Migraine

What is a Migraine?	Migraine Symptoms
Migraine Triggers	Standard Migraine Treatments
Migraine Diet	Alternative Treatments
Migraine and Children	Migraine and Pregnancy

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What Is A Migraine?

Contrary to public perception, migraine is not just a king-size regular headache. In fact, the cause of migraine pain is the opposite of ordinary tension headaches. Migraine is a neurological disorder which its sufferers have all the time, though they only periodically have 'attacks.' Migraine is not 'just pain,' it can increase the risk of aneurysm, permanent or temporary blindness, dental problems, and stroke, as well as being debilitating during an attack.

Frequent migraines may even be indicative of other aggravating factors, such as sleep disruption, chronic dehydration, food or drug reactions, or other conditions. Migraines regularly occuring more than once a week or persisting after a full night's sleep can indicate more serious underlying conditions.

According to the MAGNUM website, 60-70% of migraine sufferers have not been properly diagnosed by their doctors. Male patients are even less likely to be properly diagnosed, and may be less willing to seek treatment. Migraine sufferers are often given misinformation or inappropriate treatment, and are not taught how to minimize their risk of attack or manage other consequences of migraine. Their doctors may not bother to inform them about the treatments they prescribe. Migraineurs may be dismissed, ignored, or told that it's 'all in their head.' Sometimes, they find themselves in the position of needing to educate their doctors.

Migraine occurs when blood vessels in the head contract (which is the cause of tension headache pain) which occurs during the aura phase of the headache. Symptoms may be subtle, but many people with migraine can learn to recognize the sensations they experience before the onset of pain. Then the blood vessels expand, and stay over-dilated for from 4 to 72 hours. (If your pain lasts longer than 72 hours, read below and seek medical treatment.) This expansion and contraction of the blood vessels happens in everyone, but in migraine sufferers this reaction is intense and prolonged.

Some medical professionals think there may be some swelling of the meninges (the thin layer of tissue that covers the brain) involved, since migraine symptoms so closely parallel the symptoms of the disease meningitis, an infectious inflammation of the meninges. It is also suggested that much of the pain may be triggered by abnormal overactivity of the trigeminal nerve which runs between the brain and the face, which then releases chemicals that increase tension and the sensitivity of nerve receptors for pain. Muscle tension and release of other hormones in reaction to the pain may accelerate pain and other symptoms.

Migraineurs may have an insufficiency of the neurotransmitter serotonin, which can make them particularly vulnerable to an attack if it gets too low. Serotonin is also involved in regulating the digestive system, and migraine sufferers may find themselves prone to digestive difficulties. This may be why a preventive therapy that involves adjusting the diet proves useful to so many. Also, a deficiency of monoamine oxidase (an enzyme that breaks down amines) can be seen in some sufferers. This is believed to be the reason why foods containing amines (chocolate, cheese, red wine, MSG, etc.) are among the most common migraine triggers.

Migraine treatments span the range from prescription and dietary treatment to relaxation and biofeedback. It is rare that one of these treatments will completely prevent migraines, and they may not work at all for some people. Certain combinations of treatments have been found to be very successful by individual sufferers, but there really isn't a magic bullet. Treating and preventing migraine effectively often involves lots of trial and error, and learning about how your individual system reacts to different treatments and triggers.

Migraine Symptoms

Up to a day before an attack, a migraine sufferer may experience mood changes, memory problems, alteration of the senses (particularly vision), or speech difficulty. Fatigue, or a 'foggy' feeling may be experienced.

Just before the pain sets in, visual disturbances or flashes of light may be seen. The person may experience numbness in the extremities or mouth. This is called an aura, and is similar to the experience of some epileptics prior to an attack. Migraine with aura may be referred to as 'classic migraine', while migraine without aura may be called 'common migraine.' It is more accurate to refer to them as migraine with or without aura, as aura in migraine is quite common.

As the attack begins, pain may start on one or both sides of the head, and may move between sides or spread. Neck pain is not uncommon, and the sufferer may find that their face and jaw clenches tight during this phase. Ocular side effects like extreme pain or sensitivity of the eyes, or a feeling of intense internal pressure may occur. The pain can be accompanied by extreme sensitivity to light or sound, and may also experience disturbance in the sense of taste, smell, or touch. Nausea may accompany this phase, and may be worsened by what the sufferer experiences as unpleasant sensations from any of the five senses. During the attack, mood changes, confusion, and difficulty concentrating may be very pronounced. If the sufferer is in a vehicle, motion sickness may be experienced.

After the pain stops, the sufferer may still feel nauseated or fatigued.

Cautions: Some causes of headache, or states of migraine can be quite dangerous and serious. If you experience an attack with unusual symptoms, particularly any of the following, seek medical attention.

Glaucoma - Intense throbbing pain in the eye itself accompanied by blurred vision may be symptomatic of acute narrow angle glaucoma caused by an increase of fluid pressure in the eye. Seek emergency medical treatment immediately, or you may experience irreversible damage to your vision within 12-48 hours.

Infection or Bleeding - If you have a stiff neck in combination with a migraine (not just painful to move, but actually less mobile), this could be a sign of infection or internal bleeding and you should see a doctor.

Status Migrainousus and Stroke - If you have a migraine where the headache phase lasts for more than 72 hours (with no more than four hour pain free intervals, not counting sleep), seek medical attention immediately. You are in a state called status migrainousus which could be caused by drug toxicity (rebound), hormone changes, or depression. You are at a greatly increased risk for stroke, and need preventive treatment.

You may particularly require fluid and electrolyte replacement and drug detoxification, as well as care for nausea and ongoing pain. You may need to stay in the hospital for a few days. This is a serious condition, even if not all doctors are familiar with it.

You do not need to have taken what would typically be considered an overdose of a drug for it to initiate this severe rebound condition, you just need to take it a little more often than your sensitive system can handle. If you find yourself having attacks the day after you use any pain treatment, or that they are increasing in frequency, take action to change the method of treatment or prevention you use before it triggers a dangerous reaction.

Migrainous stroke causes around a quarter of all strokes for people under the age of 45, killing more people than handguns. While individual risk of stroke is low, migraineurs are at an elevated risk, and sufferers who experience auras are at a slightly higher risk. Women with migraine who are taking oral contraceptives are urged not to smoke, as they are then at an even greater risk for stroke. (Smoking in combination with taking oral contraceptives dramatically increases the risk for stroke anyway, particularly if you are over 30 years of age.)

Migraine Triggers

While there are many migraine triggers, even avoiding all of them (if that were possible) might not completely eliminate your migraines. It's important not to buy into the myth that migraine is just a symptom of poor stress management, or some other personal failing. Even the best medical treatment can usually only reduce the number of incidents, and help manage the pain during an attack.

Depression: If you suffer from depression, you may have an increased likelihood of low serotonin levels, which can trigger migraine. If you find that it's persistent, you may consider taking some form of long term therapy which reduces your depression. There are both natural and medical means of doing this, but not all depression treatments mix well with all pain treatments, and depression medications should not be mixed with each other. See the standard treatments section to read about potential drug interactions in detail.

Diet: Migraine sufferers should not, as a general rule, embark on a diet regime that involves starving themselves. Being hungry can trigger a migraine in many people, and they can experience a hypoglycemic-like reaction even though blood sugar tests are normal. Try to eat 5-6 small meals a day, or at least have a healthy snack between regular meals, and do not skip meals. Go for snacks that are high in lean protein or complex carbohydrates, and low in sugar. Refined sugar is not your friend if you are prone to migraines, so try to minimize your intake and avoid having it on an empty stomach. Sugar substitutes can be even worse, with aspartame a common and fast-acting migraine trigger.

Food Intolerance: While figuring out your food triggers can be a tedious business, you may be rewarded with a sharp decrease in migraine attacks. This is an under-discussed method of preventive therapy which can be combined with any form of treatment, and doctors don't usually mention it to you except in the fine print. It would be hard to emphasize strongly enough how much relief can be had from avoiding the foods that may set you off. Some people find that the great majority of their headaches can be entirely prevented by avoiding certain key items and managing their diets differently.

Hormone Changes: Women often experience greater incidence of migraine around menstruation, and a decrease in attacks (sometimes a stop) after menopause. A tie-in with a hormonal cycle does not occur in everyone, though it is often seen in female migraineurs.

Sleep Disorders: Poor sleep quality can greatly increase the incidence of attack. Whether you cannot sleep, or don't sleep very deeply (if you don't feel rested after a full night's sleep, you may not be sleeping deeply,) this could be worsening your condition. While migraine is under-diagnosed in itself, sleep disorders are often just as poorly diagnosed and treated. If you have frequent insomnia, or often find yourself feeling tired during the day, investigate methods for improving your sleep.

The book 'No More Sleepless Nights,' by Hauri and Linde is an excellent place to start. If you have a sleep problem that resists your best efforts to treat it, do see your doctor.

Many prescription sleeping pills will make you drowsy or affect your clarity the next day. Ambien and Sonata are recently developed medications that may be much milder. They usually feel like a normal night's rest, and are out of your body in about four to six hours, though they may be more expensive than other sleeping pills. When taken as prescribed, their abuse potential is low, and they are much less likely to create addiction than the benzodiazepenes. Common varieties of sleeping pills may actually cause headaches as a side effect, so read your labels.

If your doctor prescribes an antidepressant to reduce your incidence of migraine, you might ask him about Sinequan. Taken daily in the evenings, it can do double duty to help you rest.

As a natural treatment, supplemental 5-HTP taken in the evening may help you. It can help regulate your serotonin levels, promoting a normal sleep cycle over time. 5-HTP is a chemical step between the amino acid tryptophan and the neurotransmitter serotonin. If you are taking an antidepressant, you should not take 5-HTP.

Fibromyalgia sufferers, who sometimes have a high incidence of migraine, are particularly prone to poor sleep and can benefit in other ways from treating this aspect of their disorder.

Stress: Of course stress can trigger a migraine, but not invariably. While stress management is an important part of your long term preventive care, this does not mean that your condition is 'all in your head.' Everyone has stress in their lives, but all people under stress do not get migraines, whereas a migraine sufferer may get a painful attack in the middle of a lovely vacation. Many migraine sufferers point to their attacks as a major cause of stress in their lives!

Because you are more sensitive to outside triggers, it can help to learn relaxation or meditation techniques, and to try to relax chronically tense muscles. While it's hard to concentrate during an attack, try to keep bringing your focus back to keeping your jaw and face relaxed, as tension in these areas can greatly add to the pain of the headache phase. Also, the exercise can help take your mind (briefly) off the pain. Biofeedback is suggested as a method of learning to control these responses to an even greater degree. You can still be triggered, but you may be better able to shut down the reaction or to minimize the pain.

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Standard Migraine Treatments

Migraine sufferers are often not able to get any relief from ordinary pain medication. They may be prone to increase the dosages of over the counter pain medication, or to mix medication in order to get some relief. Sometimes only a prescription drug can be of any help. Just remember that whether you use prescription medication or over the counter medication, all medications do not mix well together. Always talk to your doctor if you are unsure about mixing any treatment, or about mixing your migraine treatment with medication you may be taking for any other condition.

While you are in the throes of a debilitating attack, you can feel like you would try anything to make it stop, but please don't. Plan ahead, be aware of any possible interactions with other medications you might need, and keep a small supply of a safe treatment with you when you can. Keep track of your precursor symptoms, and take action to minimize your pain before it gets desperately bad. Be sure to thoroughly investigate your self-care and prevention options to be sure that you have as few attacks as possible.

Never take any medication in higher doses, or more often, than recommended by your doctor. Always talk to your doctor about any allergic reactions you may have had to medication in the past, or any allergy to food ingredients or colorings. If you are a diabetic, be aware that certain preparations of these medications, particularly oral suspensions, may contain sugar.

Pain

Many pain medications lose their effectiveness, or even cause rebound migraines, when used too often. If you find yourself using pain medication on several consecutive days, more often than 2-3 times per week, or if you find that the frequency of your attacks has increased, speak to your doctor. You may need to try another medication or preventive therapy.

Many of these medications pose the risk of stomach, kidney, or liver damage when used often, or for long periods of time. If you take any of them regularly it's a good long term health strategy to avoid excessive drinking and get plenty of plain water every day. Your liver can regenerate given time and minimal 'poisoning', and kidneys are usually just fine as long as they get lots of water, so there's no need to let them be a casualty of your migraine management. Using non-steroidal anti-inflammatories (NSAIDs), which includes most over the counter pain medication, for long periods of time greatly increases your risk of stomach or digestive tract bleeding. Speak to your doctor about minimizing the possibility of any of these side effects.

While in certain cases it is more dangerous than others, make it a general rule not to combine pain treatments without specific instructions from your doctor or pharmacist. This may strongly increase the risk of organ damage. If you take one medication, wait out the full time specified on the package to wait between doses before taking a different medication.

Acetaminophen (Tylenol) - This non-narcotic pain medication is an ingredient in several powerful pain relievers where it may be mixed with a barbiturate or a narcotic. Do not mix acetaminophen, or any drugs containing acetaminophen, with over the counter pain relievers. Ask your doctor about possible interactions with oral contraceptives, blood-thinners, or high cholesterol treatment. Do not drink excessive amounts of alcohol with acetaminophen, as it can increase your risk of liver damage. Do not mix with NSAIDs.
Aspirin (or any salicylate, such as salicylamide, or salicylic acid) can cause kidney or liver damage when taken in high doses, and over long periods of time, in combination with acetaminophen. When taken in the recommended doses for a short time, it has not been seen to produce this effect, but caution is still advised. Do not mix aspirin with other pain relievers. If you are taking aspirin as a preventive heart disease regimen, you should still not take it with other pain medications; speak to your doctor about alternate or non-interacting treatment.
Barbiturates - Fioricet and Fiorinal are barbiturate combination pain relievers commonly prescribed for migraine. Barbiturates may make oral contraceptives less effective, and should not be mixed with alcohol, most antidepressants, narcotic pain medication, or other medications that have a depressive effect on the central nervous system.
Caffeine - Whether it's taken in combination with some other medication, in chocolate, tea, or a cup of coffee, some people find that caffeine can help relieve a migraine. But caffeine is often only effective at aborting a migraine if taken in the aura phase, before the pain actually starts. If taken at the peak of a migraine it may worsen the pain. Also, in some people caffeine has mild physical withdrawal symptoms which can include constipation, irritability and... headache or migraine. Taking caffeine to relieve a migraine one day could give you one the next day, depending on how much you normally consume. Some people find that the virtual elimination of caffeine from all sources can reduce their incidence of attack.
Ergotamine Derivatives - Ergotamine based migraine treatments such as DHE 45 injections, Cafergot, Ergostat, or Migranal nasal spray, may be used for treatment of attacks. They should not be taken with each other, with the migraine preventive treatment Sansert, the senility drug Hydergine, or any other ergot alkaloid for any reason. Do not take these medications within 24 hours of any triptan medication, and avoid taking it with cold or decongestant remedies that contain ephedrine compounds or phenylpropanolamine. Do not take them with any form of nicotine (cigarette smoke, patches, or gum), or with the migraine preventive treatment Inderal (propranolol). Not all antibiotics are safe to mix with ergotamine treatment. Tell your doctor, dentist, or nurse that you take an ergotamine, especially if you are being prescribed a post-surgical regime of antibiotics to prevent infection and are not dealing with your regular doctor. These medications must be used only during an attack, and no more often than suggested by your doctor.
Narcotic pain medication - These include Codeine, Demerol (meperidine), Buprenex (buprenorphine), Darvon (propoxyphene), Dilaudid (hydromorphone), MS Contin or Kadian (morphine), nalbuphine, OxyContin (oxycodone), Percocet (oxycodone, acetaminophen), Stadol (butorphanol), Talwin compound (pentazocine), Vicodin (hydrocodone, acetaminophen), and Vicoprofen (hydrocodone, ibuprofen). There are many brand names for most of these, so look for the generic ingredients on the label. These medications should not be mixed with barbiturates, some antidepressants, or each other. Do not take these with cough medications containing alcohol or a narcotic (codeine or hydrocodone), or Tylenol with codeine. Do not mix them with over the counter pain medication unless your doctor specifically tells you it is safe to do so.
Non-Steroidal Anti-Inflammatories (NSAIDs) - Such as Motrin or Advil (Ibuprofen), or Naprosyn (naproxen). These medications can relieve pain without the strong central nervous system effects of narcotics and barbiturates. Ibuprofen, a common over the counter pain reliever, can be found as a generic ingredient in combination with some narcotic pain medications. These drugs can be hard on the liver and kidneys, and can increase the risk of ulcers or internal bleeding. They should never be taken in combination with aspirin, acetaminophen, or any other anti-inflammatory. You should avoid alcohol while taking it. Be sure to speak with your doctor about taking these drugs if you are taking blood pressure medication or a blood thinner.
Triptans - These include Amerge (naratriptan), Imitrex (sumatriptan), Maxalt (rizatriptan), and Zomig (zolmitriptan). These medications act to stop migraine symptoms in their tracks. They are most effective if they are taken as soon as the headache phase begins. Some people find that even if this medication does not always stop the attack, it often reduces the pain, nausea, and light/noise sensitivity to manageable levels. These medications should not be taken in combination with any drug or supplement that affects serotonin levels. This sort of interaction could be fatal. These medications have no effect on other types of pain, and it may be safe to use another pain reliever afterwards if you are sure that the treatment has not worked, but ask your doctor about this. You may find that their effectiveness can vary from attack to attack, but that they often increase the pain relief effect of other treatments. If you do not respond to triptan treatment over time, or have an allergic reaction to it, this does not mean that you don't have migraines. No treatment works for everyone, even when it works for most people.

Prevention

While these medications are not effective pain treatments for migraine, your doctor may suggest one of them to try to reduce the number of attacks you have. They may take several weeks to work, so unless you have a bad reaction to the treatment itself, take these exactly as directed and give them some time.

Anti-Seizure Medication - Depakote (Divalproex, also called Valproic Acid) has been found to prevent the occurrence of migraine for some individuals when taken in its extended release form. Consult your doctor about possible drug interactions if you are taking any of the following: tricyclic antidepressants, aspirin, barbiturates, benzodiazepines (Valium, Xanax, etc.), cyclosporine (Neoral, Sandimmune), oral contraceptives, other anti-seizure drugs, sleep aids, or tranquilizers. This treatment poses a severe risk of dangerous liver or pancreatic damage, and individuals taking it should be carefully monitored by their physician. Do not drink any alcohol while taking this medication. Step off your treatment slowly, under the direction of a doctor, if it does not seem to work for you. No matter what you are taking it for, abruptly stopping anti-seizure medications increases the risk of seizures.
Beta-blockers - Inderal (propranolol), Lopressor (metoprolol), or Tenormin (atenolol), medications for the control of high blood pressure, have been shown to be effective as long term preventive therapy for some migraineurs. This medication may interfere with blood sugar levels, and should be used cautiously by patients with a history of heart, kidney, liver, or lung conditions such as asthma. Individuals with certain heart or circulatory conditions should not use this medication at all. This medication should not be combined with alcohol, calcium blockers, ergotamine derivatives, tranquilizers or barbiturates, epinephrine, oral diabetes medications, thyroid medications, or NSAIDs such as ibuprofen. Alert your doctor, dentist, or anesthesiologist if you are planning on having any kind of surgery, as these medications may interact with surgical drugs. If you already take these medications for a heart condition, the cautions are exactly the same. Step off your treatment slowly, under the direction of a doctor, if it does not seem to work for you. No matter what you are taking it for, abruptly stopping this medication increases the risk of heart complications. Insomnia may result from this treatment, which could worsen your migraines.
Botox injections - A cosmetic surgeon administering botox injections to diminish forehead lines found that some patients who had migraines reported that their migraines went away or decreased after treatment. Botox acts to prevent wrinkles (and apparently some migraines) by paralyzing the muscles of the forehead, preventing them from being tightened up in the course of daily activity. This kind of treatment is temporary (6-8 months), expensive ($500-750), and not covered by many health plans. It is part of orthodox (cosmetic) medical treatment, provided only by a physician.
Calcium Channel Blockers - Calan (verapamil) and flunarizine (not available commercially in the US) have been found to be effective migraine and cluster headache preventive treatments. This medication is commonly prescribed as a treatment for high blood pressure and irregular heartbeat. Check with your doctor or pharmacist about whether or not the brand you've been prescribed should be taken with food. This medication should either not be mixed, or used with extreme caution with any of the following: ACE inhibitors, alcohol, aspirin, other high-blood pressure medication, beta-blockers, other types of heart medication, certain diabetes medication, tricyclic antidepressants, diuretics, Lithium, barbiturates, certain ulcer medications, antispasmodics/anti-seizure medication, or nitrates. Supplemental calcium may decrease the effectiveness of these medications. This treatment may take several weeks to work. You are encouraged to gradually decrease your dose if this medication does not work for you. Insomnia may result from this treatment, which could worsen your migraines.
Ergotamine Derivatives - The ergotamine based medication Sansert (methysergide) can be prescribed as a preventive therapy. It must be used sporadically and its use monitored carefully as it can trigger unpredictable but dangerous side effects. This medication will not stop an attack in progress, do not take it more often than prescribed by your doctor. Sansert is not usually prescribed for more than six months at a time, follow your doctor's advice about stepping off your treatment gradually or you may experience rebound migraines. This medication may not be suitable for people with circulatory, kidney, liver, or lung disease. All cautions about other ergotamine treatments apply, Sansert may not be used in combination with any other ergotamine taken for any reason.
Lithium - This antidepressant has around two decades worth of use as an effective preventive medicine for cluster headache. Lithium may lead to fluid loss through frequent urination or sweating, so 10-12 glasses of water per day are recommended to avoid dehydration. Avoid caffeine and diuretics, which may increase fluid loss. Lithium should not generally be mixed with other antidepressants, and only cautiously with calcium channel blockers. This drug may also interact with amphetamines, anti-inflammatories, antiseizure agents, certain antibiotics, certain antifungals, and iodine. If you have a brain or nerve disease, diabetes, heart or kidney trouble, seizure or tremor disorders, thyroid disorders, or are generally frail, you may need to take special precautions while using this medication.
Tricyclic Antidepressants - These include Elavil (amitriptyline), Asendin (amoxapine), Anafranil (clomipramine), Pertofrane or Norpramin (desipramine), Sinequan (doxepin), Tofranil (imipramine), Aventyl or Pamelor (nortriptyline), Vivactil (protriptyline), and Surmontil (trimipramine). These medications may dangerously increase central nervous system suppressant effects when taken in combination with barbiturates or narcotics. They should not be mixed with alcohol, and you should not drink excessively while they are part of your treatment. These may affect your mood in unexpected ways if you are not being treated for depression. Some, like Elavil, may interfere with your sleep patterns, whereas Sinequan can help you get a good night's rest. They are not all the same. If your doctor thinks these may help you, discuss possible complications and interactions with other health conditions. If you plan to quit taking them, step off your dosage gradually, or you may experience unpleasant side effects including rebound headaches. Also be aware that weight gain is a more likely problem with tricyclic antidepressants than with many other treatments. If you already have a weight problem or are prone to rapid weight fluctuation, you may want to monitor your weight more carefully on these medications.

Other Medications

Some medication you might take for other conditions may not mix well with your migraine treatment. Be sure to read the list of drug interactions on your package inserts, and ask your doctor or pharmacist to check the safety of combining multiple prescription medications you may need. As always, over the counter medications or supplements are not beyond suspicion:

Alcohol - It can be very dangerous to mix alcohol with certain prescription treatments for migraine. If your pain medication contains a barbiturate or narcotic, you could risk dangerous slowing of the nervous system, possibly coma or death depending on the amounts involved. If you take a tricyclic antidepressant as a preventive medication, you should also not drink alcohol. Your doctor or pharmacist can advise you if it is ever safe to drink during your treatment, but be aware that alcohol is a common migraine trigger (especially red wine.) Alcohol is one of the single most dangerous drugs to mix with other drugs or medications that act on the nervous system, and is implicated in many cases of fatal overdose due to drug interactions. Alcohol is especially likely to increase the likelihood of risk taking and aggressive behavior in combination with other medications. Many medications pose a risk of liver damage if used over long periods of time, and excessive alcohol use can greatly increase this risk. While moderate consumption of alcohol has been seen to have health benefits, be aware of possible interactions, and avoid drinking excessively.
Antibiotics - If you take an ergotamine derivative for your migraine and need to take antibiotics for another condition, be aware that all antibiotics are not safe to mix with ergotamines. Advise the doctor prescribing your antibiotics that you are taking an ergotamine, especially if these are prescribed for post-surgical treatment or dental surgery, as you may not be dealing with your regular physician. Antibiotics may also increase sun sensitivity, so avoid unprotected sun exposure, especially if you are also taking another medication which makes you sensitive to sunlight.
Benzodiazepines (a class of antidepressants, anti-panic agents, and muscle relaxants) - These include Ativan (lorazepam), Valium (diazepam), Halcion (triazolam), Restoril (temazepam), Librium(chlordiazepoxide), Xanax (alprazolam), Tranxene-SD (clorazepate), Paxipam (halazepam), ProSom (estazolam), Klonopin (clonazepam), and others. They should not generally be taken during treatment with any other antidepressant medication and should not be mixed with narcotics or barbiturates.
Cold, Decongestant, or Sinus medication - Do not take cold medication containing either alcohol or a narcotic, such as codeine or hydrocodone, with either barbiturate or narcotic pain medication. Do not take cold medicine with a pain reliever in combination with any other type of pain reliever within the amount of time the package directs you to wait between doses. Cold or sinus medication that contains an ephedrine based component (such as the pseudoephedrine found in Afrin or Sudafed) or phenylpropanolamine should not be mixed with ergotamine derivatives.
Ephedra - Plant based ephedrines can be found in herbal stimulants, herbal or nutritional sports drinks and powders, and herbal diet pills available over the counter. Do not mix these supplements with ergotamine derivatives. If you are unsure, don't risk it. Your doctor or pharmacist may not be familiar with these ingredients; if they are at a loss to advise you, it doesn't mean that it's safe to take.
Nicotine - Should not be mixed in any form (cigarettes, inhalers, patches, secondhand smoke) with ergotamine derivatives. This drug combination is very dangerous, and could cause serious heart complications.
Oral contraceptives - Oral contraceptives can increase the incidence of attacks, as fluctuating estrogen levels can be a trigger for migraine. Taking oral contraceptives in combination with smoking can increase the risk of stroke, for which migraine sufferers are already at a slightly elevated risk. Some migraine treatments such as some barbiturates, and certain pain medications can decrease the effectiveness of some oral contraceptives. When taken in combination with certain antidepressants, over-sedation may result.
Selective serotonin reuptake inhibitors (SSRIs) like Celexa (citalopram), Paxil (paroxetine), Prozac (fluoxetine), Luvox (fluvoxamine), or Zoloft (sertraline) must not be mixed with any of the triptans (Amerge, Imitrex, Maxalt, Zomig) as described above. If you are taking one of these medications for depression, be aware that both classes of drug affect the availability of serotonin in your body, and could increase it to dangerous levels. This drug combination could be fatal.
Sleeping pills - Whether you use an over the counter or prescription medication for insomnia or another sleep disorder, you should know that some of them will actually increase the likelihood of migraine attacks (while you should be aware of the possibility, you may not react the same to all these medications). This is not usually the case with the newer prescription medications Ambien (zolpidem) and Sonata (zaleplon), though they also may result in an attack in some individuals. Be aware that these medications should not be mixed with either barbiturate or narcotic pain medications that you may take for a migraine. Do not take a sleeping pill within several hours of barbiturates or narcotics, and check with your doctor or pharmacist to be sure to leave enough time between them. Do not combine any sleeping pill with alcohol, this could result in dangerous or fatal overdose.
Street drugs - Do not combine street drugs of any kind with prescription treatments for migraine as this could result in a dangerous or fatal overdose. The most common and dangerous overdoses come from mixing different drugs or medications. From accelerating the slow down of the central nervous system to elevating or depleting serotonin levels, the possible interactions are as numerous as they are dangerous. Especially avoid the following: Do not take LSD in combination with ergotamine based substances, or triptan treatment, as it is also an ergot alkaloid derivative. Do not take two stimulants together (drugs that cause you to feel 'wired' or more energetic), or take two central nervous system depressants together (any drugs that leave you feeling drowsy or more relaxed). Do not take any hallucinogen in combination with ergotamines or any drug affecting your serotonin levels. Never combine any street drug with alcohol, this may strongly increase toxicity and the likelihood of dangerous risk-taking behavior. Many drugs are far more dangerous in combination than they are alone, and these don't have an ingredient list and a warning label.
Tryptophan or 5-HTP supplements (taken alone or in a mixed amino acid supplement) - Do not mix these with triptan (Amerge, Imitrex, Maxalt, Zomig) treatment, as this supplement is a precursor of serotonin and could push your serotonin levels dangerously high. This supplement should not be used in combination with any medication that affects your serotonin levels, though it is otherwise very safe.

Migraine Diet

As Hippocrates said, "Let food be your medicine and medicine be your food." These preventive dietary guidelines have assisted many migraine sufferers in sharply reducing the frequency of attacks. While guidelines about specific foods may vary widely among individuals, we have tried to include the ones that tend to apply to the broadest group of sufferers.

Dehydration: Not getting enough water can make your headaches worse even if it isn't a cause. Some people have reported that a small glass of water every 15 minutes or so can ease a migraine reaction in process, and that getting more water daily can reduce frequency. Be especially careful to get enough water when exercising, you may avoid a headache later in the day. Remember that by the time you're thirsty, your body is already mildly dehydrated.

Low Blood Sugar: Migraine sufferers often have a condition that manifests the symptoms of hypoglycemia (weakness, dizziness, shakiness, unusual hunger, or mood swings), though their blood sugar tests normal. Some specialized tests have indicated that the blood sugar spikes experienced may last only a few minutes, and so be missed by an ordinary test, but the result could be a painful migraine. Try eating every 3-4 hours without fail. Having 5-6 small meals per day can be more effective than three large ones if you have these symptoms.

While refined sugars may bring these symptoms on rapidly, unrefined sugars and whole fruit should not cause this effect in moderate quantities. Refined sugars (including most fruit juice) seem to be missing something that slows your body's absorption of sugar. Some people report that taking chromium picolinate can moderate this effect. Chromium regulates the blood supply of sugar and is present in most naturally sugary foods, but is stripped out in processing. (Note: If you are diabetic, chromium may make your body more responsive to insulin.)

Stevia (a sweet tasting herbal extract) is available in powder and liquid forms at health food stores, and some people find that it is a good substitute for sugar. It has not been reported to trigger migraine, and does not affect blood sugar. Stevia is safe for both hypoglycemics and diabetics. Natural honey and maple syrup in moderate quantities may be much milder than refined sugar, and often require smaller amounts to achieve a particular level of sweetness. Avoid artificial maple syrups, or honey with added sugar.

Make sure your diet contains sufficient protein and the right kind of fat. Protein releases energy into your body slowly, and may slow the release of sugars from high carbohydrate foods. Women in general, and vegetarians in particular, often eat diets too low in protein and useful fats. These foods help to maintain your blood sugar levels at a steady rate, instead of quickly increasing them at an unstable rate like high carbohydrate foods. A diet high in lean protein also helps to maintain your serotonin levels. Low serotonin levels can lead to a craving for the rush of high carbohydrate foods. Try to include eggs, olive oil, cold-water fish (salmon, cod, etc.), and flax (Flaxseed meal can replace oil in some recipes, the unprocessed oil can be used in cold dishes. Flaxseed oil should not be used in cooking.) in your diet on a regular basis.

Food Triggers: There is a very long list of potential food triggers, and it can be difficult to eliminate the main culprits from the diet. But people who have successfully brought their migraines under control without medication recommend this route most often.

Triggers may include:

Artificial sweeteners - Especially aspartame
Refined sugar of any type
Caffeine - Some medical professionals recommend caffeine to stop a headache, but this usually only works well at the onset of a headache. It may make the pain worse if taken later in an attack, and some sufferers report that caffeine withdrawal then brings them on again. Migraine sufferers should probably limit their use of caffeine.
Chocolate - Chocolate is a common migraine trigger, having both caffeine and refined sugar, but more importantly a potent amine compound which has been shown to be able of triggering a migraine on its own. Occasional use may not set you off, but daily or frequent use is not recommended. If you find yourself getting migraines multiple times a week, try to stay away from chocolate.
Nuts - Especially almonds, but any kind may be a trigger
Cheese - Especially aged cheese, these products contain the second strongest amine found to trigger migraine. Cottage cheese is not usually a problem.
Alcohol - Red wine is an especially common trigger. If you find that you have a gluten sensitivity, beer may be a trigger as well.
Wheat or Gluten - May be hidden on food labels as 'modified food starch', or 'vegetable protein'. If gluten is the problem, most grains are off-limits. Not only wheat, but kamut, spelt, semolina, durum, oats, barley, and rye. Tabouli is right out. Rice, quinoa, amaranth, millet, buckwheat (not related to wheat), and bean flours should be safe. A cookbook series called "The Gluten-Free Gourmet" can help if you get stumped on what to use in place of wheat-based bread and pasta in your diet. If you do have a problem with wheat or gluten, the reaction may be cumulative and not manifest in immediate headaches. (Gluten sensitivity may, but does not always, indicate celiac disease, a hereditary inability to tolerate gluten. This is most common in individuals of Northern European descent.)
Dairy intolerance - A sensitivity to dairy may lead to a highly acidic state in your body, making you more susceptible to other migraine triggers. Leaving dairy out of your diet if you try an elimination regime can sometimes help you feel better more quickly even if dairy does not trigger migraines.
Nitrates (Commonly found in processed meat, but also a range of products)
Pineapple
Pork
Shrimp
Pickled Herring
Avocados
Corn
Beans
Peas
Lentils
MSG

An elimination diet, removing all suspect foods, should be tried. Often people find at least one or two foods that will trigger a headache within 30 minutes to a couple hours. Sometimes there are more culprits, but eliminating them all is the only way to be sure that these food triggers really are affecting you. If your migraines decrease substantially in frequency with these foods gone, you can begin adding them one at a time every four to seven days after you've been feeling good for a few weeks. If your migraines do not decrease with an elimination diet, at least you'll have eliminated another possible cause.

The difficulty with an elimination diet is that sometimes a food trigger may act in combination with other things, and not cause a migraine every time you eat it. Also, avoiding a food for a long time may decrease your sensitivity to it. With gluten or dairy sensitivity in particular, the reaction may be cumulative, where constant overexposure will build up to make you highly sensitive to any trigger. Some foods (gluten, dairy, refined sugar) may act to decrease your ability to eliminate problem foods from the body, and taking them out of your diet can decrease your sensitivity to other triggers, making you feel better even if you do not always have a direct reaction to them. For these reasons, an elimination diet can be unsuccessful if you remove only one suspect item at a time from your diet.

While trying an elimination diet, be sure to drink plenty of water and get several serving of fruits and vegetables every day. It may work better for you to minimize dairy, citrus, vinegar, and processed foods as much as you can so your body can better clear out any accumulated toxins.

Some people have reported that fresh foods are much better for migraine sufferers than preserved or aged foods. For example, red wine and cheese are common triggers, but fresh milk and grapes are not. Compounds called amines are suspected; they are naturally present in chocolate, and form in foods like cheese with the aging process as a byproduct of bacterial activity. Amines have been shown to be able to trigger migraines in clinical studies.

Alternative Treatments

Acupuncture: Some migraine sufferers report great success with acupuncture as a long-term migraine reduction therapy. After a few weeks of 1-2 sessions a week, you may find that the frequency of attacks goes down significantly, and that you only need an occasional maintenance visit to retain the benefits. More insurance plans are covering this form of treatment, so call to ask.

Acupuncture is a branch of Chinese medicine that uses slim needles placed at specific points on the body in order to realign your body's natural energy flow. If you are especially sensitive, an experienced acupuncturist should be able to relax you by various means that allow treatment to proceed normally. Acupuncture is not usually more than mildly uncomfortable for a few moments, and does not involve any medications that may interact with each other. Some practitioners may suggest herbal remedies which may help; no significant concerns have been voiced about these treatments, they are generally very safe. Be sure to go to an accredited practitioner who sterilizes their needles.

Biofeedback: Some people suggest that biofeedback training can teach people to reverse the physiological responses that trigger a headache, and can stop it in its tracks. They indicate that migraine attacks often begin with a biological fear response that people can learn to be aware of and control with a few weeks of biofeedback training. Migraine sufferers sometimes have a subconscious physical fear response triggered by chemicals in food, some are especially sensitive to stress that they may not consciously be aware of.

Supplements: Certain supplements are recommended as part of a natural preventive therapy for migraine. Please remember that while supplements are typically very safe, not all of them should be combined with prescription therapies or with certain medical conditions. Certain supplements can cause adverse effects if taken in large quantities. No food supplement should be taken as though it were candy. (Though considering the prevalence of sugar sensitivity among migraineurs, sufferers probably shouldn't be eating candy like candy.) Look for hypoallergenic supplements that are labeled as being free of common allergens. If you try an elimination diet, contamination from supplements can interfere with the accuracy of your observations. These statements have not all been approved by the FDA, as per their guidelines on food supplements.

5-HTP - This supplement improves your body's ability to manufacture serotonin, which regulates sleep and digestive cycles. Low levels of serotonin, as well as digestive and sleep difficulties, have been linked to migraine attack. Do not take this supplement in combination with the triptans (Amerge, Imitrex, Maxalt, Zomig) or with any SSRI antidepressant (Paxil, Prozac, Zoloft). 5-HTP may make some individuals drowsy an hour or so after taking it, try having it in the evening with dinner or a snack. A dose of 150 mg in the evenings may prove most effective in the long run.
B-Vitamin Complex - The B3 vitamin (niacin) is often recommended for migraineurs. This vitamin is not recommended for individuals who suffer from liver problems or high blood pressure. While taking high doses of one of the B vitamins may be useful for a short time, a complete B-complex supplement should be the long term treatment of choice. Taking large doses of one of the B vitamins can disrupt the activity of the others.
EFA (Essential Fatty Acids) Complex, Flaxseed, or Primrose Oil - Natural anti-inflammatory, aids with fat metabolism. Found in oily fish, flax seed oil, raw nuts and legumes, seeds, and unsaturated vegetable oils as well. Heat can destroy these compounds, you should not cook with flaxseed oil, though you can substitute flaxseed meal for oil in some recipes.
Magnesium - Magnesium is suggested to regulate muscle tone and the transmission of nerve impulses. Taking large doses of magnesium by itself for long periods of time is not recommended. For best results, take it with calcium, as these minerals work together and need to be in balance. A ratio of no more than two parts calcium to one part magnesium is good, but some nutritionists recommend identical doses of these minerals. Look for calcium and magnesium in a chelate form.

Migraine and Children

Though migraine sufferers tend to experience their first migraine at puberty at the earliest, younger children may have them as well. Severe recurring headaches in small children should not be ignored or discounted. Sudden onset or other unusual symptoms such as stiffness of the neck may indicate infection or bleeding and should be treated immediately.

Often, the prescription treatments for migraine given to adults can be too strong for children, putting their developing bodies at greater risk of side effects and organ damage. Be sure that they are prescribed reduced doses for any medication your doctor thinks may be helpful.

At a young age, dietary changes and biofeedback therapy may be most useful. Children's habits are often more flexible, and they can be encouraged to make a game of it while learning coping mechanisms that will help them all their lives.

Migraine and Pregnancy

While there is no reason for a migraine to affect the health of a child, many prescription treatments should not be used during pregnancy, or if you are planning to become pregnant. If you intend to have a child, speak to your healthcare professional about alternative methods of prevention and pain control. You may need to investigate different methods on your own, as your doctor may not be familiar with all the available therapies.

If you find that you have an extensive list of food triggers, or that your food triggers are very common items in a normal diet, please consult a nutritionist. During pregnancy, you will need extra protein (particularly in the first trimester) and larger amounts of certain vitamins and minerals, which may be harder to get on a restricted diet. While B vitamin supplementation is a common recommendation for pregnant women, migraineurs may use these nutrients up faster than other individuals, so ask if you should take larger doses.