Similarities and differences between migraines and epilepsy

This article discusses similarities and differences between migraines and epilepsy.

Migraine and epilepsy have several things in common: they often co-occur and share similar symptoms, each is generally undertreated, one is often misdiagnosed as the other,1 and various medications are effective in treating both disorders.2 Recent research may help elucidate the relationship between the two and shed light on more appropriate diagnosis and treatment options.

“Patients with migraine are more likely to have epilepsy, and patients with epilepsy are more likely to experience migraine,” Pavel Klein, MD, director of the Mid-Atlantic Epilepsy and Sleep Center, told Neurology Advisor. In fact, people with seizure disorders are twice as likely to experience migraines which can often lead to misdiagnosis.3

There are commonalities between the two disorders “in clinical symptomatology, particularly with regard to visual and other sensory disturbances, pain, and alterations of consciousness.”3 For instance, if a patient has a migraine that causes focal neurological symptoms — numbness in the arm or face, for example — it can appear to be a seizure. It is also known that stress can trigger seizures, and in a less common scenario, “in someone with very severe migraine, it is possible that the stress of the pain could trigger a seizure,” Klein explained.

The potential reasons for the close relationship between the two disorders are just as varied. “There could be common substrates that cause both headaches and seizures,” said Klein. For example, a condition called benign epilepsy of childhood is commonly associated with migraine and is often misdiagnosed as such,3 while another possibility is that migraine could lead to mild forms of brain damage that increase the risk of epilepsy. Studies have found that MRI of some patients with migraine show small areas of abnormal lesions or scarring.4,5 Researchers are not yet sure of the cause, but it is possible that the scarring is a result of a stroke that is otherwise asymptomatic, and the “scarring leads to reorganization of the local network that could lead to seizures,” said Klein.

What Role Do Genetics Play?

Research published in Epilepsia in 2013 was the first to investigate the role of genetics in the co-occurrence of migraine and epilepsy.5 After testing 730 participants with epilepsy, researchers divided them into two non-overlapping groups — one with migraine with aura and one with migraine without aura — and interviewed participants about their family history of seizure disorders. The results showed that a history of migraine with aura was “significantly increased in enrolled participants with two or more additional affected first-degree relatives,” supporting the researchers' hypothesis of a shared genetic susceptibility to migraine and epilepsy.

“The hope of scientists, caregivers, and families with epilepsy is that genetics will offer a novel and wider understanding of the causes and the pathophysiology of epilepsy,” study co-author Melodie R. Winawer, MD, MS, an associate professor of neurology at Columbia University, told Neurology Advisor.

Approximately two thirds of epilepsy cases have no known cause, and genetic factors may play a critical role in that subset of cases. A ground-breaking aspect of these findings is in regards to reconceptualizing disease boundaries.

“A disorder does not stand alone but can be seen as part of a network of intersecting disorders — in fact, there have been intersecting bidirectional relationships identified for epilepsy, migraine, anxiety, depression, suicidality, and psychosis,” she said. “As we start to understand that some of these disorders are occurring in a network or a cluster rather than standing by themselves, I think it is going to completely transform treatment strategies” and potentially affect preventive efforts.

Ultimately, the knowledge of a shared pathophysiology could lead to the development of new treatment options, as well as recognition of accompanying disorders beyond seizures that can severely impact a patient's quality of life.

After all, failing to treat co-occuring disorders is a disservice to patients, said Winawer. Treatment of any condition — including migraine and epilepsy — should consider potential comorbidities that could worsen or improve depending on the chosen treatment. “We really need to understand epilepsy in its context,” said Winawer. “There is a huge move in the last few years to do that and I think this work is part of that larger question.” 

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A new drug may be able to preemptively treat migraine headaches before they happen.

Patients may now have a solution to their migraines even before the attack happens, as experts found a new class of drugs shows great potential for migraine management. These medicines are the first of its kind that specifically target prevention of migraine. Research findings show that these drugs can greatly help alleviate the symptoms of the patients.

The drug belongs to a new class called Calcitonin Gene-Related Peptide (CGRP) monoclonal antibodies. CGRP is a neurotransmitter or chemical that transmits signals within the brain and throughout the body. So far, the compounds are exhibiting favorable effects in the management of chronic migraine and frequent but intermittent migraine.

"We've known for a long time that CGRP was involved in the mechanism of migraines, so during migraine attacks you can measure elevation of CGRP in the blood of the person having the migraine," said Dr. Richard Lipton, director of the Montefiore Headache Center at the Albert Einstein College of Medicine in New York. "If you treat it, CGRP blood levels fall."

Various pharmaceutical companies have been testing the effects of substances that target the CGRP; these companies include Amgen, Alder Pharmaceuticals, Teva Pharmaceuticals and Eli Lilly and Company.

Teva conducted its studies and submitted it to the American Headache Society meeting. In the phase IIb trials, where patients with migraine were tested, patients experienced a notable drop in the hours of headache experienced one week after the trial was started. Half of the said patients reported that the frequency of headache was reduced by 50 percent or more.

Lilly also presented how efficient their product is. They conducted their phase II trials by testing their product against a placebo, which were both administered every month. Amgen also presented their phase II data that reveal how their product was able to reduce the days of migraine attacks by 50 percent in half of their study participants in a span of 12 weeks. Alder Pharmaceutical also demonstrated their phase II trial results, but specific details were not presented at the meeting.

"The potential of these new compounds is enormous and gives us real hope that effective specific treatments for migraine may be on the near horizon," said Peter J. Goadsby, MD, PhD, Chief of the UCSF Headache Center and chair of the American Headache Society's annual Scientific Meeting. "The development of CGRP antibodies offers the simple, yet elegant and long awaited option for migraine patients to finally be treated with migraine preventives; it's a truly landmark development."

In America, more than 36 million people have migraine, which is far more than the incidence of patients with diabetes and asthma combines. Chronic migraine, which is characterized by 15 migraine days monthly, is experienced by approximately four million Americans.

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FDA Approved Nasal Spray to

The FDA recently approved a nasal spray to treat migraines in children. Please see the entire press release for more information.

Impax Specialty Pharma, a division of Impax Laboratories, Inc. (NASDAQ: IPXL), announced today that the U.S. Food and Drug Administration (FDA) has approved ZOMIG Nasal Spray for use in pediatric patients 12 years of age and older for the acute treatment of migraine with or without aura.

ZOMIG Nasal Spray is the first nasal-delivered prescription medicine approved for the treatment of acute migraine attacks in pediatric patients. Nasal sprays may offer an alternative method of administration when patients experience migraine-associated nausea, have difficulty taking oral formulations, or do not have liquids available.

ZOMIG Nasal Spray's approval came after the FDA's review of safety and efficacy data from pivotal clinical trials demonstrating that ZOMIG Nasal Spray 5 mg is significantly more effective than placebo in providing no headache pain, relief of headache, and other associated symptoms of migraine when treating migraine in pediatric patients. In clinical trials, the medication also had a safety profile similar to that demonstrated in adults. For full safety and efficacy information, please see the prescribing information.

The American Migraine Prevalence and Prevention (AMPP) Study estimated the 1-year prevalence of migraine among US children ages 12 to 19 at 6.3%, with prevalence among boys at 5.0% and among girls 7.7%.2 "Until now, there have been few medications to treat pediatric patients with painful, debilitating attacks of migraine," said Dr. Alan M. Rapoport, Past President of the International Headache Society and Clinical Professor of Neurology at the David Geffen School of Medicine. "We are pleased that ZOMIG Nasal Spray has been approved by the FDA for use in patients ages 12 to 17."

"Treatment options have been limited for pediatric patients and we are pleased with FDA's decision and look forward to bringing migraine relief to pediatric patients by making ZOMIG Nasal Spray available to this 'school age' patient population," said Fred Wilkinson, President and Chief Executive Officer of Impax Laboratories. "This expanded indication exemplifies our strategy to broaden the reach of our current product portfolio to address unmet needs in underserved therapeutic areas, thereby adding value for patients and shareholders alike."

The recommended starting dose for ZOMIG Nasal Sprays in pediatric patients 12 years of age and older is 2.5 mg. As the individual response to ZOMIG Nasal Spray may vary, the dose should be adjusted on an individual basis. The maximum recommended single dose of ZOMIG is 5 mg. The maximum daily dose should not exceed 10 mg in any 24 hour period.

About ZOMIG Nasal Spray

ZOMIG Nasal Spray was first approved by the U.S. Food and Drug Administration (FDA) in September 2003for the acute treatment of migraine attacks, with or without aura, in adults. In clinical trials, ZOMIG Nasal Spray provided relief in as soon as 15 minutes for some patients and the maximum effect was reached within 2–4 hours for most adult patients. At 2 hours, 69% of patients taking the 5mg dose had headache response (taking the patient from moderate to severe pain to mild or no pain) and 36% were pain free.1

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Migraines linked to carpal tunnel syndrome

An association was found showing that those who suffer from carpal tunnel syndrome more prevalently have migraine headaches.

Plastic surgeons at UT Southwestern Medical Center have demonstrated for the first time an association between migraines and carpal tunnel syndrome, with migraines more than twice as prevalent in those with carpal tunnel syndrome as those without, according to the study.

Researchers found that 34 percent of patients with carpal tunnel syndrome also reported migraines, compared to 16 percent of patients reporting migraines without carpal tunnel syndrome. Researchers also found the reverse: 8 percent of patients with migraines reported having carpal tunnel syndrome, compared to 3 percent of those with migraines but no carpal tunnel syndrome.

"Because carpal tunnel syndrome and migraine headache are so common, this association is relevant to the large number of people who suffer from these conditions. The association of these two distinct disease processes is a fascinating connection that needs to be explored further," said Dr. Douglas Sammer, Associate Professor of Plastic Surgery and Orthopaedic Surgery, and Chief of the Hand and Upper Extremities Division in Plastic Surgery. "Although we have theories, at this time we simply don't know why people with carpal tunnel syndrome are more likely to have migraines, and vice versa. A deeper understanding of how and why this connection exists may lead to earlier diagnosis or even the ability to implement preventive measures."

The findings suggest it may be worthwhile for physicians to perform peripheral nerve compression exams in the head and neck on patients with migraines, the researchers concluded.

Further studies are needed to determine whether migraines may be an early indicator for future nerve compression problems such as carpal tunnel syndrome, the researchers said, as well as whether there is a hereditary component to the diseases. Because migraines are more common in younger patients, and carpal tunnel syndrome is more prevalent in older patients, it could be that migraines sensitize the central nervous system to develop pain signals from later nerve compressions, according to the study.

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Migraines in children

This article discusses how migraines manifest themselves in children.

Migraines aren't just a problem for adults -- about 6 percent of children and more than one-quarter of teens aged 15 to 17 have migraines, according to the American Migraine Foundation (AMF).

"There are many things that can be done if your child suffers from migraine, or if you suspect that he or she does," foundation chair Dr. David Dodick, a professor of medicine at the Mayo Clinic College of Medicine in Scottsdale, Ariz., said in an AMF news release.

If you suspect your child has migraines, take him or her to a doctor to be assessed and receive treatment if necessary. Options include treatment to stop the pain and prevent a migraine from getting worse, along with measures to prevent or reduce the frequency, severity and duration of migraines.

If your child is prescribed a migraine medication, it's important for you to make sure he or she takes the medicine as directed. Inform your doctor if there are changes in your child's migraines, such as becoming more frequent or severe. A new treatment approach may be required, according to the headache experts.

A number of factors may contribute to your child's migraines, such as too little or too much sleep or stress. Parents need to help their children follow healthy lifestyles and cope with stress. Recent research in stress management suggests that a type of counseling called cognitive behavioral therapy can benefit children with chronic headache, according to the AMF.

Other potentially helpful stress-control techniques include relaxation therapy and biofeedback.

Keeping a migraine diary can help youngsters understand why they get migraines and how to prevent them. The diary tracks migraines, the severity, how long they last, what patients were doing before and during the migraine, and what foods they ate.

Mobile phone apps may be an ideal way for children and teens to tracks their migraines and to take their medications as prescribed, the experts suggested.

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Study: No link between migraines and breast cancer risk

A study found no association between migraine headaches and breast cancer risk in women.

A large, new study should reassure the millions of American women who have migraine: The debilitating headaches don't raise the risk for breast cancer.

"There is no association between migraine and breast cancer risk," said lead researcher Rulla Tamimi, an associate professor of medicine at Harvard Medical School. "There is no positive association, so there is no reason for concern, and there is no protective effect either."

About 18 percent of American women and 6 percent of men suffer from migraine, according to the Migraine Research Foundation. Migraine is a syndrome involving severe headaches that are often accompanied by visual disturbances, nausea, vomiting and sensitivity to sound and light. Attacks can last from four to 72 hours.

The idea that migraine and breast cancer might be connected arose because both involve sex hormone levels, Tamimi explained.

"We don't really understand the cause of migraines, but there has been a suggestion that they may be triggered by hormone levels," she said. "We know that hormone levels are also associated with breast cancer, so perhaps there could be a link between migraine and breast cancer."

But the report -- based on more than 100,000 women -- observed no association between migraine and breast cancer or migraine and female sex hormones, Tamimi said. The findings were published Dec. 12 in the Journal of the National Cancer Institute.

The research data, which included analysis of four other studies, hinted that migraine might even lower the risk for breast cancer, but that appeared to be a result of study design and not necessarily a real link, the researchers said.

Dr. Mark Green, a professor of neurology at Mount Sinai Hospital in New York City, said that the idea that migraines might be protective against breast cancer is intriguing.

"There is a suggestion that migraine is linked to a lower incidence of breast cancer. However, the numbers were small, and it's not appropriate to suggest that yet, but it's an interesting idea," said Green, who was not involved with the study.

Dr. Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City, discussed the study's significance: "In the ongoing quest to find out what contributes to the causes of cancer, sometimes a negative association can also shed light on the subject," she said. "This study will give relief to many migraine sufferers, and give them one less thing to worry about."

The study relied on data on over 115,000 women who took part in the Nurses' Health Study II, about 18,000 of whom suffered from migraine. Over 20 years of follow-up, no association with breast cancer was observed.

Tamimi's team also looked at the levels of sex hormones of about 2,000 premenopausal women and found no link between hormone levels and migraines.

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Nasal spray to treat migraines

This article explains a nasal spray being developed to treat migraines.

Scientists from Nevada's Roseman University of Health Sciences presented their work on a nasal spray formulation of the antipsychotic prochlorperazine for the treatment of migraines at the American Association of Pharmaceutical Scientists annual meeting in San Diego.

"Prochlorperazine is a dopamine receptor antagonist that is widely used as an anti-nausea medication," said Venkata Yellepeddi, assistant professor of pharmaceutical sciences at Roseman University, in a statement. "Comparative clinical studies have shown that prochlorperazine provides better pain relief than other anti-migraine drugs such as sumatriptan, metoclopramide and ketorolac. Currently, there are no marketed nasal spray formulations of prochlorperazine available for the treatment of migraine. Prochlorperazine is only available in tablet form, which has delayed onset of action."

According to the FDA and the National Institutes of Health's medicine library, the generic drug prochlorperazine maleate is available in tablet form from Sandoz, the generics unit of Novartis, and Teva for the treatment of severe nausea and vomiting, schizophrenia and the short-term treatment of generalized nonpsychotic anxiety.

The Roseman University team hypothesizes that the reformulation will be effective, fast-acting and improve patient adherence, according to the release. It also avoids side effects associated with the use of preservatives.

Using high-performance liquid chromatography and microbiological assays, Yellepeddi showed that the nasal spray remained stable for up to 120 days, according to the release. Next, he will test the safety, efficacy and pharmacokinetics of the spray in rats. His research is being funded by a grant from the International Academy of Compounding Pharmacists Foundation.

While Yellepeddi's research is still in the early stages, in June, Avanir Pharmaceuticals touted positive results from a Phase III trial of its AVP-825 sumatriptan intranasal powder for migraines as compared with an oral formulation of the same treatment.

- read the release

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Migraines in children from toddlers to teens

This article discusses migraine headaches and how they present in children from toddlers to teenagers.

A toddler is having bouts of projectile vomiting, quite frequently but not every day. Fearing something is "terribly wrong" with her daughter's digestive system, her mother takes her to the doctor. Within 20 minutes, the pediatrician has traced the girl's symptoms to motion sickness – she gets sick every time she rides in the car, or shortly after. Although she's never had a headache, by age 3 the girl is diagnosed with the neurological disorder called migraine.

What Is Migraine?

A simple definition is a “recurrent, episodic headache, or head pain, that typically lasts between two and 72 hours untreated,” says Andrew Hershey, chair and a professor of neurology at Cincinnati Children's Hospital Medical Center​​​​. For some people,​ migraine comes with nausea or vomiting, while others experience light and sound sensitivity. Headaches are usually throbbing and partial​​ (involving one side of the head) and moderately or severely intense.​ Migraine has a strong genetic component.

Hershey, director of the CCHMC Headache Center, says while most migraine episodes come and go, they can evolve into chronic migraine: “About a third of our patients get to the point that the headache just never leaves them.”

At least 10 percent of kids have migraine, Hershey says.​ While the rate is about 4 percent in preschoolers, by late teens it affects up to 15 percent of boys and 20 to 25 percent of girls. The youngest patient Hershey ever treated started at 10 months old.

What Triggers Migraine​?

“Migraine is more than a headache. It’s a generalized disturbance of function that involves brain and body,” says Joel Saper,​ a neurologist and director of the Michigan Head Pain and Neurological Institute in Ann Arbor.

Although many people believe stress "causes" migraine, researchers are still working to determine the complex causes for the condition. What's known is that children have a variety of migraine triggers that can set off an episode, including food sensitivities, fatigue, bright lights, loud noises and sleep changes.​

In younger kids, non-headache signs or “migraine equivalents” can include stomach pain, episodes of dizziness, vertigo (spinning), visual disturbances and sudden mood changes, Saper says. Motion sickness is migraine equivalent, he notes, and it’s been recently established that colic in babies is a forerunner to migraine.

Before starting any kind of treatment, it’s crucial to pin down the diagnosis. Some 300 other medical conditions cause headache in kids, Saper says. Emotional causes also have to be ruled out – like school avoidance in a kid who’s anxious or being bullied.

For parents, Saper says it’s key to find a knowledgeable health care provider, whether it’s a specialist, family practice doctor, nurse practitioner or physician assistant.

Life With Migraine for Kids

Two decades ago, Cathy Glaser ​was concerned about her 3-year-old daughter Samantha, who was having cyclical bouts of vomiting and upset stomach. Through careful questioning, the pediatrician traced the episodes to motion sickness.

Glaser knows a lot about migraine. “We like to say my daughter was doomed since both parents have migraine. It runs through both of our families,” says Glaser, who eventually started the Migraine Research Foundation in New York.

Although Samantha was stoic, Glaser could always tell when she had a migraine coming on. “I could look into my daughter’s eyes and see she was getting a headache,” she says. “I could look at her face – she was ashen. All of a sudden those sparkly child’s eyes were absolutely dead. And her whole affect changed.”

Migraine invaded every aspect of Samantha’s childhood, and she visited the emergency room several times a year. It hijacked family trips. On their way to a family reunion at Hersheypark in Pennsylvania, they were forced to pull off the New Jersey Turnpike, because Samantha was green with motion sickness.

School presents many challenges for kids with migraine. Glaser says that as a parent, you need to be your child’s advocate. And you have to be proactive.

“I used to go to school every year at the beginning, or before, with a doctor’s note about migraine and my own daughter’s treatment explain when she raises her hand and says, ‘I need to take my medication now,’ they need to let her go,” she recalls.

Samantha “didn’t want to miss her life,” Glaser says. Even as an 8-year-old, she would say “Mom, I can be alone and feeling horrible, or I can be at school with my friends feeling horrible. I choose school.”

Every summer Samantha's parents sent her off to sleep-away camps, ​and every time they got calls in the middle of the night to come get her – the camp couldn’t handle it. “This is the life of a child who has regular headaches who insists on living the life of a kid,” Glaser says.

Sameness Helps

Boys and girls get headaches equally until age 12 or 13 – but when girls start their periods, the picture changes. Migraine is an “estrogen-vulnerable” disorder, Saper explains. Hormone cycling in girls and later women – from menstruation, oral contraceptives and menopause – can make migraines worse. Boys are more likely to grow out of migraines than girls.

As she entered her teens, Samantha developed menstrual migraine. (She also gets weather headaches, when there’s a change in barometric pressure or a storm’s coming on.)

With migraine, “Sameness helps,” Saper says. Sleep is a big issue, and regular bedtimes and waking times are important. If kids have trouble sleeping, he says melatonin “is a particularly good medicine” to help.

Some children with migraine are food sensitive. “What they eat may make a difference, whether it be the gluten, cheese or dairy products – there’s a long list,” Saper says. Kids shouldn’t miss meals or skip breakfast.

Dehydration can also trigger migraines, and healthy habits include drinking plenty of water or other non-caffeine drinks. Exercise also helps, and so do relaxation and stress-management techniques. 

Not Your Parents’ Headache

For migraine that goes beyond a headache or two a month, research suggests the best approach combines medication and cognitive behavioral therapy. The two main drug categories are medications for treatment and for prevention.

NSAIDs such as Aleve and Ibuprofen are used to break acute headaches in kids, Hersey says ­– aspirin should be avoided because of the risk of liver problems. And parents and patients should be alert to overuse. For prevention, the drugs amitriptyline and topiramate are most commonly prescribed.

At Cincinnati Children’s Headache Center, after kids undergo a neurological and headache exam, the team comes up with a multipronged treatment plan, including medication choices and learning healthy habits. Kids with chronic headaches return for cognitive behavioral therapy, which takes about six weeks to absorb.

Part of the goal is getting kids to accept that they have a chronic illness and teaching them to manage their own care, Hershey says: “We often say to the kids, ‘It’s your headache – it’s not your mom and dad’s.”

Scott Powers, a pediatric psychologist at the center, is working with his team to fine-tune a migraine app that kids can use to track their episodes and symptoms electronically. The app also allows researchers to better connect the dots between triggers and headache timing.

College and Migraines

With the importance of regular sleep, healthy eating habits and keeping stress on an even keel – what could possibly go wrong when kids with migraine leave for college?

But when the time came, Samantha insisted on going away to a big school, Glaser says. After much discussion they agreed that Samantha would go to a school within driving distance, near a hospital and with a well-staffed campus health center.

“Her view about college was ‘I want to stop being 'Migraine Girl,'" Glaser recalls her daughter saying. “’I want to stop being defined by my disease.’” 

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Link found between migraines and seizures

This article explains a link found in the brain between migraine headaches and seizures.

Seizures and migraines have always been considered separate physiological events in the brain, but now a team of engineers and neuroscientists looking at the brain from a physics viewpoint discovered a link between these and related phenomena.

Scientists believed these two brain events were separate phenomena because they outwardly affect people very differently. Seizures are marked by electrical hyperactivity, but migraine auras -- based on an underlying process called spreading depression -- are marked by a silencing of electrical activity in part of the brain. Also, seizures spread rapidly, while migraines propagate slowly.

"We wanted to make a more realistic model of what underlies migraines, which we were working on controlling," said Steven J. Schiff, Brush Chair Professor of Engineering and director of the Penn State Center for Neural Engineering. "We realized that no one had ever kept proper track of the neuronal energy being used and all of the ions, the charged atoms, going into and out of brain cells."

Potassium and sodium contribute the ions that control electricity in the brain. The Penn State researchers added fundamental physics principles of conservation of energy, charge and mass to an older theory of this electricity. They kept track of the energy required to run a nerve cell, and kept count of the ions passing into and out of the cells.

The brain needs a constant supply of oxygen to keep everything running because it has to keep pumping the ions back across cell membranes after each electrical spike. The energy supply is directly linked to oxygen concentrations around the cell and the energy required to restore the ions to their proper places is much greater after seizures or migraines.

"We know that some people get both seizures and migraines," said Schiff. "Certainly, the same brain cells produce these different events and we now have increasing numbers of examples of where single gene mutations can produce the presence of both seizure and migraines in the same patients and families. So, in retrospect, the link was obvious -- but we did not understand it."

The researchers, who also included Yina Wei, recent Penn State Ph.D. in engineering science and mechanics, currently a postdoctoral fellow at University of California-Riverside, and Ghanim Ullah, former Penn State postdoctoral fellow, now a professor of physics at University of South Florida, explored extending older models of brain cell activity with basic conservation principles. They were motivated by previous Penn State experiments that showed the very sensitive link between oxygen concentration with reliable and rapid changes in nerve cell behavior.

What they found was completely unexpected. Adding basic conservation principles to the older models immediately demonstrated that spikes, seizures and spreading depression were all part of a spectrum of nerve cell behavior. It appeared that decades of observations of different phenomena in the brain could share a common underlying link.

"We have found within a single model of the biophysics of neuronal membranes that we can account for a broad range of experimental observations, from spikes to seizures and spreading depression," the researchers report in a recent issue of the Journal of Neuroscience. "We are particularly struck by the apparent unification possible between the dynamics of seizures and spreading depression."

While the initial intent was to better model the biophysics of the brain, the connection and unification of seizures and spreading depression was an emergent property of that model, according to Schiff.

"No one, neither us nor our colleagues anticipated such a finding or we would have done this years ago," said Schiff. "But we immediately recognized what the results were showing and we worked intensively to test the integrity of this result in many ways and we found out how robust it was. Although the mathematics are complex, the linking of these phenomena seems rock solid."

The ability to better understand the difference between normal and pathological activity within the brain may lead to the ability to predict when a seizure might occur.

"We are not only interested in controlling seizures or migraines after they begin, but we are keen to seek ways to stabilize the brain in normal operating regimes and prevent such phenomena from occurring in the first place," said Schiff. "This type of unification framework demonstrates that we can now begin to have a much more fundamental understanding of how normal and pathological brain activities relate to each other. We and our colleagues have a lot on our plate to start exploring over the coming years as we build on this finding."

The National Institutes of Health and the Mathematical Biosciences Institute of the National Science Foundation supported this work.

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The impact of migraines on the whole family

This article discusses the impact that migraine headaches have on the entire family.

Most Migraine sufferers will tell you that their migraines are worsened by stress. Stress can come from a number of sources, but the ones that seem to be on the top of the list are school, or work, and family. Though all three are tremendously significant, it is infinitely easier to change a classroom, school or even job than it is to change one’s family.

Whether it be marital discord, money concerns, or parent – teen conflict, families issues have a tremendous impact on the migraineur and ignoring this is likely to result in less than successful migraine therapy.

On the flip side, having a supportive, understanding family can be an enormous help to the migraine sufferer…to an extent. Unfortunately, we find that very often with our adolescent patients, the parents are too focused on the migraine; so called “helicopter parents” who are hovering over their teen with repeated inquiries about their pain. In my clinic I had one parent ask her 16 year old son how he was feeling 4 times in a 15 minute visit. This kind of attention only serves to increase the focus on a problem that we are trying to minimize.

Often, having the whole family involved in the therapeutic process is the answer. It may mean scheduling visits at a time that spouses or parents are available, and it may involve family counseling. People often find the prospect of family counseling threatening. It really should not be viewed as such. Seldom do people take classes on being a spouse or a parent before having to be one. Processes that seem right and become family habit sometimes are detrimental in ways not obvious to those involved.

Making the effort to work on sources of family stress and how the family responds to them; learning to be supportive without being overbearing can be the key to improving the life not only of the migraineur, but the whole family.

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When to go to the hospital for a migraine

This article explains when it is appropriate to go to the hospital for a migraine headache.

Headache is one of the most common reasons for an emergency room visit. Some people go due chronic headache or Migraine problems that do not go away with treatment, and in other cases, headache is a symptom of another medical problem.

The best reason for an ER visit is for unusual symptoms that are new to you. You may seek attention to make sure there is no chance of another problem such as aneurysm or meningitis. A severe headache that starts very suddenly (within a second or two) can mean another disorder such as stroke. New symptoms such as a fever, weakness, vision loss or double vision, or confusion are some of most concerning symptoms. If you have a new symptom and serious, life-threatening medical problems such as liver, heart or kidney disease, are pregnant, or have a disorder which affects your immune system such as HIV infection, an ER visit may be more essential.

For many patients, an ER visit for headache or Migraine happens after a long period of severe headache lasting days or weeks. After long time of experiencing severe headache, you may reach the "last straw" and no longer be able to deal with the problem. ER doctors are not specialists in headache and Migraine, and their goals are to make sure there is no serious life-threatening problem and help reduce suffering. Different ER doctors have different ways to treat acute headache and Migraine: there is no universal protocol for emergency treatment of headache disorders.

When going to the ER, be sure to mention:

• your symptoms, including any that are new or unusual for you;
• any medications you have taken, especially in the last few days; and
• if you have had good results from a particular medication regimen, that can be helpful to the ER.

Often ER doctors will want to order tests such as a CT scan of the head or spinal tap to make sure there is no bleeding in the brain, large stroke or meningitis. If you are having your typical severe headache or Migraine, and no new symptoms, the chance these tests will be helpful are extremely low and you have the right to refuse them. (See 5 Things Migraine and Headache Patients and Doctors Should Question.)

The majority of persons coming to an ER for severe headache or Migraine do not get lasting results from the medications given in the ER, so having a good long-term plan and relationship with an outpatient doctor who treats your headache disorder is very important. If you have even occasional long-lasting headaches or Migraines, a good preventive plan is very important, and you should have at least one rescue medication to prevent future ER visits.

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Screening tool available for chronic migraines

This article describes a new screening questionnaire for chronic migraines.

Researchers have developed a new tool that can accurately identify patients with chronic migraine (CM).

The screening questionnaire — called the ID-CM — can potentially be used by physicians or by patients themselves.

"The way we imagine it in clinical practice is that someone completes this questionnaire in a physician's office and it provides a suggestion that the patient may have chronic migraine," said researcher Dawn Buse, PhD, director of Behavioral Medicine, Montefiore Headache Center, Bronx, New York. "The physician would still go through a careful history and physical and complete the diagnostic criteria."

"It may be helpful for people living with chronic migraine who don't realize there's a term for what they're living with," she said. "It might help connect them with specialist health care professionals who can treat them well, and it may help connect them with the right treatment."

The only treatment approved by the US Food and Drug Administration for chronic migraine, defined as having 15 or more migraine days a month, is onabotulinum toxin A (Botox, Allergan Inc), although patients do use other migraine therapies, including triptans.

Dr. Buse presented the research, funded by Allergan, here during PAINWeek.

Rigorous Process

Developing the tool took almost 3 years and involved a rigorous multi-step process. The research team reviewed existing instruments, sought input and consensus from headache physicians and research scientists from around the world, and had a group of people with CM assess the relevance of the questions being developed.

Another important step in the development process was psychometric validation. "This is where we look at someone with chronic migraine, someone with episodic migraine, and someone with no headache and see how well a particular item (for example, whether the pain is pulsating or how often the pain is severe) identifies or separates the different groups," explained Dr. Buse.

As well, headache experts used a semi-structured clinical interview to provide their own diagnosis, which was used as the gold standard. Compared to this gold standard, the screening tool had a sensitivity of 82%, a specificity of 87%, a negative predictive value of 77%, and a positive predictive value of 90%.

Among other things, the final 12-item screening tool asks respondents how often their pain is moderate or severe, how often they're unusually sensitive to light and sound, how often they feel nauseated or sick to their stomach, and how often they worry about missing work, school, or social events because of headaches.

Despite its substantial economic and quality-of-life burden, chronic migraine remains underdiagnosed and undertreated.

Dr. Buse and her colleagues hope to have the screening tool available in the next month or 2 and are working on a manuscript for possible publication.

Findings Relevant

Asked to comment, pain expert Lynn Webster, MD, vice president, scientific affairs, PRA Health Sciences, Salt Lake City, Utah, said he thought Dr. Buse's presentation was "very interesting" and relevant to the average physician who sees many patients with headaches in his or her daily practice.

"An accurate diagnosis is challenging for many physicians and a tool to help make that diagnosis would be welcomed," said Dr. Webster.

The tool appears to be reasonably accurate and sensitive, "which is always a challenge in developing such tools," added Dr. Webster.

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Migraines worse for women during menopause

A study claims that women's migraines may get worse during menopause.

New research confirms what women with migraine headaches have told their doctors for years: migraine attacks seem to get worse in the years before and during menopause.

"In women who have migraine, headaches increase by 50 to 60 percent when they go through the perimenopause and menopausal time periods," said Dr. Vincent Martin, professor of medicine and co-director of the Headache and Facial Pain Program at the University of Cincinnati.

The new finding, Martin said, "basically confirms what women have been telling us physicians for decades. We finally have some evidence."

The perimenopausal period is the time when the body is transitioning to menopause -- when monthly periods end. Perimenopause can last several years, and is often marked by irregular periods, hot flashes and sleep problems. Perimenopause can begin in the 40s, and menopause occurs, on average, at age 51, according to the U.S. National Institute on Aging.

The study is due to be presented on Wednesday at the American Headache Society annual meeting in Los Angeles. Findings presented at meetings are generally considered preliminary until they've been published in a peer-reviewed journal.

Martin and his colleagues surveyed just over 3,600 women, aged 35 to 65, in a mailed questionnaire that asked about their menopausal status and whether they had migraines and, if they did, how often. The women were classified as having high frequency headaches if they had 10 or more headache days a month.

The women in the study were about evenly divided among the three groups: premenopausal, perimenopausal and postmenopausal.

While 8 percent of the premenopausal group had frequent headaches, 12.2 percent of the perimenopausal group did along with 12 percent of the menopausal women.

At first, the results might seem puzzling, since experts know that younger women often get migraines right before and at the beginning of the menstrual cycle, said study researcher Dr. Richard Lipton, director of the Montefiore Medical Center Headache Center and professor of neurology at the Albert Einstein College of Medicine, in New York City.

"Women with migraine are most likely to get them a couple days before bleeding through the first few days of the cycle, when estrogen and progesterone both fall. The idea that women who have fewer periods [during perimenopause] would get more migraines seems paradoxical," said Lipton.

However, he said, experts believe decreasing estrogen levels explain the headaches in both cases.

The study provides welcome information on the problem of migraines, according to Dr. Elizabeth Loder, chief of the division of headache and pain in the department of neurology at Brigham & Women's Hospital in Boston.

"I think this study is particularly valuable because they went to the trouble of carefully determining what phase the women were in," she said.

Loder agreed that the study validates what patients have been telling doctors for years. Its size also lends credibility.

However, she said, it's important to put the study in perspective. "Although the relative differences [in headache frequency] between groups look big, the absolute numbers are not," Loder said. She pointed out that 8 percent of premenopausal women and about 12 percent of older women had frequent headaches.

For relief, Martin suggested, women could ask their headache specialist about adjusting or switching their migraine medicine.

The women might also ask about taking hormone replacement therapy for a brief time, he added, reasoning that raising estrogen might help decrease headaches. However, women and their doctors should discuss the benefits and the risks -- such as an increased risk of stroke -- with hormone use.

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