The Good Health Magazine : MEDICINE : ESCAPE FROM AGONY CERTAIN : NEW DRUGS AND THERAPIES CAN ABORT MIGRAINES. OTHERS CAN PREVENT THEM FROM OCCURRING

I don’t remember my first headache. I don’t even recall when I first started getting headaches. But many of the headaches themselves are burned indelibly into my memory.

I remember driving to Missouri on vacation and arriving with a blockbuster that put me into bed for two days. I remember driving to Los Angeles every month when I was in graduate school in Santa Barbara and starting to feel the pain as soon as we hit the smog in the San Fernando Valley.

I remember drinking two glasses of burgundy and paying for it with two days of agony.

And we are not talking Excedrin headache No. 23 here, the run-of-the-mill annoyance where you take two painkillers and in half an hour your pain is gone. We’re talking anvils pounding in your forehead, room lights that feel like the noonday sun in the Sahara Desert, ticking clocks that sound like triphammers.

We’re talking about refusing to speak, huddling inside a self-imposed shell separate from the rest of the world. We’re talking nausea that makes you feel like your last meal came from the city’s garbage truck.

We’re talking about pain that has driven my son, who also suffers migraines, to pound his head against the wall in frustration and anger, pain that leads people to contemplate or even attempt suicide.

We’re talking migraine.

And, increasingly, we’re talking about something it is no longer necessary to endure.

A small band of scientists, unorganized and without government research funds but united in their commitment to headaches--which many of them suffer themselves--have been making great strides in treating migraines, as well as other types of disabling headaches.

They have developed widely used drugs and therapies that can abort migraines in the majority of people and devised others that, used regularly, can prevent migraines from occurring in the first place. Other drugs, now entering clinical trials, promise to be even more effective and to help a higher percentage of victims.

At least 75% of patients can eliminate or greatly alleviate their headaches with drugs and biofeedback, according to Dr. Joel R. Saper of the Michigan Headache and Neurological Institute in Ann Arbor. Another 15% are not helped by drugs as much but can be taught to cope with their headaches--through relaxation techniques--enabling them to return to work. “The other 10% are simply not helpable, and we’re not sure why,” Saper says.

But many physicians believe even that last 10% eventually will be helped. “We’re very close to some big breakthroughs,” for that group, says Dr. Seymour Diamond, who operates the Diamond Headache Clinic in Chicago.

VIRTUALLY EVERYONE gets headaches. By some estimates, as many as 95% of Americans have an occasional tension headache, triggered by stress and fatigue, that requires a couple of aspirin or a short nap. In a study published in April, Dr. Walter Stewart and his colleagues at the Johns Hopkins School of Hygiene and Public Health in Baltimore reported that most Americans suffer 10 to 12 headaches a year.

The direct and indirect costs of headaches to society, for medical care and lost workdays, total as much as $10 billion annually, according to the National Headache Foundation in Chicago. Each year, Americans spend more than $400 million on aspirin and other over-the-counter pain relievers, primarily to counter headaches.

But a remarkably high number of individuals--an estimated 45 million, according to the National Headache Foundation--have more serious chronic or disabling headaches.

Even though headaches are the seventh most common complaint patients bring to physicians’ offices, according to Stewart, they receive little attention from researchers. “Headaches are not fatal and (often) aren’t chronic, so they don’t grab attention like other, more dramatic illnesses,” Stewart says.

It’s not easy to study headaches. There are no animal models. Dogs, cats and laboratory mice do not get headaches--or, at least, if they do, they are not able to tell researchers about them. So there is nowhere to study the physiology of headaches or to test new drugs except in humans themselves.

Even in humans, headaches are difficult to study. There are few objective measures by which to get a handle on them. You can’t take a picture of a headache with an X-ray machine or a CT scanner; you can’t track it with an electroencephalograph; you can’t find its traces in a blood assay or urinalysis.

Few physicians are knowledgeable about headaches, whether for diagnosing them, for treating them or simply for knowing where to send a headache victim for help. “It’s not taught anywhere,” says Dr. Lee Kudrow of the California Medical Clinic for Headache in Encino. The majority of headache sufferers who seek medical help report that they tried doctor after doctor with no success.

Susan Taubman’s experience is typical. The Long Beach housewife began getting migraines seven years ago, averaging two three-day bouts per month with frequent, less severe headaches in between. “All I wanted to do was just lie down and do nothing,” she says.

Over a six-year period, Taubman sought help from a gynecologist, an internist, a neurologist, an allergist, two eye, ear, nose and throat specialists and even a chiropractor without success. “They all said about the same thing, that they didn’t know much about headaches,” she says. “Some prescribed drugs that didn’t help much but left me all doped up. Others said it was all in my head.”

It’s not only physicians who think that severe headaches “are all in the head.” Parents, spouses, teachers and employers often dismiss headaches as psychosomatic, accusing the victims of malingering or worse. My own wife says often that she didn’t appreciate the seriousness of my migraines until she saw our children developing similar agonies.

It is perhaps not surprising, then, that many physicians who study headaches and treat their victims are sensitive to the problem because they themselves are victims or have afflicted family members. In an informal survey of 132 of his neurologist colleagues, Dr. Joseph Scheller of the San Diego Children’s Hospital Center found that 50, or 38%, suffered migraine or cluster headaches--another form of vascular headache, more severe than migraine, in which the headaches come in groups--nearly twice the rate (20%) among the general population.

“It’s a wonderful thing to have the disorder you are researching,” says Kudrow, who suffers from debilitating cluster headaches. “It gives you immense insight.”

ONE OF THE GREAT ironies of headache research is that the brain, where most headaches seem to be centered, actually has no nerve endings whatsoever. You can cut into the brain itself, drill a hole into it, even cut off large chunks without generating any pain.

Headaches arise in the complex webbing of blood vessels that surrounds and feeds the brain, in the muscles that move the scalp and in the thin membrane that surrounds the brain.

Although physicians only now are beginning to unravel the physiological mechanisms that produce headaches, there is widespread--but not universal--agreement that the most serious chronic headaches, migraines and cluster headaches result from a dilation of the blood vessels that surround the brain. The walls of the arteries stretch and, like any other body tissues put under pressure, release certain chemicals that stimulate nerve endings in the blood vessels to create the pain.

Migraine (from the Greek hemikrania, or “half a skull,” reflecting the fact that migraines typically are felt most strongly on one side of the head) is by far the most common form of chronic headache. Fully 26% of all women and 7% of men in the Uniited States suffer migraines. Researchers trace the higher incidence in women to female hormones that can trigger migraines.

The ancient Greeks and their predecessors in the early civilizations clustered in the Tigris and Euphrates River valleys were familiar with migraines. Aristotle suffered from migraines, as did Thomas Jefferson, Sigmund Freud, Virginia Woolf, Lewis Carroll, Ulysses S. Grant and Frederic Chopin.

At least six different types of migraines exist, but 80% are the so-called common migraines and another 15% are “classic” migraines. Typically, in the common variety, the pain begins without warning in one small area of the forehead or temple. It throbs and pulsates while it grows larger and more painful. In my case, it feels like the left side of my head is crammed to the breaking point with cotton, and then more is stuffed in.

As the headache becomes more severe, the victim loses appetite, becomes nauseated and may vomit, and avoids light and sound. Such headaches often last as long as three days.

In “classical” migraines, the victim perceives an “aura” before the headache begins. The aura is characterized by flashing lights, zigzag lines and scintillating patterns of light and darkness. The aura begins 30 minutes to two hours before the actual headache and fades away as the headache itself develops.

In other, less frequent forms of migraine, the victim may suffer the aura without having headaches or may have a variety of additional symptoms, including speech problems, weakness and numbness or tingling on one side of the body.

One-third of the people who suffer from common migraines, like Taubman, also get muscle-contraction headaches during the periods between migraines. These headaches, caused by tension in scalp muscles, are duller, less intense and more persistent than migraines. “They are not as severe as the migraines, but they are bad enough to make me feel awful,” she says.

Migraines have a strong genetic component. If both parents have a history of migraines, each child has a 70% risk of developing them. If only one parent suffers from them, the risk is reduced to 40%. Families often have clusters. All three of my sons suffer from them, for example, as do all three of Diamond’s daughters.

In women, hormones play a crucial role in triggering migraines. Like about 70% of female migraineurs (migraine victims), Taubman found that her episodes tended to cluster around the times of the month when she was ovulating or menstruating. Both times she was pregnant, the headaches went away, only to return after she gave birth.

n fact, many women who have menstrual headaches don’t realize that they are migraines and don’t seek treatment, Kudrow says. “They are so good at accepting discomfort that they are not interested in naming it.”

Paintings and sculptures by migraineurs often vividly illustrate the torture they suffer. One such painting shows skulls drilled by tiny devils, another a cranium being crushed in a vise.

“It’s very difficult to get people to understand what suffering from headaches means,” says Dr. Egilius Spierings of the Headache Research Foundation in Boston, who solicited such artwork for a recent exhibition.

“Through art, patients can express features of their headaches unrestricted by existing medical concepts,” Spierings says. “Ultimately, the patients are going to teach us what is right and wrong about our concepts of the headache.”

CURRENT THEORY HOLDS that migraines involve a disorder in the metabolism of serotonin, a neurotransmitter that acts as a chemical messenger in the brain. The brain may not produce enough serotonin, overactive enzymes may destroy it too rapidly, or receptors on the cells that take up serotonin may not bind to it properly. As a result of this defect in serotonin metabolism, blood vessels in the head dilate more easily in response to outside stimuli, although researchers do not yet know precisely how this happens.

Migraineurs have “an extreme sensitivity to internal and external stimuli,” says Dr. David E. Sosin of the Headache Treatment Center of Orange County in Tustin. “It’s like they have a hair trigger. They are overly responsive to the environment.”

One important stimulus, surprisingly, is relaxation. During the work week, the normal stress and tension of a job, perhaps combined with the effects of caffeine, keeps the blood vessels of the scalp tightly constricted. Comes the weekend, release of stress and perhaps the failure to have morning cups of coffee allow the vessels to dilate, producing a migraine.

“The most common day of the week for migraines is Saturday,” says Dr. Alfred Scopp of the Northern California Headache Clinic in Mountain View.

I’ve often had weekends spoiled, and others share the experience, which can strain family relations. Says Taubman: “It often seemed like my husband was spending all his days off taking care of the kids because I wasn’t up to it.”

Changes in routine, such as not getting enough sleep, also can trigger episodes, as can severe stress or tension. Every time my wife and I have an intense disagreement with our 19-year-old son, we know he will have a migraine the next morning.

Chemicals in liquor, especially red wines, are another trigger that can disrupt serotonin metabolism and trigger migraines. “I can’t go near red wine,” says Dr. William Bracciodieta of USC. “Just wave it under my nose and I get a migraine.”

Some physicians similarly believe that chemicals in certain foods can initiate migraines in at least some people. Nitrates (which are used in preserving meats), monosodium glutamate, aged cheeses and chocolate all have been associated with migraines at one time or another, although the evidence is mixed at best. Diamond says that perhaps 25% of migraine sufferers are sensitive to foods.

Kudrow, in contrast, argues that food plays little part in starting migraines: “I don’t buy that at all. If you have a craving for something, eat it.”

Paradoxically, one of the most common causes of migraines and muscle-contraction headaches is the daily use of pain relievers--aspirin, acetaminophen, ibuprofen and other products.

Unfortunately, in addition to alleviating pain, the analgesics also dull the effectiveness of the brain’s own pain-control center, which produces chemicals called endorphins that block pain, Kudrow says. Normal pain-control functions cease working, while the individual develops tolerance to the effects of the analgesics. The net result is more headaches.

Many people who have migraines take an average of six to eight pills every day in an attempt to stave off headaches. Of course, they don’t work, but the pills are a psychological trap easily fallen into.

Habitual users of the analgesics also get a rebound effect when they quit using them, with increased numbers of headaches for the first two weeks.

Despite the rebound effect, the first thing physicians like Kudrow and Diamond do with new patients is have them stop taking analgesics. Frequently, that action alone is enough to greatly ease or eliminate the muscle-contraction headaches.

Taubman stopped taking analgesics in January and “what has happened is incredible. I hardly get any of the dull headaches anymore, and the migraines are less severe.”

ALTHOUGH ANALGESICS are of little value in treating migraines, and can even cause them, other drugs are more useful.

Treatment of migraines takes two forms, abortive--to stop the pain once a headache begins--and prophylactic--to prevent future pains. The most common abortive drug is ergotamine (Cafergot), an alkaloid derived from fungi that causes blood vessels to contract. It is effective in 60% to 70% of migraineurs if given during the first three hours of the headache.

It is given intravenously in the hospital for severe cases and orally for patients at home. Because it is intensely nauseating, migraineurs often are given an anti-nausea drug such as fenergan so that they can keep the Cafergot down.

Researchers are studying a number of new drugs that promise to be much more effective in aborting migraines. Most of them interfere with serotonin metabolism. The furthest along is a compound called GR-43175, developed by Glaxo Holdings PLC of London and now undergoing clinical trials.

Although the results of those trials have not yet been released, “it is probably the most exciting thing in headache work in 20 years,” says Dr. Jerome Goldstein, director of the San Francisco Headache Clinic

Glaxo hopes to begin marketing GR-43175 in 1990, and many other companies have similar products entering or ready to enter clinical trials. The Wall Street Journal estimates that the market for such drugs will total as much as $1 billion a year, up from $215 million in 1987.

When an individual has migraines at least twice a month or for more than four days per month, most physicians recommend the daily use of a prophylactic drug. The most commonly used are a family of heart drugs called beta-blockers, such as propanolol.

“We have absolutely no idea how it works,” Kudrow says, “but I am amazed by its efficacy.” As many as 80% of the people who take propanolol stop having migraines or have them much less frequently.

Another commonly prescribed drug is amitriptyline, an anti-depressant whose mechanism of action also is unknown. This drug is most effective in preventing muscle-contraction headaches , but some physicians believe it also reduces migraines.

I have been taking amitriptyline for six years and it has markedly reduced the number of headaches I suffer. Those that I do get are generally less severe as well. When I get a migraine now, I take a Tylenol-3 and go to bed, and it is usually gone in a couple of hours.

One other alternative that is frequently used for migraines is biofeedback, a process that uses imagery--such as depictions of a person’s brainwaves or bloodflow--to help in the conscious control of bodily functions. Many people can will their fingers to warm by as much as 15 degrees simply by imagining they are being warmed over a fire.

The process diverts blood flow to the hands and causes a constriction of blood vessels elsewhere in the body, particularly in the head.

Growing evidence suggests that muscle contraction headaches can be relieved by biofeedback, but not migraines..

Although I still remember my headaches vividly, overall, their impact is fading. Women often say that the brain blocks out the pain of childbirth; otherwise they would never have a second child. Well, my brain is slowly blocking out the pain of the migraines because it has been so long since I’ve had a really serious one. And that, probably, is the greatest thing I can say about my doctors: I’m beginning to forget what the pain was like.