Doctors develop better undertanding of migraines
SAN FRANCISCO — A 13-year-old patient once came to Dr. Robert Cowan with an unusual request: She wanted to go to an amusement park and she needed him to talk her mother into it.
The mother assumed Cowan, a neurologist treating the girl for severe migraines, would take her side. Surely a day in the sun, riding roller coasters and sprinting around the park, would trigger a terrible headache.
“And I said of course she should go,” Cowan said recently with a laugh. “And she went, and she got a headache, and she said it was totally worth it.”
Cowan, director of Stanford University's new headache clinic, could relate to the girl. He has suffered migraines his whole life. Just two years ago, he risked a major headache to see an Eric Clapton concert. He understands all too well the choices “migraineurs” — the word migraine sufferers often use to describe themselves — have to make to live as normal and productive lives as possible.
Migraines — the most common type of chronic or recurring headaches — affect more than 10 percent of Americans and are one of the main reasons people see a doctor or show up in emergency rooms.
Migraines can be debilitating. People who suffer them regularly can be disabled by pain, or sensitivity to light, sound or touch. They miss work or school. Sometimes they can barely function.
But it's only in the past decade or two that migraines have been taken seriously by the mainstream health care industry, headache experts say. Triptans, the first, and so far only, type of drug developed specifically for migraine treatment, were introduced in the early 1990s. And new imaging techniques have allowed researchers to look at the brains of migraine sufferers and determine exactly what is happening during a bad headache.
More recently, doctors have begun specializing in headache treatment, and major medical centers have opened headache clinics.
“Headache is finally coming of age,” said Dr. Peter Goadsby, director of the University of California-San Francisco headache clinic, who is leading research into the causes and potential treatments of migraines.
“The thing I'm most excited about is understanding which areas of the brain are most involved,” he said. “They're going to be the targets. You can't develop new preventive medications if we don't know where to look.”
Almost all of what doctors understand about headaches, and migraines in particular, was uncovered in the past two decades, and there's still a lot that research hasn't explained.
Headaches once were assumed to be caused by constriction and dilation of the blood vessels leading into and out of the brain, but recent research suggests that headaches are more directly related to neurons in the brain itself.
No one understands exactly how migraines begin, but they often start with a “trigger,” which can include anything from a glass of red wine to a stressful day, lack of sleep or a few hours in the sun.
The first step to dealing with migraines is identifying the triggers that start them, doctors say. For some people that may be easy — they know drinking a glass of red wine will set off a migraine, so they drink white instead, or no wine at all. But for others, identifying triggers can be a long and complicated process. Doctors will often recommend that they keep a migraine “diary” to track their habits in the days or hours before a migraine starts.
At the Stanford headache clinic, Cowan is working with a team of primary care doctors, as well as nutritionists, physical therapists, psychologists and sleep specialists, to treat patients. That's the key, he said — working with more than just a patient's head.
“You have to disabuse a patient of the idea that there is some secret medicine. You have to move the control away from the doctor and back to the patient,” Cowan said. “The decisions they make on a moment-to-moment basis are what are going to determine their quality of life.”