurology for Kosair Children’s Hospital and was in private practice prior to joining the University of Louisville.  Appointments for children, adolescents or adults with headache or facial pain disorders may be arranged by calling 589-0802.

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