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News from Migraine Research

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Vision Loss During Migraines Linked to Strokes
Triptan Drug Now Available in England
Studies Offer Conflicting Views on Migraine-Heart Connection

Vision Loss During Migraines Linked to Strokes

NEW ORLEANS, Feb. 3 - Two studies presented at the American Stroke Association's International Stroke Conference seemed to confirm a strong link between migraine headaches and strokes.

In the first study, Italian researchers investigated whether migraine (with or without aura) could be a risk factor for strokes in patients ages 16 to 44. Examining data from 238 male and female stroke patients, and an equal number of control subjects, they found that 63 stroke survivors had experienced migraines compared with only 33 people in a control group. Researchers were able to rule out smoking, alcohol intake, and contraceptive pill use, as factors that might explain the difference. When migraine was combined with high blood pressure, the stroke risk increased even more, said Massimo Camerlingo, M.D., head of the neurologic unit at Policlinico San Marco in Osio Sotto (Bergamo), Italy.

The second study addressed the question of whether there is a link between strokes and migraine-related vision loss. Migraines are often preceded by aura, sometimes of an auditory nature but more often as visual phenomena including visioni loss. Migraines with visual aura have been associated with ischemic stroke, but researchers at the Centers for Disease Control in Atlanta wantedto know if strokes could be linked with any particular type of visual disturbance. Their study whoed that women who experience vision loss as a symptom of migraine have a 70 percent increase for the risk of stroke compared to women who don't have migraines.

"Our study found that women who suffer migraines with loss of vision or partial loss of vision were 1.7 times more likely to have stroke compared with women who do not have a history of migraines," said study author Wayne H. Giles, M.D., M.S., associate director for science in the Division of Adult and Community Health at the CDC. The study included 963 women between ages 15 and 49; 542 of them had suffered strokes.

Women who see spots and lines during or just before migraine had a 25 percent increased risk of stroke over women without migraines. But women who experience vision loss during or before migraine had a 70 percent higher risk. This may indicate that vision loss is more likely to represent transient cerebral ischemia than seeing spots and lines.

The prevalence of migraine - in general - is about 17 percent in women, and the prevalence of migraine with aura, is about 5 percent in women, Giles said. Of those with aura, more than 90 percent of patients report visual symptoms, such as light sensitivity; seeing lines or spots; seeing flashes of light or temporary loss of vision, he said.

"Other case-control studies had shown that migraine with aura was more strongly associated with stroke, but ours is the first to examine the type of aura symptom and the likelihood of stroke," Giles said.

These findings need independent confirmation from other investigators, but they indicate that women with migraine and aura should address all other stroke risk factors, particularly smoking. Women with migraine and aura should also be aware that oral contraceptives may increase their risk of stroke, and they should discuss the risk/benefit ratio of these agents with their doctors, Giles said.

Giles emphasized that migraine sufferers who experience new neurological symptoms, including transient loss of vision, should be evaluated by a doctor to exclude other causes such as transient ischemic attack (TIA). A TIA, which is caused by reduced blood flow in the brain, can result in a temporary loss of vision and can occur independent of migraine, he said.

[SOURCE: American Heart Association.]

Triptan Drug Now Available in England

British regulators have approved for the first time the over-the-counter sale of a triptan drug. The approved drug is called Imigran Recovery, a GlaxoSmithKline product, which contains the active ingredient sumatriptan. Sumatriptan was the first of the "triptan" drugs -- the first non-narcotic medications that can reduce or eliminate a migraine in most persons.

Imigran Recovery contains 50 mg of sumatriptan. The prescription drug Imitrex, also by GlaxoSmithKline, contains 50 mg or 100 mg per tablet. Imigran Recovery will be sold for $15.00 US for a two-pack, about half the cost of the prescription 50 mg Imitrex tablet. (At the same time, a generic version of Imitrex should be available soon in the U.S. See related article below.)

Sumatriptan (Imitrex) was the first of the triptan drugs. It was approved as a prescription medication in England in 1990, and a few years later was approved for sale in the U.S. by the Food and Drug Administration. Sumatriptan is the most widely prescribed medicine in this category with over 800 million prescriptions world-wide since launch.

It is likely that GlaxoSmithKline and other manufacturers of triptan drugs will now be looking for approval of over-the-counter triptan drugs in the U.S. (See related story below.)

[SOURCE: Food and Drug Administration, GlaxoSmithKline, Ozone Communications.]

Studies Offer Conflicting Views on Migraine-Heart Connection

Conflicting reports on whether migraine headaches are linked in some way to heart disease illustrate the fact that researchers are still a long way from having a good understanding of the pathophysiology of migraine.

A major study in The Netherlands, involving nearly 6,000 participants, seemed to show that people with migraine headaches are at greater risk for developing cardiovascular disease than the general population. “For reasons that are not yet clear, people with migraine—particularly those with aura—may be more likely to present with risk factors associated with cardiovascular conditions,” said lead author Ann Scher, PhD, of the National Institute on Aging in Bethesda, Md. “It is known that migraine with aura increases the risk of stroke before the age of 45, although the reason for this is not yet clear.”

Men and women with migraine were 1.78 times more likely to have a mother with a history of early heart attack. Whether migraines “cause” cardiovascular problems or vice versa is still very much in doubt. The research shows simply that there may be a shared predisposition toward both migraine and heart disease, said Lenore Launer, PhD, also of the National Institute on Aging and the senior author on the study.

By contrast, a study reported only two months earlier in the same journal indicated that while people with migraine headaches report more angina (chest pain), they do not seem to be at higher risk for heart disease. The study was conducted at the University of North Caroline , where researchers looked at the medical records of 12,409 individuals.

According to the report: “After adjusting for factors such as age, race, hypertension, smoking and total cholesterol, participants with a history of migraine or other headaches with aura were three times more likely to report a history of exertional chest pain that those without a history of headaches. “No significant association was seen between headaches and verified coronary heart disease.” (Emphasis added).

Additional research into the possible link between migraine and heart disease is ongoing and the results will be published here.

[SOURCES: For the study, see Neurology, February 2005. For the University of North Carolina study see Neurology, December 2004. Neurology is the scientific journal of the American Academy of Neurology: www.aan.com ]

New Products

October 10, 2009 - The FDA has approved a new drug that combines 85 mg of sumatriptan and 500 mg of Naproxen. Sumatriptan (Imitrex) targets the nerves and blood vessels and while very effective for most migraineurs works in ways scientists no not yet understand. Naproxen relieves inflammation.

The brand name is Treximet. It is made by GlaxoSmithKIline.

Cindy McCain Lived a Nighmare During Presidential Campaign

As a migraineur it is hard for me to imagine a more nightmarish situation than that endured by Cinday McCain, wife of the Republican presidential nominee. She has had severe and frequent migraines for many years, and New Yorker wrtiter Lauren Collins wrote about her situation in the Sept. 21, 2009, issue of The New Yorker Magazine. Mrs. McCain has decided to become a public advocate for migraine research.

From The New Yorker Magazine, September 21, 2009:

Cindy McCain has endured a number of public tribulations, including miscarriage, stroke, knee replacement, ruptured disks, and an addiction to painkillers. Last year, as her husband, John, campaigned for President, her weight dipped below a hundred pounds. During a rally in West Bloomfield, Michigan, she suffered a handshake injury—a minor sprain, aggravating an old carpal-tunnel problem—sustained, her husband said, when a supporter “very vigorously” pumped her right hand. It was thus surprising to learn recently that Cindy McCain had, all along, been engaged in “a silent struggle,” one “that has burdened her through many political campaigns, her charitable work, and her day-to-day life.” The bearer of the news was the American Headache Society, and the adversary was migraine. “You know the picture in People magazine with me in the little dress?” McCain recalled. “That was the worst. We were with President Bush—where was it, Arizona? Anyway, I got up, because I had to, and once I got on the airplane I collapsed.”

McCain was speaking as the guest of honor at a luncheon given by the A.H.S. in a private room at Le Bernardin. (The next day, in Philadelphia, she would be the keynote speaker at the Fourteenth Congress of the International Headache Society.) She was dressed in spectator pumps and a chartreuse piqué suit. Everything about her seemed lemony—tart yellow bob, pursed lips. Her commentary, aided by a stack of blue index cards—one listed migraine sufferers in history: “THOMAS JEFFERSON, JOAN OF ARC, VIRGINIA WOOLF”—was astringent. She recalled, “The first doctor I went to basically said, ‘Well, you’re just neurotic, you’re just stressed, your husband’s a senator. Go home, put your feet up, and have a drink.’ ” She continued, “What affected me the most was being talked to like I was dumb. That infuriated me.” McCain has decided to become an advocate for the disorder, which, in her view, is a disability. “I’ve missed part of my life. I’ve missed my children in many ways,” she said. “I’ve made every important event, but there’re times I’ve been throwing up out the car window.”

Treating migraine is an inexact science. McCain has tried everything: acupuncture, acupressure, massage, tricyclics, analgesics, biofeedback. Once, in the Micronesian islands of Yap, where she had travelled as part of a charity mission, a medicine man crushed up some guava leaves and stuck them in her mouth. (“It did help,” she said.) McCain adheres to a daily regimen of pills to manage the condition, and this year she participated in a clinical trial to test the effectiveness of Botox in alleviating migraine. “You know, they ring your head in it,” she said. “It hurts like the dickens. But I’ll do anything, including chew broken glass, if it would help me get rid of this.”

Her goal is to raise money for research into treatments explicitly for migraine. At Le Bernardin, she said, “For the first time in my life, I’m going to go to Congress, and I’m going to be tenacious and be forceful and be honest and tell them that it’s time. If you can give five million dollars to study flatulence in cows and its effects on the ozone layer, you can give me some money for migraine research.”

McCain is also considering making a video diary of a migraine, in the mode of Farrah Fawcett’s cancer documentary. “It’s so dramatic when it happens,” she said. “I wind up going into an infusion unit, and it’s traumatic, because I’m a hard stick, and I’m crying half the time.” She paused. “People don’t really understand, because a headache’s more than just a headache.” ♦

New Views on Wine and Headaches

Dr. Fred Freitag of the Diamond Headache Clinic lays to rest some myths about wine and migraine, in this column from the Wine Spectator.

Fred Freitag, associate director of the Diamond Headache Clinic, says there are distinct types of headaches that some people experience when they drink wine: "There is a unique headache associated with red wines, which is different from the headache some people get from drinking wine of any sort, which is different still than the migraines some patients experience related to wine ingestion." As such, identifying the specific triggers that cause these headaches can be tricky, however, Freitag says that there are some "myths" that can be ruled out.

Freitag believes histamines, which are found in higher amounts in red wine, are an unlikely source for the causation of headaches, as they are found at greater levels in other frequently consumed foods: "there is more histamine in 4 ounces of fish or a serving of eggplant than in 4 ounces of red wine." In addition, he reports that a more common allergic reaction to histamines is a stuffy nose, rather than headaches.

Sulfites, small amounts of which are found in wines, also are mistakenly identified as a headache-causing agent, says Freitag. They too are found in many food sources, like dried fruit, baked goods and pickled vegetables. An allergic reaction to sulfites usually encompasses breathing and rashes, not headaches.

Headaches could be triggered by alcohol, says Freitag, which would explain why red wine, which is generally higher in alcohol, seems to pose more problems for certain people.

According to Freitag, other elements in wine that could trigger headaches include tyramine (an amino acid derivative that is formed during fermentation), which has been linked to migraines, or one of the many chemical compounds created during the winemaking or aging process, called congeners. Some of these compounds are found on grape skins, and it would follow that wines that are fermented on their grape skins, like red wines, would have more of this compound. Other compounds are extracted from the woods used in fermentation and aging, so to determine if these are problematic triggers, you would want to compare your reaction wines that are fermented in stainless steel and wines fermented in oak.

Alessandro Panconesi, an internal specialist in Florence, Italy, recently published a review of migraine studies that followed wine intake in the Journal of Headache and Pain. He reports that headache triggers could be many things, and even come from "stress or emotions that concur with [the consumption] of alcoholic drinks."

The best plan of action is to consult with your doctor, as migraines can be ameliorated with special treatment. In addition, carefully monitor your intake of wine to try and determine which specific types of wines, or occasions when you drink wine, are causing you problems to see if there is a pattern that would help you avoid the offending agent.

What migraines have in common: hypersensitivity to stimuli

The evidence keeps piling up that one thing shared by migraine sufferers is a hypersensitivity to stimuli. This explains why so many migraineurs suffered from car sickness and sea sickness when they were children. (See "Motion Sickness in Migraine Sufferers" in the Abstract section.) Others have noted that antiepileptic drugs are helpful for some migraine patients, and infer ca connection between migraines and the hyperexcitabilty of epilepsy. (See "More Evidence for 'Hyperexcitability' Theory" in the Abstracts section.)

Any doubts about the connection between migraine sufferers and hyperexcitability to stimuli should be put to rest by a new book called The Migraine Brain by Carolyn Bernstein, M.D. (Simon and Schuster, 2008, $25).

"The biggest myth is migraine is a type of headache," writes Dr. Bernstein. "This is wrong. Migraine is a complex neurological disease that affects your central nervous system. Headache is one of its symptoms, but migraine almost never consists of head pain alone. There are many other possible symptonms, including nausea or vomiting, sensitivity to light or sound, tingling or strange sensations in your skin, visual changes, hunger pangs, and slurred speech. Almost everyone experiences several symptoms during a migraine attack.

"Ordinary headaches that occur randomly do not comprise a disease. But migraine is a chronic, neurological illness that you were born with. It's something you live with, a presence in your life like arthritis, although you usually can't predict when it will leap up to consume and ruin your day (or days)."

Dr. Bernstein says the new science of migraine recognizes that migraine disease involves many aspects of your physiology, including your central nervous system, neurotransmitters and other chemicals in your brain, electrical impulses, your inflammatory response, a nerve in your face and head called the trigemical nerve, and other systems. "The latest research points to a 'cortical spreading depression' as the physical reaction that begins a migraine attack." Cortical spreading depression is a dramatic wave of electrical 'excitation' that spreads across the surface of the brain ... when something antagonizes or upsets it.

Other researchers have long noted that during epileptic attacks, this "cortical spreading depression" happens very quickly. In migraines it spreads more slowly.

Dr. Bernstein is one of the first researchers to connect migraines and "sleep apnea," a dangerous health problem that causes you to stop breathing for short periods of time while you are sleeping. Sleep apnea is one of the most undertreated major health problems in the country. Effective devices are available to control it.

In The Migraine Brain Dr. Bernstein describes the reasons migraine is a neurological illness, discusses migraine triggers and offers ways to self-treat migraine.

News from Migraine Research

Dr. Fred Freitag of the Diamond Headache Clinic lays to rest some myths about wine and migraine, in this column from the Wine Spectator.

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