Chronic Migraines - Solving the Mystery
A combination of triggers, including certain foods, can make your head pound.
About two years ago, all I wanted to do was sleep. I was caring for my 10-month-old daughter, Nora, and napping whenever she did. Yet it didn’t matter how much rest I got, I needed more.
Hoping to find an underlying physical explanation, I visited my doctor. He drew blood, ran some tests and ruled out anything medically wrong. I was left without answers—and still craving sleep.
A few months later, still tired, I returned to the doctor's office but this time because of headaches. I’d started suffering from occasional migraine headaches in 2001 and at the time was given a prescription of naproxen, the same medicine in over-the-counter Aleve. As the years passed and the number of headaches increased, I'd begun using the drug almost every day. Ultimately, the daily dosing had prompted such stomachaches that I just decided to quit. It wasn’t long before the headaches returned—with an intensity that ibuprofen and other over-the-counter medicine couldn't assuage.
The doctor examined me and diagnosed mixed headaches— a combination of tension and migraine—and prescribed another medication, Midrin (Motrin mixed with a muscle relaxant), to control them.
"We’ll talk about the next step if you don't feel significantly better within two weeks," he said.
I didn't. The next step was a neurologist who promptly diagnosed migraine and a form of chronic daily headache, specifically an analgesic rebound headache.
About 4 percent of Americans suffer from chronic daily headache—a headache that occurs at least 15 days out of every month. The specific type I had, medication-overuse headache, occurs in about 1 percent of people in North America, Europe and Asia. Those years of daily dosing on naproxen had left me physically dependent on the drug; my headaches were withdrawal symptoms.
The treatment? No more naproxen or Midrin. Two to three months without analgesics of any kind to let my head regain equilibrium.
Once off the meds, I discovered that the drugs had been managing—and masking —massive amounts of pain. Within 24 hours, my head began to throb like it was swelling from the inside out. Over the next two months, I spent nearly as much time in bed as on my feet. Nora, by now a toddler, began saying "my-gain" and brought me gifts of yarn when I was in particularly rough shape. (Not that I was in any condition to knit, but the thought was sweet.)
After this withdrawal period, I began to feel optimistic. For the first time in months, I actually had a few days that were headache free. I also had much more energy. When I asked my doctor about this, he pointed out that one effect of migraines is fatigue; while the naproxen and midrin had eased the pain of the headache, they apparently had not addressed the fatigue that often accompanies a migraine, which was why I’d been so tired.
Even with the good news, however, I was growing more frustrated and discouraged. It was true that the daily headaches were now less frequent. But now it was becoming clear that the migraines were growing more severe. Before long, they were happening four or five times a month and lasting approximately four days apiece.
All in Your Head
Migraines are common in the United States. A 2007 study found that in any given year, more than 17 percent of women and over 5 percent of men will experience a migraine. Of those, 60 percent suffer self-described "severe impairment," requiring bed rest. About 22 percent experience recurrent migraines that cause moderate-to-severe levels of disability, limiting their ability to work, attend school or enjoy family activities.
Neurologists generally recommend two methods to assist patients—medication and lifestyle adjustments, such as regular bedtimes, stress reduction techniques and elimination of potential triggers, often foods.
I have so-called "classic migraines," which means that many of my migraines begin with an aura—a visual or tactile phenomenon that develops before the migraine starts and ends as the pain begins. My aura is one of the more common types, resembling a visual "flash” that grows larger until I go nearly blind on one side. About 20 minutes later, my sight returns and the headache begins. Like most people with migraines (called migraineurs), I usually feel severe aching on one side of my head, throw-up while I'm having a headache and experience such grinding pain that performing even the most basic of daily activities—cooking, driving, standing upright, you name it—can become virtually impossible.
Finding the Cause
For the next few months, I visited my neurologist regularly as he adjusted my medications and monitored the progress of the migraines. At one of my appointments, we carefully went over a list of foods that are often linked to migraines—aged cheeses, red wine, nitrates, preserved meats. I had either eliminated each of these items for months at a time or had never eaten them in the first place. Then the doctor mentioned Chinese food.
"Seriously?" I asked. My husband, who'd come to my appointment, and I looked at each other. We'd begun to frequent a Chinese restaurant that was gracious about adapting their food to my gluten-free diet and as I'd been feeling more ill and fatigued over the past many months, we’d been eating there three or four times a week.
"Actually, we eat tons of Chinese food," I told the doctor.
"Give it a shot," he said. “Stop eating Chinese.”
So we cut out our favorite Asian restaurants entirely for a few weeks. And amazingly, I had my first headache-free week in many months. But I still didn't know exactly why. Was it an additive in the food—MSG (monosodium glutamate), too much salt, something I didn't know about? Or was it an ingredient I was eating in Chinese cuisine and at other meals that I should cut from my diet—mushrooms, bok choy, tofu?
I began to strongly suspect MSG when, over a long weekend of travel, I shared a bag of chips that contained MSG with my husband. On our way home, I had one of the worst migraines of my life.
"MSG is a guaranteed trigger for most patients," explains Christine Lay, M.D., director of the Women's Comprehensive Headache Center at St. Luke's-Roosevelt Hospital Center in New York City. "Food colorings, preservatives, stabilizers—these things are fairly potent triggers for migraines."
My rescue medication, one of a class of drugs called triptans that are commonly used to treat migraines, barely touched the headache I had after eating those chips. It was a week before the pain subsided completely. My sudden sensitivity to MSG really puzzled me. I'd eaten the same foods before with no ill effects.
Part of my confusion stemmed from my misunderstanding about how migraines work. When I was first diagnosed with migraines in 2001, they were very infrequent. At that time, the doctor handed me a list of potential triggers— common foods and situations that were thought to directly cause migraines in many people. The explanation was one of cause and effect. Drink a glass of red wine on Monday evening; wake up with a migraine on Tuesday morning.
What’s Eating You?
The list of migraine-aggravating foods still stands but newer research on migraines has changed the way doctors look at the relationship between food and headaches.
"It's pretty rare for a person to say, 'If I eat a certain food, I always get a headache. And if I never eat this food, I almost never get a migraine,'" Lay says.
The prevailing medical thinking puts tension and migraine headaches on a continuum rather than considering them separate entities. It posits that the brain is pushed toward a migraine by environmental stresses that can build over time. The brain can turn off the process that causes a headache at any point—after the aura (in people who get an aura) or even in the period before a headache starts when many migraineurs are tired or moody. In people prone to migraines, the brain tends not to "turn off" before a headache starts.
"We generally believe that migraines occur in people who have genetic susceptibility to them. For some reason, this susceptibility makes people who suffer with migraines more likely to get a headache if certain conditions occur. For instance, when the weather changes, or, in a woman, during a hormonal fluctuation. These triggers tend to build to a threshold to turn on a migraine,” Lay says. “So you may have a patient whose menstrual cycle is due and who has a glass of red wine. She gets a headache and thinks, 'Gosh, it must have been the red wine.'"
In people who are susceptible, the combination of environmental and food triggers can push them over their personal threshold for developing a headache. For migraineurs, that threshold can be low, indeed. This means that there is a relationship between foods, associated medical conditions and lifestyle issues that can cause migraines—but it’s looser than previously thought.
This is why discerning food issues for migraineurs can be so complicated and why, unlike celiac disease or food allergies, there may be some cases where migraine patients who are sensitive to certain foods can eat small amounts of their danger foods without getting a headache. When other aggravating factors are absent, depending on the person, problem foods may be okay in limited amounts.
"It's good in a way because patients who, for instance, like chocolate or love ginger ale know they can enjoy it sometimes," says Lay.
Teasing out exact food issues, however, is challenging for many migraineurs. It can be difficult to separate what you've eaten from any emotional and environmental stressors that may also be playing a role. For me, an elimination diet was the key to figuring out my major food sensitivity. I had already eliminated all my migraine food triggers—except for the MSG.
Lay recommends that patients keep a food diary as a way to determine with their neurologist the foods that might be culprits.
"We try to see if certain food items tend to pop up more often than others and then look at them more closely," Lay says.
As for me, I still get migraines, most of which I can trace to hormones, changes in barometric pressure or a rough night's sleep. But now that I’ve eliminated MSG from my diet, I have many more pain-free days. Most important, my migraines don't rule my life and the life of my family any more. I've gone from being "sick" to having a condition I can manage. LW