Effective help is available for migraine sufferers
Although it’s the third most prevalent illness in the world, migraine is widely misunderstood and frequently undiagnosed. Until quite recently a common “remedy” for migraine was to lie in a dark room and wait for the pain to pass. But today there are treatments that work – and new medications formulated specifically for migraine are in the pipeline.
The World Health Organization lists migraine -- the condition that produces recurring, severe, often-incapacitating headaches and other debilitating symptoms lasting from a few hours to a few days -- as the third most prevalent illness in the world, behind only tooth decay and tension-type headaches. More than 38 million Americans suffer from migraine, including approximately 28 million women, who are afflicted at a rate three times that of men. The nonprofit Migraine Research Foundation says health care and lost-productivity costs associated with migraine are estimated to be as high as $36 billion annually in this country.
Despite those (and many other) daunting statistics, migraine is still widely misunderstood and frequently undiagnosed. And until quite recently the most commonly prescribed "remedy" for migraine was to lie in a dark room and wait for the pain to pass.
"It used to be that people with migraine were largely ignored and had to sequester themselves off someplace for hours or even days," said Juline Bryson, M.D., a neurologist and headache specialist at Wake Forest Baptist Medical Center. "But people who have migraine don't have to suffer. We have treatments that work, and even better ones are in the pipeline."
The first thing to realize about migraine, Bryson said, is that it's not just a bad headache. Rather, migraine is a complex neurological disorder that is genetic in nature.
"It's a strong hereditary trait," she said. "If one of your parents has migraine, there's a 50 percent chance you will, too. If both parents have it, there's a 75 percent chance."
In people who have this genetic predisposition to migraine the brain is abnormally sensitive to certain stimuli.
"When the brain is irritated it slows everything down, which is why people can't see clearly, feel clumsy, can't think straight, can't speak well, feel nauseous," Bryson explained. "Blood vessels get super-sensitive with increased blood flow, which causes throbbing pain.
"And the trigeminal nerve [the large nerve on both sides of the head that supplies sensations to the head and face and controls the muscles used in biting and chewing] flips out and sends all sorts of pain signals."
Not all migraine attacks are the same -- some, for example, are preceded by visual disturbances called aura -- nor are the triggers that initiate them.
And because migraine doesn't produce a visible sign like a bruise or rash and can't be detected by an X-ray or other imaging technique, doctors have to depend on patients' accounts of their episodes to know exactly what they're dealing with.
"We do rely on what patients tell us," Bryson said. "But people don't have very good recollections of their migraines. Some people think they have more headaches than they actually do, some fewer. So we tell a lot of patients to do a headache diary. When they keep a record of their migraines, when they occur, how bad they are, how often they last, what they did or consumed before they happened, we can get a much better idea of how to proceed."
Some of the factors than can trigger migraines or make them worse are common to most patients. These include fluctuations in estrogen levels in women, a drop in barometric pressure (as when a storm is approaching), anything that causes inflammation (such as a cold or any type of infection) and the overuse of over-the-counter medications and prescription opiates. Physical conditions such as obesity and sleep apnea also can contribute, as can lifestyle choices like smoking, drinking alcohol and eating foods high in preservatives and artificial sweeteners. But by no means does the list stop there.
"I could talk for hours about migraine triggers. There are probably as many triggers as there are patients," Bryson said, adding that some people have no clear triggers.
The prescription medications currently used to prevent migraine were all developed for other purposes. These blood pressure medicines, anti-seizure drugs and antidepressants have proven effective in reducing migraine. There's also onabotulinum toxin type A (Botox), which is approved as a preventive measure for people who have attacks more than 15 days a month. Medicines in a group called triptans can be taken at the onset of migraine attacks to lessen their effects.
"There are some good medications, but not everybody responds to them," Bryson said. "Fortunately, we have a whole new class of medications formulated specifically for migraine that are probably going to be released in the next year or two, which should change the face of migraine treatment strategies as we know them."
Those treatment strategies are not limited to drugs. Bryson and her colleagues in the headache program at Wake Forest Baptist take an integrative approach that can include sleep studies, psychological counseling, relaxation techniques, physical therapy, exercise and lifestyle changes.
Another member of the Wake Forest Baptist team, Rebecca Wells, M.D., is currently conducting a clinical study of stress reduction as a treatment for migraine.
"We don't just give somebody pills and send them on their way," Bryson said. "We look at a variety of factors and try to address them. It's my job to educate patients, to help them learn how to control their headaches, but they have to do their part."
However, no treatment program can totally eliminate migraine.
"Patients can do everything perfectly -- take their meds, lose weight, get enough sleep, stop drinking coffee, whatever -- and still get migraine, because it's genetic," Bryson said. "We'll never completely stop migraine headaches, but we can reduce them so people can be in control of their pain instead of their pain controlling them.
"Even if somebody has only one or two migraines a month, those hours with pain are lost to them, their families, their work, the enjoyment of their lives. Anyone who has migraine should see a doctor as soon as it interferes with their life. Period."
Imaging studies and other research suggest that there is a biological basis for transgender identity.
Male and female brains are, on average, slightly different in structure, although there is tremendous individual variability. Several studies have looked for signs that transgender people have brains more similar to their experienced gender. Spanish investigators—led by psychobiologist Antonio Guillamon of the National Distance Education University in Madrid and neuropsychologist Carme Junqu Plaja of the University of Barcelona—used MRI to examine the brains of 24 female-to-males and 18 male-to-females—both before and after treatment with cross-sex hormones. Their results, published in 2013, showed that even before treatment the brain structures of the trans people were more similar in some respects to the brains of their experienced gender than those of their natal gender. For example, the female-to-male subjects had relatively thin subcortical areas (these areas tend to be thinner in men than in women). Male-to-female subjects tended to have thinner cortical regions in the right hemisphere, which is characteristic of a female brain. (Such differences became more pronounced after treatment.)
“Trans people have brains that are different from males and females, a unique kind of brain,” Guillamon says. “It is simplistic to say that a female-to-male transgender person is a female trapped in a male body. It's not because they have a male brain but a transsexual brain.” Of course, behavior and experience shape brain anatomy, so it is impossible to say if these subtle differences are inborn.
Ads (one even by Ronald Reagan) promoted the health benefits of smoking. "Reach for a treat, instead of a sweet." In 2014, the Nation marked the 50th anniversary of the first Surgeon General’s Report on Smoking and Health. In 1964, more than 40 percent of the adult population smoked. Once the link between smoking and its medical consequences—including cancers and heart and lung diseases—became a part of the public consciousness, education efforts and public policy changes were enacted to reduce the number of people who smoke. These efforts resulted in substantial declines in smoking rates in the United States—to half the 1964 level.
However, rates of cigarette smoking and other tobacco use are still too high, and some populations are disproportionately affected by tobacco’s health consequences. Most notably, people with mental disorders—including substance use disorders—smoke at higher rates than the general population. Additionally, people living below the poverty line and those with low educational attainment are more likely to smoke than those in the general population. As tobacco use is the leading preventable cause of mortality in the United States, differential rates of smoking and use of other tobacco products is a significant contributor to health disparities among some of the most vulnerable people in our society.
What is the scope of tobacco use and its cost to society?
Approximately one fourth of the population uses tobacco products, and 19.4 percent smoke cigarettes. According to the 2016 National Survey on Drug Use and Health (NSDUH), an estimated 63.4 million people aged 12 or older used a tobacco product during the past month, including 51.3 million cigarette smokers. Smoking rates continue to go down year to year; the percentage of people over age 18 who smoke cigarettes declined from 20.9 percent in 2005 to 15.8 percent in 2016, according to the 2017 National Health Interview Survey.
However, smoking rates are substantially higher among some of the most vulnerable people in our society. The 25 percent of Americans with mental disorders, including addiction, account for 40 percent of the cigarettes smoked in the U.S.More than 40 percent of people with a General Education Development certificate (GED) smoke—which is the highest prevalence of any socioeconomic group.Also, people who live in rural areas, particularly in the South Atlantic states, use all forms of tobacco at higher rates than people who live in urban areas. These differences cannot be fully explained by different levels of poverty or affluence.
Smoking among youth is at historically low levels. According to the NIDA-sponsored Monitoring the Future (MTF) survey,in 2015, an estimated 4.7 million middle and high school students used tobacco products during the past month, according to data from the National Youth Tobacco Survey (NYTS)e-cigarettes) were the most commonly used tobacco products among middle (5.3 percent) and high school (16.0 percent) students in 2015. E-cigarettes deliver synthetic nicotine and do not contain tobacco; however, they are classified as tobacco products for regulatory purposes. These findings are echoed by other studies, including theMTF survey. Scientists have not yet determined the medical consequences of long-term e-cigarette use or the secondhand effects of e-cigarette vapor.
Between 1964 and 2012, an estimated 17.7 million deaths were related to smoking leads to more than 480,000 deaths annually. If current smoking rates continue, 5.6 million Americans who are currently younger than 18 will die prematurely from smoking-related disease.
In addition to the tremendous impact of premature deaths related to tobacco use, the economic costs are high. Experts estimate that between 2009 and 2012, the annual societal costs attributable to smoking in the United States were between $289 and $332.5 billion. This includes $132.5 to $175.9 billion for direct medical care of adults and $151 billion for lost productivity due to premature deaths. In 2006, lost productivity due to exposure to secondhand smoke cost the country $5.6 billion.About 70 percent of current smokers’ excess medical care costs could be prevented by quitting.