Migraines can keep sufferers, employers guessing
They affect 12 percent of the U.S. population, according to the U.S. National Library of Medicine, and many experts today say migraines are underdiagnosed. For those who suffer from them, the pain is intense and sometimes debilitating and can put added pressures on employment and the personal life.
“It used to be a long time ago most headaches were not migraines. Now the pendulum has swung the other way. We used to underdiagnose and now we’re all saying we need to look at migraines more,” said Patricia Alpert, an associate professor and chairwoman of the physiologic department in UNLV’s school of nursing.
Alpert, who is also a licensed nurse practitioner, worked in a neurology practice for two years where she saw her share of headache complaints that needed to be checked for possible migraines.
Dr. Venkatachalam Veerappan, president of Desert Neurology in Las Vegas, said migraine sufferers make up about 20 percent of his practice, and narrowing down whether a patient is experiencing one can be tricky. In many cases, he’ll see referrals from a primary care physician for a patient with a chronic sinus headache. Patients don’t know how else to describe their symptoms, and when they appear congested it’s easy to assume the pain is the result of sinus pressure. One way the expert rules out a migraine is duration. A migraine lasts a minimum of four hours.
“When someone tells me a headache lasts one or two hours, then I know it’s not a migraine,” Veerappan said.
What to watch for
Migraines can present themselves differently among sufferers. A commonly held belief is that migraines affect one side of the head. But experts say that’s not always the case.
“A lot of patients don’t fit into the classic textbook definition of a migraine. A tension headache from the back of the neck can cascade into a migraine and intensify on one side or both,” said Dr. Sam Colarusso, owner of Las Vegas Chiropractic Group.
A migraine is pulsating in nature, and when discussing symptoms, physicians often look to events before actual onset. Experts have broken down migraine onset into four phases. The first phase, the prodrome, usually involves symptoms that can be easily overlooked as a symptom, such as irritability, depression, diarrhea, drowsiness, food cravings and constipation.
The second phase, which occurs in about a third of migraine sufferers, is called the “aura.” Most auras are described as wavy lines across one’s eyesight. For some they are yellow or red . Some people see geometrical shapes . These symptoms can be accompanied by sensitivity to light (which may be constant for some migraine sufferers), blind spots, other ocular flashes, tingling in the arm or leg and ringing in the ears. An aura lasts 10 to 30 minutes just before the migraine.
“Some will describe an odd feeling like they are floating. They have some inkling they know the headache is coming,” Alpert said.
The actual headache is considered the third phase of the migraine process. A migraine could last as long as several days. Following a migraine is what’s called the “postdrome” phase where a person can feel completely drained. Sadly, migraines also happen with some regularity.
“Probably the hallmark of a migraine is recurrence. It does happen over and over again,” Colarusso said. “It can be debilitating. Most people can have a headache and go through their day, but a migraine can knock you out cold. You can’t do anything. You want to go into a dark room and shut down.”
Some children can have abdominal migraines as well, Alpert said. Those symptoms will appear as gastrointestinal problems such as stomach pain, nausea, abdominal cramps and vomiting. The pain usually occurs near the naval. Children who experience abdominal migraines usually end up being migraine headache sufferers later in life and likely have a family history of migraine headaches. Without much research behind them, some experts think abdominal migraines are caused by changes in histamine and serotonin levels, which could be influenced by stress and anxiety .
“Those are tough to really find,” Alpert said, “because the kid is not coming in complaining about a headache.”
For some severe migraines, symptoms can even look strokelike, for example a drooping look to one side of the face or losing function in an arm or leg. Women are more prone to migraine headaches because of fluctuating hormone levels. A 2010 Centers for Disease Control and Prevention survey indicated women were more than twice as likely to have migraines or severe headaches than men (21.8 versus 10 percent). Young women who are slightly overweight are at a greater risk, Alpert added.
Veerappan also said neurological exams should be normal for migraine patients. If a neurological exam is not, then the doctor must look for underlying conditions such as a tumor, aneurysm or other pathology.
“That’s the thing you always really worry about. You don’t want to miss that secondary cause,” he added.
Prevention, control
Some migraine sufferers like to use acute care medications that are taken at the first sign of a migraine to either lessen the severity or head them off entirely. These patients are likely in tune with themselves when a migraine is about to happen, as they must take the medicine before onset, otherwise it is not useful after the headache has begun, Alpert said.
Triptans, which restrict blood vessels in the brain to relieve swelling, are often used this way to keep migraine pain under control. Brand-name triptans include Axert, Frova and Maxalt. Some sufferers take them along with an over-the-counter headache medicine such as Tylenol.
Alpert advised caution with overusing over-the-counter migraine medications. Many contain caffeine, which may work in the short term to relieve pain, but if used for a long period of time patients may endure headaches because of caffeine withdrawal.
Low daily doses of anti-seizure, tricyclic antidepressants or blood pressure medicines are also used to prevent migraines. Veerappan uses these approaches with several patients. But he also pays close attention to potential side effects associated with them. They tend not not be suitable for women who are pregnant or are in their child-bearing years. For extreme situations where migraine sufferers experience 15 headaches or more a month, Botox is being used with FDA approval.
Veerappan likes to complement his prevention approach with more natural options such as magnesium oxide, which has been found to be helpful in some studies, vitamin B1 or the herb feverfew.
In Colarusso’s field, he sees plenty of musculoskeletal complaints associated with the body and neck areas that can be starting points for a migraine.
“When someone comes in and complains about migraines, I try to test some of the structure of the head and neck. The idea is to relieve as much pressure from the spine as we can, which leads to more blood flow,” he said.
He also uses soft tissue therapy to relieve muscle tension around the head and neck area and cautions against running too quickly to pills. He encourages migraine sufferers to use cold compresses, maintain hydration and try better sleep patterns for prevention. Even ibuprofen, he said, can be toxic to the liver and other organs if used too much. Like Veerappan, he too uses feverfew and other herbs such as melatonin for his patients.
Experts agree that the best way to keep migraines at bay is to identify triggers and avoid them. Veerappan said triggers are a big part of the early conversation with his migraine patients. Narrowing in on environmental factors such as a food or drink additive, MSG, alcohol, smoky environment or a particular situation where strong fluorescent light are used can be a trigger, and are the first and most important step to avoiding migraines.
Other triggers could include sleep deprivation, dehydration, low blood sugar and stress. It is also not uncommon to see migraines in those suffering from multiple sclerosis or epilepsy. For some sufferers biofeedback, yoga, meditation and other relaxation techniques can be helpful.
Migraines at work
Enduring a migraine is hard enough, but doing it at work can be challenging to the employee and employer. For some, perfumes or odors from other people could be a trigger, which could create some employee tension if not addressed properly.
Colarusso said it’s the responsibility of employers to keep their workplaces clean and well-ventilated but also be aware of any sensitivities employees might have. And employees also must communicate to employers their sensitivities.
“We’re very cognizant of creams, lotions, smells in the medical office. Everything in our office is very hypoallergenic,” Colarusso said.
Veerappan has seen culinary employees with difficulty working during certain shifts that may disrupt their sleep cycle, thus causing migraines. Some in other fields have a hard time working in hot weather.
He also sees migraine sufferers with computer screens, a main part of their work environment, that provoke migraines. They often need a cover or glare filter on their monitor to be productive. Veerappan writes letters on behalf of his patients asking for adjustments to work schedules or their environment.
“Most employers in town really are quite accommodating,” he said.
