This past fall, the FDA approved the use of botulinum-toxin type A—a.k.a. Botox—for chronic migraines after testing it in 1,400 patients in North America and Europe. “The data is pretty clear,” says Amy Stone of the Neurology Center in Fairfax. “Botox gets better and better over time. After six months, some patients who had 20 headache days a month are down to eight or nine.”
Much in the way it smooths wrinkles temporarily, Botox freezes muscles in the head and interrupts pain messages sent to the brain, scientists believe. Botox is injected into a patient’s forehead, temples, neck, and shoulders. When it works, treatment is repeated every three months. Some patients get a pain where the injection is inserted or a residual headache, which usually goes away after a day.
Botox has been used unofficially for about ten years to treat some kinds of migraines, “but now the use is based on better scientific studies,” Ailani says. “It is no longer experimental.”
And the wrinkles in your forehead? Botox injections for migraines are higher on the forehead than they are for cosmetic purposes, Stone says, so they probably won’t affect your appearance.
Trained as an anesthesiologist, Bernard Filner treats migraine patients at his Pain Center in Rockville with a non-heating, low-power laser that looks like a space-age flashlight. Using his knowledge of disarming trigger points in the body as an anesthesiologist does, Dr. Filner places the laser over a trigger point for one to three minutes to make the pain go away. Patients may need multiple treatments. Some chiropractors use this method as well, though it’s not common practice among neurologists.
“It is a low-to-no-risk treatment,” says the Einstein College of Medicine’s Richard Lipton. “My take on cold laser is I’d love to see some good studies on how it works. In the meantime, why not?”
THE DO'S-AND-DON'TS DIET
David Buchholz, a neurologist at Johns Hopkins, takes a three-pronged approach to migraines. First, he tells patients to get off any over-the-counter meds such as Excedrin, because it has caffeine, and any decongestants. “They may help in the short run by constricting blood vessels,” Dr. Buchholz says, but they can cause rebound headaches.
Step two: “Do what you can to reduce triggers,” he says. You can’t do much about the weather or hormonal cycles, but you can cut out trigger foods. Caffeine is the number-one culprit, according to Buchholz, followed by chocolate, red wine, MSG (found in more than just Chinese food), citrus fruits, and bananas.
Step three, his last resort: Use preventive medications such as beta-blockers, antidepressants, or anticonvulsants.
This method of cutting out foods is not without controversy. “If you eliminate 50 things from your diet and only five bothered you, how are you going to know what the triggers are?” Dr. Ailani says. She suggests a less radical approach: keeping a diary to try to pinpoint what foods might cause a migraine.
Doctors also stress the importance of getting enough sleep, exercising, keeping your weight down and your blood pressure in check, and getting off over-the-counter medications.
Doctors try to rule out other causes of head pain when first seeing a patient. They may look for tumors, infections, and cluster headaches—which, as the name suggests, come in clumps and disappear only to return in another batch. The pain from these can be severe and often occurs near one eye.
Some patients don’t find relief despite trying different approaches. “Thirty percent of chronic migraine patients just don’t respond to treatments,” Ailani says. “Headaches aren’t curable. You can treat them, but you can’t make them go away.”
Some patients simply outlive the pain. When people age, estrogen levels stabilize, especially in women. “Estrogen drops before your period; it’s that drop in estrogen that we think triggers migraines,” Ailani says. “During menopause, estrogen levels become stable, so 70 percent of women stop having migraines.” Migraines also typically stop during pregnancy.
Birth-control pills regulate estrogen as well and can lessen the onset of migraines. “The problem is that for some patients oral contraceptives worsen headaches,” Ailani says. “I always advise patients to pay attention to the frequency of their headaches while on oral contraception. If the headaches worsen, they should consider changing to a different formulation or stopping altogether.”
In difficult-to-treat cases, doctors may probe beyond the physical symptoms and ask about depression. “There is a lot of connection with migraines and anxiety, depression, and bipolar conditions,” says Dr. Suzan Khoromi, a neurologist at George Washington University Hospital, which will open a center devoted to headaches in a few months. “A migraine has a biological dimension, a psychological dimension, and a physical dimension. The most beneficial treatments are those that offer coping mechanisms for all three.”
This article appears in the June 2011 issue of The Washingtonian.