A 56-year-old woman came to Samaritan House Clinic, where I am a volunteer internist, complaining of recurrent headaches. My first thought was that she had migraines. 

In my experience, migraine headaches are the most frequent cause of severe headaches. Although most common in those between 18 and 44 years of age, they can occur throughout life. According to the National Institutes of Health, migraines are more than twice as prevalent in women than in men, and they tend to occur more in disadvantaged populations.

Migraine headaches are thought to be caused by genetic mutations in the brain. Patients describe migraines as painful throbbing headaches, often on one side of the head, which can last anywhere from 4 to 72 hours. They can be so severe that one may not be able to perform one’s usual daily activities. Other symptoms might include nausea, vomiting and sensitivity to light.  

There are three main types of migraines: migraine with aura, where signs such as flashing lights occur before the headache begins; migraine without aura, which occurs without any specific warning signals, and is the most common type; and silent migraine, where an aura or other symptoms such as flashing lights or nausea occur but without headache.

What are some triggers of migraine? In a retrospective study of 1,750 people with migraines from the journal Cephalgia, 76% reported at least one trigger, including emotional stress (80%), hormones in women (65%), not eating (57%), weather (53%), sleep disturbances (50%), odors (44%), neck pain (38%), lights (38%), alcohol (38%), smoke (36%), sleeping late (32%), heat (30%), food (27%), exercise (22%) and sexual activity (5%). I advise my migraine patients to keep a headache diary so they can track their specific triggers. 

The keys to diagnosis are a thorough health history and neurological exam. The warning signs that prompt me to order a brain scan in order to exclude more serious causes of headache include a complaint of “the worst headache I’ve ever had”; a change in the severity or pattern of headaches; new neurological findings; headaches unresponsive to treatment; headache always on the same side; new-onset headaches after age 50; new headaches in a patient with a history of cancer; or headaches associated with symptoms of fever, stiff neck, change in behavior or memory loss. If patients do not have any of these warning signs or symptoms, I reassure them that they do not need a brain scan.

Most migraine headaches can be treated with over-the-counter medicines. In general, treatment is more effective if given early in the course of the headache, and a large single dose of medicine tends to work better than small repetitive doses. Prescription migraine medications are available for those who do not respond well to OTC medicines. Non-oral medications should be considered in those who have nausea and vomiting. There are also medicines to prevent migraine headaches.

A key point I tell my patients is to be aware of medication-overuse headache — that is, headaches caused by taking analgesics, or pain relievers, too often. Neurologist Dr. Scott Abramson shared that in his 40 years of practice, he saw at least one of these patients daily where the diagnosis was overlooked by the referring physician. He explained that all it takes to put someone into an analgesic rebound state is to use any pain reliever, such as Tylenol or Advil, 15 days per month for a period of three months or more.

Let’s get back to my patient. Her physical and neurological exams were normal, which enabled me to rule out potentially serious causes of headache. Because her headaches were accompanied by nausea and visual symptoms, I diagnosed migraine as her problem.  

She had three contributors to her headaches: (1) She had significant emotional stress regarding her living situation; (2) she used cocaine and drank at least six shots of whiskey whenever she bartended (alcohol and cocaine can cause headaches either directly or by withdrawal); (3) she frequently ran out of her beta-blocker medicine, metoprolol, which treats hypertension and prevents migraine headaches. 

She was grateful to know the likely reason for her headaches and appreciated the treatment recommendations.

Migraines can be a pain, but with education and prudent use of medication, they can be successfully managed.