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Getting It Right: Migraine Diagnosis and Treatment
By Kevin Brown

Nathan L. BennettIf you suffer from migraines, you understand the pain and unusual symptoms associated with this condition. You also might understand the misinformation and even misdiagnosis surrounding migraine.

Nathan L. Bennett, M.D., recently shed light on this debilitating condition. A Certified Headache Medicine Subspecialist, Dr. Bennett is founder and director of the Preferred Headache Center and is on staff at AHN Jefferson Hospital.

Migraine Misconceptions
“You won’t hear me use the term ‘migraine headache’ which a lot of people use,” says Dr. Bennett.
“Migraine is much more than a headache and, in fact, for a lot of people the headache itself isn’t even the most bothersome symptom,” he says.

“The fallacy is that you have to have a severe headache for this to be a migraine,” he explains. “There are four criteria: the headache is one-sided, throbbing, moderate to severe in intensity, and worse with activity. You only need to have two of these – not all of them. In addition, you need to have nausea and/or vomiting OR light and sound sensitivity. Many physicians think that it needs to be a severe headache or it’s not a migraine.”

According to Dr. Bennett, the most common misdiagnosis for migraine is sinus headache. “There is no such thing as sinus headache. Period,” he says emphatically. “There are studies that prove over 95 percent of people with either self-diagnosed or physician-diagnosed sinus headache meet the criteria for migraine. It is easy to understand why this happens. A lot of people have facial pain and pressure in the forehead or behind the eyes. A lot of time, the pain is worse with bending over like there is fluid building up in there. A runny or stuffy nose is a common migraine symptom and weather changes frequently trigger migraine,” he says.

Another common misconception is that neck pain causes migraine. “Neck pain occurs in 75 percent of people with migraines which is why a lot of people think that they are getting their headaches from their neck when, in reality, the neck pain is being caused by the migraine.” he notes.

“Migraine is a complex biological condition for which the basis is a hypersensitive and hyperactive nervous system – that includes the peripheral and central nervous system – where the “off” switches don’t work well,’ Dr. Bennett explains.

“That comes down to a malfunction of the neurons because they over-respond to environmental input. Everyone has different hypersensitivities and triggers – bright lights, different foods, smells, and activities. This is no longer considered a vascular disorder or a vascular headache that a lot of neurologists still hang onto. We got rid of that notion in the 1990’s,” he says.

Migraine Symptoms
Dr. Bennett also addresses the limited number of symptoms in the diagnostic criteria for migraine. “Only four different symptoms are listed: light and sound sensitivity, nausea and vomiting. Now, that’s very narrow and there are statistical reasons why it’s like that, but the reality is that is a very tiny list of the many symptoms that occur with migraine.”

Dr. Bennett says that, for example, sensitivity to smell occurs about 30 percent of the time in those with migraine. He adds that “autonomic symptoms including runny nose, stuffy nose, tearing, red eyes, swollen eyes, even flushing of the face occurs in over one-third of patients with migraine. Dizziness, vertigo, or feeling off-balance are common. Abdominal pain, depression and anxiety are common as are all kinds of visual disturbances such as blurred vision, double vision, and seeing squiggly lines or flashing lights.”

He also includes numbness and tingling of the hands or feet, weakness and facial drooping among migraine symptoms.

“There are a whole lot of symptoms that aren’t covered by the diagnostic criteria and people need to be aware of these,” he explains.

Migraine Phases
Many migraine sufferers recognize the four phases of migraine: prodrome, aura, attack and postdrome.

Dr. Bennett says that the prodrome phase can occur hours to days before the aura and attack phases.
“The prodrome symptoms can include irritability, depression, anxiety, yawning, food cravings, frequent urination, diarrhea, or stomach upset. Those are just a handful of the symptoms that can occur,” he says.

“The next phase is the aura, which occurs in 20 and 30 percent of people with migraine. The aura symptoms are usually visual, but can be sensory or can include motor weakness. Auras last from five to 60 minutes.”

“The attack, or what some experts call the “headache” phase, comes next with associated symptoms as we previously discussed such as nausea, vomiting and more. Unfortunately, the definition of migraine is only based on the attack phase which doesn’t tell the whole story. And that’s why you can miss it. You’ve got to pay attention to every phase to figure it out and treat people correctly,” he says.

“Finally, there’s the postdrome phase or the migraine ‘hangover’ which can be really debilitating. There is extreme fatigue, brain fog, nick stiffness, depression, and anxiety. Some people can feel euphoric. These symptoms can last for hours or even days.”

Treating Migraine
As for treating migraine, Dr. Bennett explains that there are “rescue” medications which alleviate immediate symptoms as well as “preventive” medications which help to reduce the number of migraines.

“Everybody should have something for rescue. There is migraine-directed medication such as the triptans. There are seven of them including sumatriptan, rizatriptan, and zolmitriptan, just to name three. We also use anti-inflammatories, anti-nausea medications, and others,” he notes.

“It’s very important to stay away from narcotics and barbiturates in treating migraine. People with migraine have a very high risk of getting hyperalgesia, which means these medications will make their pain worse very quickly. They can also lead to medication overuse headaches on top of their already disabling condition. Unfortunately, butalbital-containing compounds like Fioricet are still the most widely prescribed medication for migraine and they shouldn’t be used at all or in very sparing situations,” he says.

“The newest preventive medications are the monoclonal antibodies. Brand names include Aimovig, Ajovy, and Emgality. These are the first medications designed specifically for migraine prevention. We are seeing the fastest response with the best tolerability ever compared to other preventive medications.”

“In 2010, BOTOX was approved for prevention of chronic migraine. It is also well tolerated and has very good response rates. BOTOX and the monoclonal antibodies can be used together. Our current knowledge of the pathophysiology of migraine shows that they may complement each other and certain people may need both of them,” he notes.

For more information about migraine or to make an appointment with Dr. Bennett, call his office at (412) 650-5623. Great online resources for migraine sufferers are the American Migraine Foundation (www.americanmigrainefoundation.org), National Headache Foundation (www.headaches.org), and MigraineDisease.com (www.MigraineDisease.com).

Preferred Headache Center
The Preferred Headache Center provides the most up-to-date treatment of headache and persistent post-concussive issues. The center offers comprehensive headache assessment, individualized treatment plans, along with strategies to identify and control triggers. The focus at the Headache Center is to help patients and their families understand their condition and to develop the best treatment program to help them regain their quality of life.

Nathan L. Bennett, M.D., the center’s founder and director, is one of approximately 600 Certified Headache Medicine Subspecialists in the country. He is a member of the American Headache Society, International Headache Society, and National Headache Foundation. Dr. Bennett is involved in the development of headache guidelines and educational programs on a national level. He lectures on migraines and headache disorders to physicians, other healthcare providers, and the general public. He is also the principal investigator and author in many clinical research studies.

More information about the Preferred Headache Center can be found at www.PreferredHeadacheCenter.com or by calling (412) 650-5623.

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