Why me? Every headache sufferer at some point
asks this question. I’ve asked it, too — for myself and for the more than 10,000 patients
I’ve cared for over the last 20 years. My name is Robert Cowan. I am a migraine sufferer.
I am also a migraine researcher and the director of Stanford’s Headache and Facial Pain Clinic.
What I, and my patients and colleagues have learned about headaches can go a long way
toward helping people who have headaches. Lets take a look at the most common kind of
severe headache — Migraine. Upwards of 20 million Americans suffer from
migraines. They are three times more common in women and cost the American economy more
than 30 billion dollars a year. But why do we get migraines? We know that pain tells
us when there is something wrong — it is our body’s early warning system. But when
that system is too sensitive, it can trigger migraine. That sensitivity is inherited. It
is in our genes. Environmental changes that may not strike most people as dangerous or
harmful can set off the pain response in people with migraine. Either external environmental
factors, such as too much sun,, or internal environmental factors, such as a drop in estrogen
levels or a change in sleep patterns,) can trigger headache in those of us genetically
wired for migraine. So, what is a person with headache to do?
First we need the right diagnosis, then we need to take care of the headaches. We can’t
get a do-over on picking our parents, and certain aspects of the environment are beyond
our control. So we need to focus on those aspects of our environment that can be controlled.
It comes down to two things: observation and planning. Each of us needs to learn about
our own headaches, work with our doctor to get the right diagnosis, and then make a plan,
or treatment strategy, so we can be prepared for them and manage them when they hit.
Step 1: The Observation Not everyone gets headaches from chocolate,
and generic lists of things to avoid rarely work out. We need to observe our own patterns
of behavior to identify the things that contribute to our headaches. A great way to get started
is with the headache diary. There are a host of smart-phone apps, computer programs and
paper diaries available to help create a record. You don’t need to make a career out of it,
but by recording your headache frequency and severity, time of onset and similar information
for a month or three, you may begin to see patterns that weren’t readily obvious when
you simply “thought back” on your headaches. Of course, keeping a headache diary does no
good if you don’t analyze it, don’t go over it with your headache doctor or just forget
to keep it on a regular basis. For example, if your headache diary shows you that red
wine sometimes gives you a headache, and a lousy night’s sleep sometimes gives you a
headache, then you can make the decision about whether to have red or white with dinner based
on whether you had a good night’s sleep the night before.
Once you have your observations, it is time to make a diagnosis. A headache specialist
can help you construct a headache history, which, combined with a neurologic and general
physical examination and any testing that might be necessary, should lead to a diagnosis.
There are more than 150 headache types, and they are not all treated the same. So a plan
must begin with the correct diagnosis. Step 2: The Plan — A Treatment Strategy
A good treatment strategy should have three parts: rescue or acute treatment, prevention
and lifestyle modifications. Usually, the cornerstone of a rescue or acute treatment
is medication, but it is also important to have a strategy in place to hand off your
responsibilities, to have a safe, quiet, dark place to go, and so forth. Without these pre-determined
processes, your mind will constantly cycle back to loose ends and other stressors, making
your medication less effective and your recovery slower.
The second component of your treatment plan is prevention. Prevention is made up of the
strategies you put in place to decrease your sensitivity to the environmental stressors
that can trigger your headache. Again, medication often plays a role in prevention, and the
selection of your preventive steps is one of the most important functions your physician
can perform. There are many options, each with distinct advantages and disadvantages.
There is no one-size-fits-all preventive. But just as with the rescues, it is not all
about the medication. Behavioral strategies such as biofeedback, physical therapy, stress-
management, integrative medicine and other strategies are essential to good outcomes
for many patients. The third and final component of a treatment
plan is lifestyle modification. This is often the most important and most beneficial. By
the same token, it is often the first to fall by the way once headaches are under control.
If change in the environment can trigger a headache, it follows that providing your body
with a predictable, orderly life will be, to some degree, protective against migraine.
Thus, the goals in lifestyle modification are to maintain consistent sleep patterns,
eating patterns and exercise patterns. It is these three behaviors that influence changes
in your body’s hormonal cycles. By maintaining consistency in these cycles, your body is
better able to anticipate and adapt without spiraling out of control and into migraine.
Not every headache is our fault. To be sure, we can do some things knowing full well we
will probably get a headache. And that’s OK. We have free will, and sometimes that day
at the beach or Beastie Boys concert is worth the price. But we are genetically hard-wired
to get headache under some circumstances. So we need a plan to deal with headaches when
they happen, and the better we are at managing them, the fewer headache days we will have.