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Director of Stanford Headache Clinic answers your questions on migraines and headache disorders

Migraines and other forms of headache disorders can cause debilitating pain, disrupt lives and lead to large economic and societal costs. At the Stanford Headache Clinic, director Robert Cowan, MD, who has suffered migraines his entire life, works with colleagues to relieve patients’ pain through a treatment approach focusing on prevention and integrating medical, physical, psychological and complementary medicine.

This month we asked Cowan to respond to questions about headache disorders, recent improvements in managing them, and the use of a multifaceted approach to treating symptoms. In the following Q&A, he answers a selection of questions submitted via our @SUMedicine Twitter feed and the Scope comments section.

As a reminder, these answers are meant to offer medical information, not medical advice. They’re not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and provide appropriate care.

@ryderexpress34 asks: Are there any studies to see if migraines are physiological?

If, by your question, you mean are migraines “psychological,” then the answer is certainly that migraines are physiological. Migraine is a genetic disease and, as a result, it usually runs in families. There are distinct biochemical and anatomic abnormalities in the brains of people who have migraine. It is definitely not a “psychological condition.”

@mutterp asks: Why do doctors have a difficult time diagnosing migraines?

The problem is that most doctors do not receive proper training in the diagnosis and treatment of migraine. Fortunately, that is beginning to change. Today, there are just over 300 board certified headache specialists in the United States. While this is still not many when compared to the 60 million headache sufferers, we are moving in the right direction.

Terri asks: What’s your opinion of a holistic approach to migraine treatment where behavioral therapies are included in the treatment plan?

I think a holistic approach is far and away the best approach to managing headaches. When we combine “traditional” and “complementary” approaches, we call it “integrative” medicine. It is the approach we use here at Stanford and it is becoming the standard in many headache centers across the country.

Erin Digitale asks:  I’m wondering if any research has been done to show how acupuncture or acupressure techniques prevent migraines. What do we know about the mechanism?

There have been a number of studies exploring acupuncture for migraine and several theories offered, but the truth is we still don’t know what the mechanism is. It probably has something to do with release of tiny molecules from nerve endings at the acupuncture sites. These molecules, called neurotransmitters, then modulate pain messages going to a part of the brain called the brainstem, where pain messages en route to the brain are modulated.

Kerrie Smyres asks:  Can you summarize the research on migraine and histamine and why researchers hypothesize a connection between the two?

There are volumes on the relationship between histamine and headache – far too much to summarize here. But suffice to say histamine and other immune responses are part of the body’s response system to a perceived threat from the environment, and how the brain responds to environment is at the heart of migraine.

Kim asks: Do you recommend that migraine patients get tested for food allergies?

As a rule, I do not. There is no strong evidence that food allergies trigger migraines. But everyone’s triggers are different and if you find a food that seems to be a trigger, it makes good sense to avoid it. In other words, just because something you ingest gives you a migraine, it does not mean you are “allergic” to it, and vice versa.

Carolyn B asks: What are your thoughts on surgery for migraine?

This is a complicated issue. The surgery recommended as a “migraine cure” has not been well-studied and I have personally seen some disastrous outcomes. I have also heard of some excellent outcomes as well. So I think the jury is still out. Before going to a surgeon, I would suggest you discuss your case with a headache specialist to make sure all medical options have been explored.

Dean asks: How concerned should people be about migraines as a precursor to strokes?

In general, people with migraine are not at greater risk for stroke than anyone else. There are a couple of exceptions in people who have other risk factors along with a particular kind of migraine. This is a complicated topic and should be discussed with a headache specialist. There are several medical conditions that are more common among migraine sufferers, and again, this is a conversation to have with a headache specialist.

L asks: I have been diagnosed with migraines that come in clusters, but cluster headaches have been ruled out. Melatonin in high doses seems to quell them and kick them out of the cluster period. Is there a genetic component to this type of migraine?

While no gene for this particular type of migraine has been identified, most migraine is, in fact, genetic. As for the role of melatonin, there are two (potentially more) possible explanations. The first is that melatonin facilitates sleep and the sleep “resets” the brain. Most migraines can be broken by sleep. The second, and perhaps more compelling, explanation is that melatonin is active at the hypothalamus where many of our rhythmic activities are modulated and the “reset” occurs there. Without knowing a lot more about your particular headaches, it is hard to say more about both the “inheritability” of your headaches and the rhythmicity.

Giuliana Scarano asks:  I live in Italy, what books, or other resources, could help me learn how lifestyle changes many relieve my symptoms?

A couple of years ago, I wrote a book about this approach. It is called “The Keeler Migraine Method.” I am not sure where you are in Italy, but you might contact Dr. Bussone, a world-renowned headache specialist there. He may be able to guide you to someone who can help.

Previously: Ask Stanford Med: Director of Stanford Headache Clinic taking questions on headache disorders, Managing headache disorders during the holidays and New Stanford headache clinic taking an interdisciplinary approach to brain pain
Photo by Eunice

2 Responses to “ Director of Stanford Headache Clinic answers your questions on migraines and headache disorders ”

  1. A. Winslow Says:

    Sirs, Our hypothesis proposes that the hepatic enzyme, tryptophan oxygenase (EC 1.13.1.12.,L-tryptophan: oxygen oxydoreductase)[TO] is the physiological site of migraine genesis. TO is a hormone-induced copper-containing enzyme. Histamine stimulates estradiol. Estrogen administration increases copper and Cu levels and increases TO turnover. This may change the O2-binding equilibrium of TO, thus initiating migraine. Our hypothesis should be online by August 2013. Please inform your readers that they might find our study, titled, Migraine Unmasked, of interest. We hope you’ll visit us.
    WCDI Group

  2. A. Winslow Says:

    Sirs,
    We’re slightly behind in publishing our study to the web. In the interest of your readers, we’ll report to this site when our posting is active. For two decades we’ve maintained that tryptophan oxygenase [TO](see above comment)is the site for the physiological initiation of migraine. FYI: the gene for TO,(TDO2)has, now, finally appeared in the literature as a candidate gene for migraine! While variants in other genes are linked directly to specific characteristics of migraine, TO may associate with the MECHANISM of migraine. For this reason, there may not be greater interest in TDO2 at this time. This may change subsequent to the publication of our study. WCDI Research Group

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