Starting in her 30s, Barbara Schulties began suffering from debilitating headaches, which she describes as "someone taking a hot poker to my eye." Besides excruciating head pain, the Santa Cruz resident lists a host of accompanying symptoms: nausea, vomiting, dizziness, difficulty focusing and hypersensitivity to light, noise and even wind on her face.
"I can't spell," she says, describing a typical headache. "It's very hard for me to visualize words." Like 12% of people in the U.S., and 1 out of 3 women over a lifetime, Schulties suffers from migraine disorder, an inherited condition that affects the regulation of nerve signals in the brain.
"For some people, it's absolutely a devastating condition that impacts every aspect of their life," says Dr. Andrew Charles, professor of neurology and director of the Headache Research and Treatment Program at UCLA.
Though a throbbing, one-sided headache is the hallmark migraine symptom, it turns out that migraine is a complex neurological phenomenon. In the days and hours before a headache even begins — a period known as the premonitory phase — an electrochemical storm begins brewing inside the migraine-af¿icted brain.
"In the premonitory phase, patients will feel tired and they might have some neck discomfort," says Dr. Peter Goadsby, professor of neurology at UC San Francisco. Other premonitory symptoms include yawning, weariness, dizziness, irritability, thirst, food cravings, increased urination and difficulty concentrating. Using brain imaging, Goadsby and colleagues recently identified specific areas of the brain that are activated in the pre-headache phase.
In 25% of migraine sufferers, headaches may be preceded by another neurological symptom: the aura. Often experienced as a blind spot or a spinning wheel of light that obscures vision, an aura can also cause numbness, tingling or a loss of words. Once a migraine headache sets in, any type of sensory input becomes unbearable — ordinary light, noise and smells become jabs of pain. Hours after the headache has subsided, many people experience lingering fatigue and foggy-headedness.
There is evidence that, between attacks, migraine-disordered brains function differently from normal ones. Studies show that migraine-affected brains have a decreased ability to habituate, or get used to a stimulus. If you expose a normal person to a constantly flashing light, then measure the signals evoked in the visual part of his or her brain, the signals will get smaller with time as the brain gets used to the light. But if you expose a person with migraine to a flashing light, the signal will grow larger with time.
"That's why migraineurs will notice small things that will irritate them, like a clock ticking in the background," says Goadsby. "A migraineur gets irritated by things because [he or she] can't get rid of them easily. A person that's not migrainous will just ignore things. The difference is quite stunning."
Is it the chocolate?
Every migraineur knows about triggers: things that seem to set off a migraine attack like a flame kindles a brushfire. And there are several chemical triggers that can fuel an attack in susceptible people, such as alcoholic beverages (particularly red wine, a common trigger among Caucasians), gasoline fumes and nitrates, the last of which are found in cured meats. But identifying triggers is often complicated by confounding symptoms of the attack itself.
Many people crave sugary or savory foods during the premonitory phase, says Goadsby. "If they crave something sweet and they eat something sweet, then five hours later they get a headache, they'll tell you that if they eat sugar they always get a headache." But he explains that the craving is part of the actual attack and one of the first signs that a headache is on its way.
"Chocolate is a classic example of this," adds Goadsby. "If you actually study this and you try to trigger people prospectively with chocolate, it just doesn't work. But many people will tell you it's a trigger, and I think that the explanation for that is this very well-described premonitory phase of migraine."
What does trigger migraine attacks in susceptible people is change. It seems that the migraine brain exists in a delicate physiological balance, with any fluctuation in sleep pattern, dietary pattern, stress level, hormone level, caffeine intake or even weather disrupting that balance and inciting an attack. Women are often plagued by migraine attacks just before their menstrual period, when their levels of estrogen and progesterone decrease. (And they frequently experience a worsening of symptoms with the onset of menopause.) Like a dropped pebble causes disturbance in a pond, a missed meal, late night or extra hour of sleep can trigger a migraine attack that reverberates hours later.
Because stress is often attributable to headaches, many migraineurs are surprised when they suffer attacks over the weekend or at the beginning of a vacation. But it's this "letdown" from normal stress levels that often initiates an attack, explains Charles. It's not recommended that migraine sufferers avoid vacations, of course, but rather that they try to manage stress during normal life.
Manage the migraine
Though medication can help many people with migraine disorder prevent or treat attacks, people can minimize the frequency of attacks by adopting the theme of consistency in their lives, says Charles. Going to sleep and waking up at the same time each day, eating regular meals, moderating caffeine intake and exercising regularly can all help.
Of course, not all attacks are avoidable, just as not all triggers, such as weather changes or a bout of insomnia, are avoidable. With this in mind, Goadsby recommends that migraineurs get to know their particular disorder. He suggests that patients keep a headache journal, where they record daily activities and symptoms so they can learn to identify potential triggers as well as premonitory symptoms.
"If you're starting to get an attack, that's definitely not a day to drink alcohol or stay up late. It's a day to be a little bit cautious with yourself," he says.
"I wish I would have understood that I have a chronic illness," reflects Schulties, who now, after decades of suffering, has a greater degree of control over her migraine disorder. "I would have treated myself better when the warning signs were there."
Goadsby emphasizes that such awareness can help migraineurs stem attacks. "Try to understand your disorder so that you get to be in the driver's seat rather than the attack. Don't let migraine be your lifestyle."