More than 90% of the population has suffered on some occasion headache or headache, it is the most frequent form of pain in humans. One of its types is migraine, which can be very disabling and affects up to 12% of the population. Neurologist Patricia Pozo-Rosich, a great specialist, head of the Neurology Service Section at the Vall d’Hebron University Hospital, explains it to us.
Pozo-Rosich is also director of the Migraine Adaptive Brain Center Vall d’Hebron and Honorary Secretary of the International Headache Society. She specialized in migraine in the United States and in London. Understanding how this disease works, she explains, is crucial so that sufferers can minimize its effects.
2% of the world population cannot lead a normal life because of migraine. How far does the personal and social impact of the disease go?
Some patients are unable to work or raise a family. Migraine conditions personal relationships. For example, to find a partner you have to socialize at some point, but if you can’t because you don’t know how you’ll find yourself, this conditions your decisions. Some patients tell you: “How am I going to live with someone, if I’m sick all day?” The way you live conditions your profession, having a partner, having children… There are even patients who explain to me in consultation that they have decided not to have children so as not to give them the disease, because migraine is hereditary.
What are the causes of migraine?
There are causes of the disease and causes of the attack or triggers. This is a genetic disease and if you don’t understand why you have it, you won’t understand why the attacks come. One of the causes of the attacks is fatigue that lasts for days: I get stressed, I get tired as a result of the stress, and after a few days, I can have a migraine attack, which is a mechanism to recover. This tiredness can also be physical, caused, for example, by anemia, hypothyroidism, something that takes away energy. Physical and emotional fatigue are often linked.
There are also sensory, inflammatory, vascular causes… Give some examples.
In sensory causes, overstimulation, a very intense light, a lot of heat or a specific sensation can make the system of the prone person explode. At the vascular or inflammatory level, attacks can be triggered by trauma, infections such as covid, allergies… This is like a circuit with several switches and to turn on the light (migraine) two or three factors have to be activated. There is no single cause of the attack, it cannot be said that it is produced simply by eating chocolate.
Any other trigger for migraine attacks?
blood pressure In people who suffer from migraine the entire vascular system is different because it is more lax, with a tendency to hypotension and high heart rate. This is so because of the genes. If for reasons such as aging they become hypertensive, it may be that having high blood pressure facilitates the attacks.
Eating chocolate, he says, doesn’t trigger a migraine attack. What role does food play?
None. There is no scientific evidence that the type of food you eat gives you a migraine, although patients do not believe it. If one day you are very tired, to overcome the fatigue you start eating anything and associate that diet with the subsequent migraine, when in reality the cause is fatigue. We know, from neurophysiology images, that the pain peaks begin 48 hours before feeling it, before the patient thinks.
But can the frequency of food intake affect?
Yes. According to studies, meal times may have some relationship with attacks: people with migraine should eat little and often, they cannot do intermittent fasting because they will have attacks.
And does alcohol or caffeine have an influence?
Yes, alcohol influences migraine, like lack of water, dehydration. Caffeine is a double-edged sword: on a migraine day, coffee or caffeinated medications improve the attack due to the vasoconstrictor effect, but it goes against what the body asks for, which is to rest. If you get used to drinking caffeine you can have a headache every day, if you are predisposed. In general, it is better for people who have migraines not to drink coffee. Drinking one coffee a day is not a problem, but if the person has a migraine, his head will hurt if he does not drink it.
In menstruation or with hormonal changes, there may also be attacks. Because?
There is still very little research to explain why, but it is very clear that hormonal changes can cause migraines. There is something related to women that makes them more prone to this disease. Also, we know that this happens when there are drops in estrogen, so the migraine warns that the period is coming. This hormonal migraine is the most difficult to treat.
How can we know if we have a headache or migraine? What is the difference?
In the future we hope there will be a diagnostic test, now there are some clinical criteria that work quite well. Migraine is defined by presenting at least five attacks in a lifetime or episodic and recurrent attacks of headache, of moderate or severe intensity, incapacitating to carry out daily activities. It must be associated with photophobia (lights bother), discomfort with noise or nausea and vomiting. The pain, in migraine, is usually made worse by movement. In some cases it is associated with the aura, when the patient stops seeing normally or stops being able to speak. All the information can be found at mydolordecabeza.org.
Do all migraines have a solution?
80% of patients are much or much better than they were. For the remaining 20%, we are not able to help them. Therapies have improved a lot, but the word we can use is not to cure, but to control or modulate. We have preventive treatments and drugs that help reduce the frequency, intensity and duration of the migraine attack.
What types of treatments?
There are oral medications to facilitate rest, antidepressants are used, drugs to control blood pressure, to neuromodulate, botulinum toxin, which is injected every three months… In addition, a therapy has been approved in Spain for three and a half years more directed. It was found that several inflammatory peptides (proteins) are released during migraine, and one of them is CGRP, a vasodilator. A drug was developed to block this peptide, a treatment like a vaccine, the patient learns to prick himself monthly.
In which cases is this kind of vaccine prescribed?
The EMA allowed that from four days of migraine per month could be prescribed. In Spain, social security pays it to patients who have more than eight days of migraine per month and have tried three previous preventive treatments.
There are dozens of complementary therapies: acupuncture, osteopathy, Ayurveda, herbs… Do you recommend them?
I cannot recommend them, there is no scientific evidence that has shown that this type of treatment works, it may be because creating evidence involves a great cost in studies. They work for some people because of the placebo effect, which is very high in pain-related diseases. If someone is doing well with any of these therapies, they are welcome; but the economic costs they have are not sustainable and the patients who follow them end up leaving them.
How is migraine physiologically explained?
Genetically, it is a neurovascular disease. People with migraine have a hyperexcitable neurosensory system. When faced with stimuli, the electrical response of their system is greater, they are more sensitive. These people are less tolerant of noise, intense lights… This highly excitable system implies that they are attentive to everything, they notice everything, the prioritization system fails them, and the toll they pay is the attack, which, at the brain level, is equivalent to to a shutdown A migraine attack is like an earthquake in which a group of neurons decide to stop working. The shutdown wave propagates in time and space through the cortex, relaxing activity that is normally more excitable.
Are there common personality traits in people with migraine?
Yes, although this has not been studied, but from my experience in consultation, they are more anxious people inside, even though they seem calm. They have a need for control, they don’t like surprise, they are bothered by exaggerated stimulation… They also have circular thinking, a bit obsessive. They present a highly excitable system, with a lot of glutamate, potassium, an excitatory neurotransmitter and little inhibitory, so that thought ends up being recurrent. They are very capable, intelligent people, with a lot of activity; although from time to time they collapse and have attacks because they do not reach everything. They do their tasks efficiently and faster than other people, they understand everything, they can’t sit still, and they have moments of mandatory pause, which are those attacks.
What would be the general recommendation for a person with migraine?
A healthy lifestyle is important, but it is very good that once in a lifetime someone explains what a migraine is. Knowing migraine is not intuitive or for those who have them. All people who are suspected of having a migraine or who have recurrent attacks of headaches should educate themselves and follow special healthy lifestyle guidelines for them. It is a chronic disease and you must take care of yourself throughout your life, we have many clues on how to take care of yourself. The second great message is that it is a disease mediated by the biology of each one, and each time we have more and more ways of understanding that biology and more diversity of treatments.
Better to be treated as soon as possible, than to fear the side effects of drugs?
It is better to resort to treatments as soon as possible than not to think that the migraine or the disease will go away. It is very unpleasant to have a migraine very frequently. There are people who are very disabled in their day-to-day lives and I have the illusion that if they had asked for help from the beginning, perhaps they would not have ended so badly. There is no need to delay the use of treatments or going to a specialist. If you have four days a month of migraine, you should treat yourself.
