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Migraine: All Kinds of Discrimination?

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A recent opinion piece at the New York Times is creating a buzz about discrimination and, in particular, mental illness.  And yes, migraine does come into the picture.

Discrimination @ the Doctor's Office?

The author, who writes about personal experiences, has bipolar disorder.  Here’s an excerpt from the article:

It’s little wonder that many people with a serious mental illness don’t seek medical attention when they need it.  As a result, many of us end up in emergency rooms — where doctors, confronted with an endless stream of drug addicts who come to their door looking for an easy fix — are often all too willing to equate mental illness with drug-seeking behavior and refuse to prescribe pain medication.

I should know: a few years ago I had a persistent migraine, and after weeks trying to get an appointment with any of the handful of headache specialists in New York City, I broke down and went to the E.R. My husband filled out paperwork and gave the nurse my list of drugs. The doctors finally agreed to give me something stronger than what my psychopharmacologist could prescribe for the pain and hooked me up to an IV.

I lay there for hours wearing sunglasses to block out the fluorescent light, waiting for the pain relievers to kick in. But the headache continued. “They gave you saline and electrolytes,” my psychopharmacologist said later. “Welcome to being bipolar.”

When I finally saw the specialist two weeks later (during which time my symptoms included numbness and muscle weakness), she accused me of being “a serious cocaine user” (I don’t touch the stuff) and of displaying symptoms of “la belle indifference,” a 19th-century term for a kind of hysteria in which the patient converts emotional symptoms into physical ones — i.e., it was all in my head.

Be sure to read the whole article here: When Doctors Discriminate

It made me think about just how many different kinds of discrimination there are.  Have you experienced any of these?

  • You’re over-reacting.  I know, because you’re female.
  • It’s just because you’re stressed.  I know you’re stressed, because you have migraine.  Which you have because you’re stressed.
  • I know it seems worse than normal, but I’m sure it’s just another migraine.  You get those, therefore it’s always going to be the same thing.
  • It’s just a headache.  Take two painkillers and stop bothering me.
  • You have depression/bipolar disorder/etc.  Therefore it’s all in your head.  Just pull yourself together.
  • You don’t have depression/bipolar disorder/etc.  But everyone with migraine does.  So you’re in denial.

Thankfully, most doctors aren’t that blunt.  As a matter of fact, I believe that most doctors are actually doing a pretty good job with what they have, and they actually want to help you.  So no, this is not an anti-doctor post.

However, sad to say, there are some doctors out there who are a little too quick to jump to conclusions (conclusions that may even be true some of the time), too quick to think they know more about a patient’s symptoms than the patient (an objective view is great, but patients can actually be pretty perceptive about what’s going on in their own bodies), and too quick to buy into stereotypes.

Do you feel like you’ve experienced discrimination?  What kind?  And what have you done about it?  Let’s talk!

Migraine: Are Blood Vessels to Blame After All?

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A new study from the University of Pennsylvania School of Medicine is making the headlines – and the headlines are bringing blood vessels back into the migraine conversation.

Before we get into the study, a little background.  Migraine was once very commonly believed to be a “vascular disease”.  Migraine, it was thought, came from the way blood vessels expanded and constricted.  Research and treatments focused around this idea.

But as we learned more about the brain and migraine’s connection to neurological systems in the body, migraine was increasingly believed to be a neurological disease, at least primarily.  A study released in April demonstrated that some patients actually have little if any blood vessel dilation.

Now we’re seeing headlines about arteries and migraine again.  Are we just bouncing back and forth from one theory to another?  Is the research just going around in circles?

Absolutely not.

The study, which we’ll look at in a moment, does not say that migraine is caused by blood vessel dilation.  Even if it was suggesting that all migraine involves blood vessel issues (which it’s not), this still wouldn’t change what we said here even back in 2008 and have been saying ever since (see What is Migraine? (the scientific story).

Migraine is not likely a clear chain of events, but more like a web of events.  This impacts that, this part of your body sends a message here and a message comes back, two things work together – and an attack begins.  Yes, there are chain reactions, but that doesn’t mean that only the brain or only blood vessels (or whatever you add to the list) causes all migraine attacks.

So what does the study tell us?

Simply, that people with migraine are more likely to have a congenital abnormality (something they were born with) in blood vessels.  Yes, non-migraineurs may have this difference.  And people with migraine may not.

That’s it.

Here’s the summary at the beginning of a news release from Penn Medicine:

The network of arteries supplying blood flow to the brain is more likely to be incomplete in people who suffer migraine, a new study by researchers in the Perelman School of Medicine at the University of Pennsylvania reports.  Variations in arterial anatomy lead to asymmetries in cerebral blood flow that might contribute to the process triggering migraines.

The arterial supply of blood to the brain is protected by a series of connections between the major arteries, termed the “circle of Willis” after the English physician who first described it in the 17th century.  People with migraine, particularly migraine with aura, are more likely to be missing components of the circle of Willis.

This is an interesting discovery, confirming an earlier study in 2009, but it’s no surprise that blood vessels are involved in many migraine attacks.

Is is interesting that abnormalities were most prominent in the part of the brain that processes visual information.  This could be a further clue into the visual aura that many migraineurs experience.  In fact, people who had migraine with aura were more likely to have this abnormality, though it seems to be common in non-aura types of migraine.

In the end, researchers were careful to say that changes in blood flow related to this abnormality may “trigger” a migraine attack, not that this is the cause of migraine.

Take-aways?

  • A congenital abnormality in blood vessels may be another “internal” trigger of migraine (not the only one).
  • Blood flow does seem to be involved in many migraine attacks.
  • Understanding the connection between this abnormality and migraine gives us more clues into how migraine works and how it can be treated in individual patients in particular.
  • Our overall understanding of migraine has not drastically changed, but this is still an important study that may help us understand migraine better.

Cephalalgiaphobia – Should we treat “the fear of headaches”?

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Cephalalgiaphobia – that’s right, it’s the fear of headaches.  And, naturally, if you’ve had a few bad ones, you’re not going to want more.

But is this fear actually making the problem worse?

Do you have a phobia?

In 2007, researchers in Brazil suggested that cephalalgiaphobia should be a recognized phobia that needed to be further studied.

Now we need to understand that a “phobia”, in the technical medical sense, is not just concern that your pain is going to get worse.  It’s an irrational fear, a disorder that can actually cause other physical symptoms.

So here’s the problem – what is irrational or abnormal?  Here at Headache and Migraine News we do not consider headache to be “normal” or something to be ignored.  But surely a migraineur who avoids certain events because of a good mathematical chance that a migraine attack will strike cannot be called “irrational”.

Surely a headache sufferer who sees a pattern of worsening pain cannot be questioned if they’re concerned that their pain will increase.

There are a number of “between attack” problems that migraine sufferers may have.  Some physical symptoms may continue all the time, even when an attack isn’t happening at the moment.  And certainly anyone with chronic pain will learn how to cope in the real world by making decisions about where to go and what to do – partly based on levels of pain, chances of pain, and risk of increasing pain.

That’s not good – and it can be dangerous, but all things being equal it’s not necessarily a phobia.

However, as I say, it can be dangerous and get out of control.

In June of 2013, researchers from Italy and the USA continued investigating cephalalgiaphobia in migraine patients.  Here was their definition of cephalalgiaphobia:

Cephalalgiaphobia is the fear of having a headache attack during a pain-free period that may induce patients to use analgesic in the absence of pain to prevent headache and to improve their performances.

Again, the definition concerns me.  Technically, I would be very concerned if a headache patient was taking medication because of “fear”.  On the other hand, if someone knows that they will get a headache because they see migraine warning signs or because they almost always get a headache during a severe thunderstorm, and they take medication before the pain starts, knowing that that has solved the problem in the past – is that cephalalgiaphobia?

Researchers found that patients were more likely to take “unnecessary painkillers” if they had more headache attacks per month.  That is, the group with over 15 attacks per month were more likely to suffer from cephalalgiaphobia (as the authors defined it) than those with 4-14 or 1-3 attacks per month.

This is not a topic that should be ignored, and the researchers have legitimate concerns.  The fact that conditions such as depression often go along with migraine.  The risk of suicide in migraine patients.  The overuse of medication, and risk of medication overuse headache (rebound headache).

Should we be concerned that many patients take more medications than they need to?  Absolutely.

And one of the questions that patients were asked is certainly worth thinking about – Have you ever used painkillers to improve your performances and be more active, although you were not feeling the pain at all?

That’s no reason to take headache meds.  And it can be very dangerous.

But if you’ve ever taken medication, thinking the pain would increase, does that mean you have a phobia, or just experience?  If you fear a migraine attack when you’re feeling well, is that necessarily abnormal?  If you plan ahead knowing that you may have an attack, is that a phobia?

I think the researchers have valid concerns, and that these are questions that should be investigated further.  Far too little attention is given to the whole-life consequences of migraine.

But I think we need to be very cautious about how we define new clinical phobias.  We might end up taking too much time treating something that’s actually normal, and not enough time treating migraine and headache disorders.

The full details of the latest study can be found here:  Cephalalgiaphobia as a feature of high-frequency migraine: a pilot study

Ethosuximide for Migraine?

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Many people have successfully fought migraine with anti-epileptic drugs.  Common examples are valproic acid and topiramate.  Researchers are now taking a closer look at ethosuximide (Emeside, Zarontin).

Although this class of drugs has worked well for some, others have found more side effects than help.  Other problems, such as liver damage, have kept patients from finding help with certain anti-epileptic drugs.

Ethosuximide has had a good track record for treating absence seizures, but has not received much attention when it comes to migraine.

Looking for better ways to treat veterans in the USA with migraine, the Department of Veterans Affairs is sponsoring a rare study of ethosuximide as a migraine preventative.  The hope is that ethosuximide will successfully help some migraineurs with fewer side effects.

If you’re a veteran in the USA, you may be eligible to be a part of this study, which is being done through Thomas Jefferson University and the University of Pittsburgh.  For more information, check out the official study page here, and contact Kathy L Gardner, MD or Greg A Owens, BA from the Department of Veterans Affairs.

Do “Sea-Bands” Work for Migraine Nausea?

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Does the “Sea-Band” and other so-called anti-nausea bracelets actually work to fight migraine nausea?  Dr. Zoltan Medgyessy of the Berolina Clinic in Germany thinks so, and so do many migraineurs.

At last month’s International Headache Congress in Boston, Dr. Medgyessy reported on a study which involved the bracelets.  Patients in the study had significant migraine symptoms, including nausea.  Instead of taking nausea medication, they used a Sea-Band.

The Sea-Band, and other similar bracelets such as the Psi Band, use acupressure.  Acupressure is a concept that comes from Chinese religion and philosophy relating to Qi or Chi.  Qi is believed to be a living energy that permeates all things, usually connected with a kind of pantheism (in simplistic terms, everything is god).

More recently the medical world has shown interest in acupressure believing that pressure in certain parts of the body are certainly therapeutic.  This could be partly because of the way that pressure to certain parts of the body release endomorphins, which can fight pain.

In spite of the benefits of touch that are well known, showing in scientific studies that therapies like acupressure work has been a challenge.

In this study, 83% of patients saw a reduction in nausea, although some nausea generally remained.  44% saw a “significant” reduction.  Almost all the patients said that they would use the Sea-Band again.

Who wouldn’t want a drug-free, reusable (cheap!) treatment like that?

On the other hand, there are some serious limitations in the study itself.

First, remember that less than half saw a “significant reduction”, and we’re still not talking about actually getting rid the nausea.

The other problem is that there was no control group in this study.  The placebo effect is high with any study – and we already know that it’s high in things like acupressure.  For example, anti-nausea bands work a lot better for people who “expect them to work” when it comes to cancer nausea.

Would it work just as well to have a little wrist massage?  Human touch instead of a device?  Or do anything that you think may work?

It’s very likely that the numbers will be a lot lower in a controlled trial.

Of course most would continue using them.  Few things are more disabling than migraine with nausea – it’s easy to grasp at anything, especially if it’s said to be “safe”.

But we need to see more studies to show that a device works better than human touch or other types of non-drug treatment.

Also, we need to encourage people to get complete treatment of migraine, not to just focus on symptoms.

More on the study:

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