(Reader request) Migraines: Your Guide to Living Well Despite the Unwanted Party in Your Brain
Migraines can be debilitating. We've collected insights and remedies here- no case studies, wandering preambles, or overused AI images. There are a few puns though; I'm only human.
As a physical medicine and rehabilitation specialist, my passion is helping people live their functionally fullest lives despite whatever medical challenges they face. While I don't treat migraines as a primary focus, I've worked with countless patients whose lives have been impacted by these debilitating headaches. For the migrainers out there, let’s start by better understanding the science behind migraines- this can make it easier to wrap your head around some of the treatments.
"What's Actually Happening in There?"
Think of your brain as an incredibly complex city. During a migraine, it's like all the traffic lights suddenly start malfunctioning, the streets get congested, and someone cranks up all the speakers to maximum volume. Your brain's normal communication pathways go haywire, with something called "cortical spreading depression" – imagine a wave of disruption moving across your neural networks like a brownout rolling through different neighborhoods.
The fascinating thing about migraines is how they affect your entire body. Because we “live in our heads”- i.e., anything we sense is really just our brains interpretation of electrical signals- these irregular signals can create new sensations without the requisite stimuli. In other words, the non-headache symptoms can be widely variable from person to person and even between migraine episodes for the same person. As I’d mentioned in the stroke post, some migraines can cause symptoms that closely mimic a stroke. In other words, migraines are not just “bad headaches” – they can be full-body experiences that can impact everything from your balance to muscle control/strength to your digestive system. Understanding this helps us develop more comprehensive approaches to management.
"Why Is This Happening?" (Triggers)
In my practice, I've noticed that migraine triggers often overlap with other lifestyle factors that affect overall wellness. Here are the usual suspects:
Physical stress- poor posture, neck strain, and that terrible habit of hunching over phones or laptops.
Mental stress, including the kind that comes from trying to do too much – bottomless to-do lists are a scourge on our lives.
Sleep disruption- both quality and quantity matter here. Keep an eye out for a more detailed post about this soon, as it is one of my favorite “soap box” topics.
Dietary choices- certain foods seem to be universal culprits. These include but aren’t limited to processed meats, foods containing the amino acid tyramine (beans, aged cheeses, smoked fish, and Chianti), foods with MSG like Chinese food and soups, artificial sweeteners, dried fruits like dates/figs/raisins, and tomato based products.
Just because these cause migraines does not necessarily mean they are bad for non-migraine sufferers. Aspartame is not as evil as the internet says it is.
Environmental factors- some can tell it’s about to rain from an achy knee. Others because they’re holed up in their bedroom with the lights off whispering to their significant other to “find the Imitrex and then please go away…quietly.”
Screen time and lighting- even outside the sleep and posture ruining effect of late night laptop work, the harsh lighting is enough to trigger migraines for some.
"Make It Stop" (Evidence-Based Treatments)
First-Line Treatments
Let's talk about what modern medicine has to offer:
Triptans: These medications work to change bloodflow in the brain, limiting the release of inflammatory chemicals like CGRP (more below) and others.
NSAIDs: Sometimes the classics work just fine. These are your basic anti-inflammatory medications like naproxen and ibuprofen that can help if caught early.
Anti-nausea medications: Pretty self explanatory. These come in all kinds of flavors, but I often use old school antipsychotic medications like Compazine (prochlorperazine) or Phenergan (promethazine). The latter may actually improve some elements of the headache pain by itself.
*The “migraine cocktail” so many talk about is typically a combination of ketorolac (Toradol, an NSAID), Compazine, and a decent dose of Benadryl. Yeah, you’ll sleep, but is that the worst thing at this point? In the hospital setting, the beauty is these three medications can all be given intramuscularly if needed.
The Fancier Stuff
For more comprehensive management:
CGRP inhibitors: These directly act on that CGRP character I mentioned above, a chemical that regulates blood vessel activity. You’d take some of these as weekly or monthly injections, while some tablet forms can be taken daily to prevent or during an attack to treat migraines.
Botox: A particularly effective treatment for chronic migraine sufferers. Given the expense of botox, insurance may be a little thorny with this at first.
Nerve blocks: Sometimes providing targeted relief is the best approach. Some of these nerves are on the scalp while others are a bit more…internal… and may require some imaging guidance.
The "Whole-Body Approach"
When you’re suffering, medications can be key. But some lifestyle tweaks can hopefully prevent you from needing them:
Physical therapy focusing on neck and shoulder mechanics. Strain on the neck from any reason can trigger migraines, tension headaches, and others.
Sleep hygiene optimization. This includes both getting enough sleep and maximizing its restorativeness. Review bedtime habits for low hanging fruit to improve upon such as reducing excessive artificial lights, avoiding stressful pre-bedtime tasks (leave the IKEA furniture assembly for the morning), and minimizing alcohol, cannabis, certain antihistamines, benzodiazepine anxiety medications, and other medications that may affect phases of sleep like REM and deep sleep.
Regular exercise programs modified to avoid triggering episodes.
Stress management techniques. Not to obsess over this, but a little exercise can reduce stress, improve sleep quality, reduce inflammation, etc.
Ergonomic modifications to also improve neck and shoulder movement patterns. Adjust seat/desk height, find a pillow that supports you in your preferred sleep position, and be mindful of how you hold your phone- lift it in front of your face, don’t bring your face down to your phone.
Action Steps
Create Your Migraine Management Plan: This should be as comprehensive as planning a day trip with a cohort of toddlers. Include medication schedules, lifestyle modifications, and trigger avoidance strategies. Consider having a go-bag for when working/traveling with migraine abortive medications, nausea medications, and other useful items to reduce any sort of “range anxiety” from home. A good plan is stress-relieving in and of itself.
Build Your Wellness Foundation: Focus on sleep, nutrition, and regular exercise. Think of it as creating a buffer zone between you and potential migraine triggers.
Optimize Your Environment: Make your home and workplace migraine-friendly with proper lighting, ergonomic setups, and stress-reduction zones.
Plan for Success: Have strategies in place for both prevention and acute management. This includes having your medications readily available and knowing your early warning signs.
Insight References
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When I see a new a patient with a lifetime of nonspecific aches and pains I screen for hypermobility. Unfortunately, this is an area where medical knowledge is both lacking and quickly evolving.
Three cases of young individuals who had strokes and stroke like symptoms. Details of how they presented, were diagnosed, and are now living well after this brush with serious illness