MIGRAINE. for more than 16 million sufferers,
new drugs offer the best hope yet
By: Judy Foreman
09/08/97
It was June, 1996 and Dr. Michael Cutrer, head of
the headache unit at Massachusetts General Hospital, was hard at
work as usual in his sixth floor lab in Charlestown.
Suddenly, he'd look at somebody "and part of the
face wouldn't be there, just a shimmering blind spot" that grew
"until half of the vision in both eyes was sparkling and
shimmering," he recalls.
It was, as Cutrer knew all too well from both
personal and professional experience, a classic "aura," often the
first sign of a crippling migraine headache.
But this time, Cutrer, 41, dashed down to a
special MRI (magnetic resonance imaging) scanner on the first floor
and jumped into position - as the patient.
For the next 45 minutes, as he lay watching the
blind spot creep to the periphery of his vision, technicians tracked
sharp changes in blood flow to the visual cortex of his brain. It
was one of the first times scientists had been able to catch a
spontaneous aura in progress, and it yielded an important clue to
the underlying dynamics of migraines, which plague 16 to 18 million
Americans.
In the nick of time, just as the aura turned into
a throbbing headache, Cutrer gave himself a shot of a drug called
Imitrex, or sumatriptan. Within minutes, the pain and vomiting he
had come to expect with migraines since age 14 were gone.
In the not-so-old days - before Imitrex reached
the market in 1993 - the main remedies for migraine were addictive
painkilling drugs or ergotamine, either in a pill form that could
make you "sicker than when you started," as Cutrer puts it, or a
less nauseating injectable form called DHE-45.
But today, migraine sufferers can often abort
attacks in an hour or less with injectable Imitrex, and since last
year, with a slower-acting pill form as well. And next month, a
just-approved, fast-acting Imitrex nasal spray will become
available.
That's just the beginning. A nasal spray form of
DHE-45 is also expected to be approved soon. A number of other
remedies - an herb called feverfew, biofeedback, new Imitrex-like
drugs - are showing some promise in preventing or aborting
migraines.
And scientists, among them the MGH brain scanners
who have recorded seven auras and 15 migraines in progress, are
beginning to understand what goes wrong in a migraine headache,
including identifying alterations in genes on chromosomes 1 and 19
that seem to put some people at risk.
Chronic headaches plague 45 million Americans.
Most are "tension headaches," with vise-like pain that can be severe
- and frequent - but that often responds to antidepressants or
over-the-counter remedies like ibuprofen and caffeine.
A tiny share of headaches - about 2 percent - are
caused by brain tumors, aneurysms (weakened blood vessels in the
brain) or infections in or near the brain.
Most of the rest are vascular headaches -
migraines, which affect 18 percent of women and 6 percent of men,
and cluster headaches, which are more rare and occur mainly in men.
While migraines cause a horrible, throbbing pain,
cluster headaches cause a severe "cutting" type of pain, says Dr.
Seymour Diamond, head of the Diamond Headache Clinic in Chicago and
executive chairman of the National Headache Foundation.
In both types, some scientists believe, the pain,
usually on just one side, comes from activation of nerve fibers in
blood vessels in and around the brain.
While migraines, which often run in families, are
often accompanied by nausea, vomiting and severe sensitivity to
light and sound, cluster headaches are not. Migraines typically last
from several hours to three days; cluster headaches last several
hours but can strike two or three times a day for months.
At the onset of a migraine, some believe, the
level of serotonin, a natural chemical in the brain, drops suddenly,
allowing blood vessels in the brain and the meninges (the fibrous
tissue surrounding the brain) to dilate, which can cause surrounding
tissues to swell painfully.
But blood vessel dilation is only part of the
story, says neurologist Cutrer. Whatever the initial trigger of a
migraine - a particular food, alcohol, missing meals, changes in
sleep patterns, menstruation, bright lights, loud noises - nerve
cells in the meninges and in the meningeal blood vessels release
chemicals called pain peptides.
Signals from the meninges are then transmitted
deeper into the brain, causing exquisite pain - as millions can
attest.
Ellen Blau, for instance, a 47-year-old Michigan
woman who now coordinates support groups for the National Headache
Foundation, has had migraines since she was 17.
"I was in bed half the week for many years," she
says. Her son often "came home to notes saying, 'Quiet, I'm sick.' "
At one point, she was so sick - and so sick of being sick - that she
was "ready to commit suicide, to not live anymore."
What finally brought Blau's migraines under
control was a course of Nardil (a type of antidepressant).
Now, to prevent attacks, she takes the
antidepressant Prozac (although Prozac's effectiveness for migraine
prevention is controversial), another drug that combines a muscle
relaxant with the antidepressant Elavil, and an anti-inflammatory
drug. (Antidepressants often help people with migraine because they
not only elevate mood but combat pain.)
Like Blau, Valerie Socha, a 38-year-old Revere
computer programmer, has also suffered migraines since she was 17 -
in her case, every time she got her period.
Now, she says, her attacks have been reduced,
thanks in part to an herbal remedy, feverfew, which she takes daily
- three 380 milligram capsules morning and night.
For many people with migraine, however, among them
Patricia Poisson, 56, a self-employed Wayland businesswoman, finding
relief means trekking from doctor to doctor.
Many women find their migraines get better after
menopause, but Poisson says hers got worse: "I had seven headaches a
week - I either woke up with one or got one as the day went on."
She now swears by atenolol, a beta-blocker drug
used to treat high blood pressure. She still gets two migraines a
week, but says, "This is nothing compared to what I have had to live
with for the last eight years."
The options may keep expanding for Poisson and
others.
Encouraged by data suggesting that Imitrex aborts
migraines by constricting blood vessels and blocking release of pain
peptides, researchers are now working on a number of Imitrex
"clones."
About six months ago, researchers also reported
that Lidocaine nose drops can help abort a migraine attack. This
summer, at an international conference in Amsterdam, Belgian
researchers reported that 400 milligrams a day of riboflavin
(vitamin B-2) seemed to cut migraines by more than 50 percent.
And at the New York Headache Center, researchers
have found that half of people with migraines and cluster headaches
may have low levels of the mineral magnesium, and that intravenous
injections of magnesium may help.
But Dr. Dhirendra Bana, director of the headache
and pain center at Faulkner Hospital, cautions that in practice some
remedies fall short.
"We haven't had much luck with magnesium," he
says, or with melatonin, the sleeping aid sold as a dietary
supplement. While some data suggest high (10 mg) doses of melatonin
may prevent cluster headaches, Bana says it hasn't worked well in
his patients.
Another drug, Stadol, a nasal spray used for pain,
has also come under attack - after numerous reports of adverse
reactions.
Still, there is a powerful sense among both
migraine specialists and patients that "all of a sudden, because of
the success of sumatriptan Imitrex, there has been created an
awareness of migraine and that treatments are available," says
Diamond of Chicago.
Cutrer agrees, noting that many patients now
prevent attacks with beta-blockers, calcium channel blockers,
nonsteroidal anti-inflammatory drugs like Naprosyn, the
antidepresssant Elavil, or Depakote, an anti-epileptic drug that
also fights pain.
Increasingly, nondrug therapies are also an
option, especially biofeedback, which can teach patients to increase
blood flow to their hands, perhaps causing blood vessels in the head
to become less swollen and painful.
Once you find something that works, says Patricia
Poisson, life can be utterly transformed: "It's like having that
faucet shut off from Chinese torture. . . I don't know how I stood
it all those years."
To learn more
For more information on
migraines, call:
-
1-800-843-2256, the National Headache
Foundation.
-
1-800-372-7742, to find or start a headache
support group in your area.
If you have migraines with auras that occur after
you eat a certain food or another "trigger" and would like to
participate in the brain scan study at Massachusetts General
Hospital, call 617-726-6939.
