Me and my circumstances: migraine

58 days non-stop with migraines. One-sided throbbing pain between forehead and eyes, the intensity of which varies until it is terrible, debilitating, and gets worse with any movement; extreme intolerance to light, smells and sounds; sickness; poor concentration; irritability; tiredness and weakness; a stiff and painful neck; drowsiness; sinus congestion and tenderness; muscle pain; auras, a flashing, crescent spiral that temporarily impairs vision; a feeling of imbalance; cold sweats; as well as loss of appetite, fluid retention and digestive disorders.

This disease has been part of my life for 45 years, after suffering another ailment in my childhood, in addition to the family history on my mother’s side. Other Herrero have also needed to lie down in a quiet, dark room to cope with an attack that was then simply called a “jaqueca” (headache).

I have managed to function, I would say fully, as a member of society, in my private and professional life, although my personal circumstances, migraine, has always been lurking in the background as a heavy burden (about 4 attacks a month except for especially adverse periods). It is true that, like other negative events, it has surely aided my individual resilience.

I registered as a freelancer in 2018 and began to practice as a lawyer specialising in Animal Welfare. Since then, migraine attacks have progressively increased to levels that are very hard to cope with. In 2021 until August 15th, I have endured 193 days with migraine, which is only 34 migraine-free days over 7 and a half months.

The situation was dire and successful medical proposals not based on more medication were lacking. I recently decided to find the time and energy – while the awful attacks kept me company, like today – to start investigating seriously and to read pages website and books with a minimum level of credibility.

An internet search gives multiple results, especially in English, and in order not to get lost among all the links that I have been keeping, I decided to make an old-fashioned summary. This article has the simple intention of helping me to better understand this disease, as well as to inform those close to me, including the doctors who assist me, about my situation and the main issues of a life with migraine. The title is my little tribute to Ortega y Gasset, the great thinker of Spanish origin, and his words “Yo soy yo y mi circunstancia”/I am I and my circumstances.

Responsibility disclaimer: I am not responsible for nor do I guarantee the reliability, correctness, accuracy or usefulness of the data that I make available to readers here. The use of this article and its contents is the responsibility of each of its readers. If you suspect that you or someone close to you suffers from migraines, always see your family doctor or neurology specialist.

Imagen de Pete Linforth en Pixabay

What is migraine?
Migraine is a complex neurological disorder with a high genetic component that belongs to the group of primary headaches. During a migraine, various areas of the brain are activated and it seems the trigeminal vascular system is directly responsible for the pain. Beyond the main distinction, common and classic migraine with aura, there are several types of migraine such as hemiplegic, vestibular, etc.

A typical attack has five phases1:

  1. Prodrome would be premonitory, minutes or up to 3 days before the pain, with various symptoms (irritability, yawning, inattention, desire to eat sweets, etc.); 
  2. Aura, which only some patients suffer, before or together with pain – in my case it is a visual dysfunction, a flashing spiral, which causes partial and temporary blindness – in other patients it affects different senses such as speech or even behavior;
  3. Pain, the essential symptom of migraine. It often gets worse with physical activity; sometimes accompanied by allodynia (pain caused by a stimulus that would not normally generate it); extreme sensitivity to light, glare, sounds, or smells; gastrointestinal discomfort; changes such as paleness, sweat, or cold hands; dizziness or vertigo; irritability, anguish, fatigue or confusion, among others. If the pain does not subside in 3 days, a “estado migrañoso” (migraine status) is reached.
  4. Resolution, pain and symptoms decrease and eventually stop.
  5. Postdrome or hangover, the final phase that involves fatigue, difficulty concentrating, body pain or euphoria.

It ranks among the 10 most disabling diseases according to the WHO (World Health Organization). In Spain, more than 4 million people suffer from migraine, according to data published in 2020 by the Spanish Society of Neurology (SEN)2. Each of us, as well as our close ones, bear the enormous impact of migraine on our everyday operation and on the physical, emotional, social, professional and financial areas of our lives.

A good friend asked me what is the aetiology or cause of this loathsome disease. The answer is difficult since the mechanism that gives rise to migraine is still not fully understood, despite the millions of people who have received this medical diagnosis. Much is said about the supposed extensive biomedical research aimed to mastering the origin and to develop innovative and useful therapies – whose economic profit prospects are enormous for the pharmaceutical field given the extension of the disease among humans, mostly Caucasians.

In addition to a significant genetic load, different factors are known to play a role in this complex brain disorder. In articles published on the internet I read about calcitonin and CRGP (calcitonin gene related peptide); cortical spreading depression (CSD); hypothalamus dysfunction; glutamate; cortical hyper-excitability; progesterone; serotonin or brainstem.

Since migraine is a polygenic disorder (character determined by the joint action of several genes), one of the relevant areas of research focuses on genomic wide association (GWA). Several studies have identified genetic markers associated with migraine.

In 2010 the journal Nature Genetics published Role of Excitatory Amino Acid Transporter-2 (EAAT2) and Glutamate in Neurodegeneration: Opportunities for Developing Novel Therapeutics3.This article collects the relationship between migraine and the minor allele rs1835740 of chromosome 8q22.1, after several clinical studies with samples of European migraine patients. The rs1835740 variant is located between PGCP and MTDH/AEG-1 (plasma metaderine and glutamate carboxypeptidase), genes that influence glutamate homeostasis4 so its connection with it could be deduced. Glutamic acid or glutamate is an amino acid that participates in a good part of the normal functions of the Central Nervous System (CNS) as a mediator of excitatory signals5. However, this neurotransmitter can be highly toxic and lead to neurological conditions and neuronal death6, hence the importance of homeostasis working properly.

The MTDH/AEG-1 gene exerts a negative regulation of EAAT2 / GLT1, the major glutamate transporter in the brain, which would imply a greater cellular susceptibility to glutamate excitotoxicity. The location of the marker, allele rs1835740, would indirectly lead to the not recent theory that glutamate regulation plays an essential role in the pathophysiology7 of migraine. Thus, the excessive accumulation of glutamate in the synaptic cleft would be a pathway for migraine attacks and would also increase susceptibility, both for an aura and for allodynia – a very unusual type of pain that a neighbour of mine suffers when she takes a strand of hair during an attack of trigeminal neuralgia -.

Otro artículo qAnother article that I have been interested in reading, or at least trying, is The Role of AEG-1/MTDH/LYRIC in the Pathogenesis of Central Nervous System Disease8. Even with my ignorance I can understand and get scared when reading: “Astrocyte-elevated gene-1 (AEG-1/MTDH/LYRIC) is an HIV- and tumor necrosis factor (TNF)-inducible oncogene” y “AEG-1/MTDH/LYRIC contributes to the pathogenesis of neurodegenerative disease, glutamate excitotoxicity, reactive gliosis, and migraine headaches”.

Doctors have assured me that the cerebral blood flow is not affected and that I have no more chance of suffering a stroke than a person who is not migrainous. However, there is a lot of information available online about neurological or cardiovascular comorbidity (existence of two or more diseases) in patients who suffer from migraine. A manual by the Spanish Society of Neurology (SEN)9 states that several population surveys have shown that patients suffering from migraine have twice the risk of suffering and ischemic stroke. I try not to worry about what other serious consequences this disease may entail.

Imagen de Gerd Altmann en Pixabay  

Risk factors/Triggers

Migraine triggers are any environmental, dietary, or physiologic factor that can provoke migraine activity in the brain.

  • Anxiety and depression.
  • Caucasian ethnicity.
  • Female gender.
  • Food.
  • Genetic predisposition.
  • Hormonal changes in women.
  • Irregular daily routines.
  • Sleep disorders.
  • Smells.
  • Stress
  • Weather changes.

.

Imagen de JillWellington en Pixabay  

Food
Migraine has a threshold, and where a person is at any given time determines the frequency, duration, and intensity of pain and other symptoms of an attack. It is essential for each patient to keep a detailed record and to find out what her/his own migraine triggers are, when one is near the threshold of attack, and how to avoid or reduce the effects of such triggers.

The prominent role that different foods and substances play in causing migraines is indisputable, although in detail it is controversial. Certain researchers have been claiming for years that among migraine patients, some of us may be highly sensitive to alcohol, aspartame, caffeine, phenylethylamine, monosodium glutamate (MSG), nitrates, nitrites, or tyramine. I do not remember that the doctors who have treated me paying special attention to my diet, beyond a recommendation to be careful with my coffee.

  1. Among the substances targeted by Drs Sun-Edelstein y Mauskop in 200910:
    Alcohol. It is not clear whether red or white is a greater trigger.
    El vino contiene tiramina, sulfitos, histamina y flavonoides fenólicos, todos ellos pueden en teoría provocar migrañas. (I haven’t had any for a long time, beforehand I used to enjoy organic or biodynamic wines, as recommended by Vinosensis. A glass of wine from renowned wineries, Albariño, Ribera or Rioja, has caused me a migraine in a matter of minutes).
    Aspartame and sucralose.
    Caffeine, a substance present in coffee, tea and sugary soft drinks, as well as some drugs. The effect of caffeine on headaches is quite a paradox because it can improve and worsen them, depending on the frequency and dose.
    Chocolate.
    Cheese.
    Phenylethylamine, a substance present in cocoa that in some patients with migraine causes the release of vasoactive amines such as serotonin or catecholamines.
    Monosodium glutamate (MSG), a flavor enhancer. MSG can cause headaches through a vasoconstrictive effect and indirectly vasodilation. It is used to tenderize carcass meat and appears in many canned, packaged or processed foods under names such as: hydrolyzed vegetable protein; autolyzed yeast; sodium caseinate; yeast extract; hydrolyzed oat flour; texturized protein; or calcium caseinate.
    Nitrates and nitrites, a preservative used to color food or provide a cured or smoked flavor. After ingestion some patients have a migraine in a matter of minutes or hours, possibly due to vasodilation, according to the researchers. The names to avoid would be: sodium nitrate; potassium nitrate; potassium nitrite; and sodium nitrite.
    Tyramine, derived from tyrosine found in cured meats and cheeses, smoked fish, beer, fermented food, and yeast extracts, among others.
  2. According to the “Diet and Migraine”, an infographic from the American Headache Association (AMA)11:
    Possible triggers are:
    – Alcohol.
    – Fasting.
    – Smoked meat from dead animals.
    – Citrus fruits.
    – Caffeine.
    – Chocolate.
    – Dehydration.
    – Monosodium glutamate (MSG).
    – Cured cheeses.
    – Wine.
    Also, according to AMA:
    – Processed foods that tend to contain a lot of sodium can increase the number of attacks.
    – Taking caffeine more than 3 times / week can lead to addiction, cause withdrawal symptoms and increase the number of attacks. Medication containing caffeine should not be taken more than 2 times / week.
    – Es recomendable hacer 5-6 comidas al día y/o picar algo, con índice glucémico bajo, entre las comidas. It is advisable to eat 5-6 meals a day and / or a snack, with a low glycemic index, between meals
    – Skipping food pays off in migraines:
    Low blood sugar can cause attacks or make them worse. Fasting increases the chance of having an attack.
  3. Low Tiramine Headache Diet from the  American Headache Foundation (AHF)12:
    Tyramine appears in food due to the natural breakdown of the amino acid tyrosine and is not a food additive. Tyramine levels increase in foods when they are cured, fermented, stored for a long time, or not fresh.

Food triggers do not always cause pain in all patients, and certain foods can cause an attack in some patients from time to time. The AHF recommends that each patient be their own expert and keep a record of food consumed before a migraine attack, which will allow them to detect if eliminating any of them reduces or makes the pain disappear.

Caffeine content in certain drinks:
350 ml carbonated drink = 30 mg, normal-50 mg, unsweetened    Coffee (* watered down) 175 ml. = 103 mg.   175 ml decaffeinated coffee = 2 mg. 175 ml tea = 31-36 mg.

General rules:

  • Eat 3 meals a day with snacks or 6 small meals throughout the day.
  • Do not eat high sugar foods on an empty stomach, when you are very hungry, or in replacement of a meal.
  • All food, especially that high in protein, should be prepared and eaten fresh. Be careful with leftovers that have been in the fridge for more than 1-2 days. Freeze leftovers if you want to eat them after 2-3 days.
  • Products listed in the “to avoid” section may contain small amounts of tyramine or other vasoactive components. Those in the “use with caution” section do not contain tyramine but are potential migraine triggers.
  • If you are taking a monoamine oxidase inhibitor (MAOI), try eating small amounts of restricted foods and if it is beverages, cut them out.
  • Each person has different sensitivities to certain levels of tyramine or other vasoactive components in food. Try using restricted foods in small amounts.
  1. Dieta de Heal Your Headache (pending)

5. Recommendations by doctors Teixido and Carey (Johns Hopkins University)21

As doctors Michal Teixido and John Carey state, there are hundreds of potential dietary triggers for migraine. These are not the result of allergies but direct sensitivities to chemicals found in food and beverages. Generally speaking, they fall into two categories:

  1. Byproducts of food ageing. Found in fermented products like red wine, aged cheese and yeast in fresh bread and yogurt.
  2. Foods with chemicals similar to the neurotransmitters that our brains use. Coffee, chocolate, MSG and nitrates used to preserve many of our prepackaged foods.

The effects of such triggers can be immediate or be delayed for days. Also, many food trigger may not cause a migraine attack or symptoms alone but in combination with other partial migraine triggers – as it is happens to a friend of mine when taking chocolate and cheese -.

It is recommended that during the first phase of an initial dietary trial only the most common migraine triggers are avoided. If good results are not achieved within a couple of weeks, a comprehensive diet should be followed where all potential migraine triggers are eliminated. It may take 6-10 for a patient suffering from severe and disabling migraine symptoms to respond, and most do so. Once an improvement is achieved, suspected or restricted foods can be added to the diet, slowly and one at a time, to see whether they are relevant triggers for the patient.

6. My own diet (pending)

For the last few days I have been keeping a record and eliminating foods from my diet. The idea is to introduce them again little by little and thus detect what my own triggers are. For now I feel better and it is still too early to reach a conclusion.

Imagen de Huskyherz en Pixabay  
  • List of relevant additives authorised in the EU
  • Acetic acid or vinegar13 E-260 
  • Aspartame E-951
  • Calcium (di)glutamate E-623
  • Carrageenan E-407
  • Citric acid E-330
  • Magnesium glutamate E-625
  • Monoammonium glutamate E-624
  • Monopotassium glutamate E-622
  • Monosodium glutamate (MSG) E-621 E-625
  • Glutamic acid E-620
  • Sodium nitrate E-251
  • Sodium nitrite  E-250
  • Pectins E-440
  • Potassium nitrate E-252
  • Potassium nitrite E-249
  • Sucralose E-955
  • Sulphites, food additives14: E-220 E-221 E-222 E-223 E-224 E-226 E-227 and E-228

Spreadsheet with ingredients that contain or may contain Monosodium glutamate (MSG) and/or glutamic acid

Spreadsheet 1 that I have created for my personal use. Source: https://www.truthinlabeling.org/names.html

Medication for migraine
The drugs prescribed to me over the years act mostly on the effects rather than on the causes. The exception was a drug that brought some very unpleasant side effects and that the specialist doctor ended up removing. I have also received in the last months two medical doses of botulinum toxin or Botox -whose application my father, a health professional, always rejected- in more than 30 punctures in the forehead, skull and neck that in my case have not brought any improvement in six months and perhaps they are related to the deterioration that I have been having. The application of this toxin is not without controversy either.

Recently, a relative who also suffers from migraines told me about monoclonal antibody therapy, a preventive medication, not without adverse effects, that blocks CGRP (calcitonin gene regulator peptide) or its receptor to reduce the number of migraine attacks.

According to the American Headache Society15, a new drug that activates the serotonin receptor (5-HTIF) was approved by the US Food and Drug Administration as a migraine treatment last year.

In my case, I have been taking triptans, always by prescription, for many years. Without this medication that reduces the effects of migraine, I would not have been able to function minimally in my professional sphere, while in the private sphere I have ended up reducing my activities and personal relationships.

Rebound migraines, triptan cessation and remedies
I keep a record of attacks that shows that now it will be twelve months in which, without interruption, I have suffered a migraine for 15 days or more. The medical diagnosis I have received is “migraña crónica” (chronic migraine).

It would be relevant to mention that, starting my personal research focused on migraine, I recently discovered that the variety of chronic or rebound migraine existed due to “symptomatic mediation abuse”, something I was not aware of. Consumption of triptans greater than 10-15 days/month and of NSAID painkillers (non-steroidal anti-inflammatory drugs) greater than 10 days/month leads to chronic migraine. However, the chronification of migraine is not always due to an abuse of medication.

Faced with the prospect of continuing to drag myself through a painful, limited and minimal life, I decided to take advantage of August, the holiday month par excellence, to leave the use of triptans behind. It is not easy to endure multiple migraine attacks on a daily basis just with the sporadic support of NSAID pain relievers such as acetaminophen or naproxen. I read in a facebook group that there are fellow migraine sufferers, braver than me, who have done a crash detoxification without any support drug.

The first 6 days were horrendous. From that point my situation began to improve, from 24-hour migraine I went on to attacks in 2/3 of the day. In the last week I have mostly had migraines for a few hours each day and even two days without any pain. It has been worth it, now I will have to see if the improvement is sustained over time and specially once I resume my usual busy schedule.

I have achieved some relief during my triptan cessation period with:

  • A dark, silent and cool room where to lie down (my animals close by);
  • Cold headbands;
  • Earplugs, phone and ringer disconnected;
  • Ginger infused or chewed in small pieces (fresh root, preferably);
  • Scalp massages and pressure to the forehead;
  • Vegetarian tiger balm (like the one Rakel at Delaterra makes);
  • Acupressure, with the fingers of my hands (or an electroacupuncture device). As long as it doesn’t make me feel worse, applying pressure for a couple of ​​minutes with thumb and/or index finger or a clockwise massage:
    • The lower external part of the crease that appears when the thumb and index fingers are brought together, of the hand opposite the painful side of the body.
    • A point on the anterior face of the wrist. Place one hand flat, palm up and the thumb separated; fit the thumb of the other hand so that the index finger, straight and extended, rests on the wrist at a point between bone and tendons. Always the opposite side to the painful or even both.
    • At the nape of the neck, on both sides of the spinal column where it joins the skull, place the two thumbs or a hand forming a C.
    • In the center of the nasal crease, between the nose and the mouth.
    • In the worst moments of dizziness, I tend to hug my little finger with the other hand.

For more information on migraines and acupressure I have consulted useful books such as:

  • Arthritis Relief at your fingertips. How to use acupressure massage to ease your aches and pains, Michael Reed Gach, Piatkus, 1989.
  • Digitopuntura g-jo. Alivio de dolencias por presión digital, M. Blate, Editorial Hispano Europea, 1985.
  • Suprímase usted mismo sus dolores y dolencias con una simple presión de dedo, Doctor Roger Dalet, Daimon, 1979.

Supplements that may prevent / reduce attacks
Coenzyme Q10, a cofactor of all body cells. The AMA recommends 300 mg. Clinical trials have shown its effectiveness in reducing attacks16.
Magnesium, an element with a vital role in many physiological processes. The AMA recommends 400mg, AHF 400-600mg. According to Drs Sun-Edelstein and Mauskop, migraine sufferers have low magnesium levels during an attack and possibly systemic magnesium deficiency. There are different formulations of magnesium and not all of them have the same effects on each person.
Riboflavin o vitamine B2, essential for cellular functions. The AMA recommends 400 mg. At least one clinical trial has proven its effectiveness in reducing seizures17.
Ginger, used for centuries as an anti-inflammatory and against pain in traditional Chinese medicine; Valerian root; Feverfew (Tanacetum Parthenium) and Butterbur (Petasites Hybridus), recommended by Drs Sun-Edelstein and Mauskop18.
Herbal teas:
An aunt of mine uses chamomile tea as a traditional remedy for headaches.
Another age-old tisane for migraines used in the Serra de Mariola (Alacant) contains broad-leaf linden (Tilia platyphylos), lemon balm (Melissa officinalis), common oregano (Origanum vulgare) and lemon verbena (Lippia triphylla)19.

Imagen de szjeno09190 en Pixabay 

Other possible therapies against migraine

  • Acupuncture. In the past many acupuncturists have helped me cope with and reduce migraine attacks. For some time now, I have not been able to find a therapist with whom I feel comfortable close to my home.
  • Physical exercise, also at the beginning of an attack, as advised by Doctor Oliver Sacks in his work Migraña. In my case, dancing like a wild one to the rhythm of Raffaella Carrà, Tino Casal or Pet Shop Boys.
  • Flowers of California and Bach flowers.
  • Hypnotherapy.
  • Neuromodulation.
  • The AHA includes Stress Management, Relaxation Techniques, Cognitive Behavioral Therapy o Biofeedback Training20.

Essential reading and resources

Mercedes Camps Herrero
August 2021

Responsibility disclaimer: I am not responsible for nor do I guarantee the reliability, correctness, accuracy or usefulness of the data that I make available to readers here. The use of this article and its contents is the responsibility of each of its readers. If you suspect that you or someone close to you suffers from migraines, always see your family doctor or neurology specialist.

Footnotes:

  1. Buonanotte, C.F y M.C: Migraña, 2012 https://www.elsevier.es/es-revista-neurologia-argentina-301-articulo-migrana-S1853002812001541 
  2. Sociedad Española de Neurología (SEN): Manual de práctica clínica en cefaleas, 2020 https://www.sen.es/pdf/2020/ManualCefaleas2020.pdf
  3. Anttila, V. et al: Genome-wide association study of migraine implicates a common susceptibility variant on 8q22.1, 2010 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3130100/  
  4. Conjunto de fenómenos de autorregulación, que conducen al mantenimiento de la constancia en la composición y propiedades del medio interno de un organismo.
  5. Rodriguez de Viñas, L. y Brandi, A.: Rol del glutamato y del sistema inmune en afecciones agudas y crónicas del SNC, 2005 https://bdigital.uncu.edu.ar/objetos_digitales/1242/rodriguezrmuv1n1.pdf
  6. Medina Marín, A. M.: Sistema glutamatérgico, primera parte: Sinaptología, homeostasis y muerte celular, 2002 http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0034-74502002000300002
  7. Estudio de los procesos patológicos, físicos y químicos, que tienen lugar en un organismo vivo.
  8. Noch E. and Khalili K.: The Role of AEG-1/MTDH/LYRIC in the Pathogenesis of Central Nervous System Disease, 2013 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4204483/
  9. International Headache Society y SEN: III Edición de la Clasificación Internacional de las Cefaleas, 2013  https://www.sen.es/pdf/2014/cic3_beta.pdf 
  10. Sun-Edelstein C. y Alexander Mauskop: Foods and Supplements in the Management of Migraine Headaches, 2009  https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.530.1223&rep=rep1&type=pdf 
  11. AHA: Diet and Migraine https://americanheadachesociety.org/wp-content/uploads/2019/03/DIET-and-MIGRAINE_11x14.pdf 
  12. AHF: Low Tyramine Headache Diet, 2018 https://headaches.org/wp-content/uploads/2018/02/TyramineDiet.pdf  
  13. https://e-aditivos.com
  14. Sulfitos: por qué son un aditivo alimentario que genera dudas: eldiario.es 2019 https://www.eldiario.es/consumoclaro/cuidarse/sulfitos-aditivo-alimentario-genera-dudas_1_1724976.html 
  15. Lasmiditan, First Oral Serotonin 5-HT1F Receptor Agonist or Ditan, Available for Prescription  (AHS) 2020 https://americanheadachesociety.org/news/lasmiditan-prescription/ 
  16. Véase nota al pie nº 10.
  17. Véase nota al pie nº 10.
  18. Véase nota al pie nº 10.
  19. Belda Antolí A. y Bellod Calabuig F.J.: Plantas medicinales de la Sierra de Mariola, Universitat d’Alacant, 2006.
  20. AHA: Living Well With Migraine: Behavior and Lifestyle, 2019 https://americanheadachesociety.org/wp-content/uploads/2019/03/Behavioral-Infographic_V3-11×14.pdf 
  21. Teixido M. y John Carey: Migraine – More than a Headache, 2014 https://www.hopkinsmedicine.org/otolaryngology/_docs/migraine%20patient%20handout.pdf