OPINION: When A Migraine Sends You to the Emergency Room

Imagine sitting in English class, reading a passage aloud, when you start to see colorful, squiggly lines in the corners of your vision. Within minutes, dark spots begin to appear, obscuring the next word in the sentence. You blink hard and rub your eyes, but the visual disturbances remain. When you return to your dorm room, numbness spreads across the left side of your face and down your left arm. A dull ache forms on the right side of your head. An hour later, you cannot move without feeling searing pain.

Migraine is not “just a headache.” It is a debilitating condition that robs people of their quality of life. Women experience migraine attacks at a rate more than 3 times higher than men, and over 40% of women have experienced a migraine at some point in their lifetime. Why didn’t I know that this disabling disease is so prevalent in women?

The scene I described earlier is a recount of an experience I had last October. My pain was severe enough that I was taken to the emergency room by my grandfather. The doctors performed multiple tests, ultimately showing no acute problems in my brain. They dispensed migraine medication, which I was grateful for, and sent me home. But even when I returned to my dorm room, I continued to experience pain and vomiting. My migraine stole my entire night from me.

One thing the doctors told me before I left the emergency room was that I should stop taking my hormonal birth control pills, as they significantly increase the risk of stroke in women who have migraine with aura (the visual disturbances I experienced before my headache began). I was struck by this. Why didn’t my healthcare provider back at home ask if I experienced migraine headaches before prescribing? I could have told her I have suffered from migraine since I was 11 years old. Instead, I had been needlessly increasing my stroke risk for years.

There has been so much that I have learned about migraine since my emergency room visit. Migraine is not only more common in women, but it is also heavily influenced by female sex hormones. Furthermore, there are diseases that often co-occur with migraine that only affect women, such as preeclampsia and endometriosis. Migraine is more complex and misunderstood than I originally thought.

The American Migraine Foundation estimates that over 40 million Americans suffer from migraine. That is 11% of our country’s population. They also highlight that 40 million is likely an underestimate, as many people do not seek treatment. Migraine is the leading cause of disability for people under age 50 and the third-leading cause of disability for the entire global population. Beyond the physical toll, migraine is also a top reason for work absences and decreased productivity. On average, women with migraine require 5.6 bedridden days a year due to their symptoms. These disruptions carry economic consequences. According to one study, migraine is costing the United States approximately $12 billion each year, mainly due to absenteeism. Migraine is not just “playing hooky.” It is a painful condition that is draining our society of billions of dollars.

The scientific literature to make a diagnosis of migraine often includes specific criteria such as head pain that lasts several hours, light and sound sensitivity, nausea, and other symptoms that may vary from person to person. While this criteria may be helpful for identifying a migraine, Dr. Christopher Gottschalk, who established the first headache medicine program at Yale, has a more straight-forward definition.

“It’s simple. Migraine is a form of headache that gets in people’s way,” states Dr. Gottschalk. “When people have to stop what they're doing, change what they're doing, take a break from what they're doing, reschedule what they're doing, can't do what they want to do, and more. Any of those impacts…that's migraine until proven otherwise.”

In terms of what causes a migraine— it’s complicated. Dr. Gottschalk expressed that neurologists know that a migraine stems from overactivation of the trigeminal nerve, a major nerve in the brain that is responsible for many reflexes and sensory and motor functions. When the nerve senses something is wrong, such as a brain tumor or bleed, this overactivation can act as a warning sign of something going awry. Yet, what triggers the overactivation in a migraine remains largely unknown.

Dr. Gottschalk explained, “In the majority of cases, it’s just the [warning] system going off,” even when there is nothing physically wrong.

Because there is limited knowledge about migraine and its cause, the term is not very specific. Rather, migraine is a broad category, with many different subcategories that fall beneath it. For example, some people with migraine have an aura before the head pain begins, which is neurological activity that can cause vision changes, numbness, and even slurred speech. Additionally, when people have at least 15 headache days per month, it is called Chronic Migraine to recognize the higher disease burden than those with fewer headache days, known as Episodic Migraine.

The most cited reason for migraine affecting women more than men is the sex hormone estrogen. Fluctuations in estrogen levels can trigger a migraine and make headaches worse. As a result, different stages of a woman’s life can affect how often a woman experiences migraine. Let’s break it down:

Pre-pubescence

According to Dr. Gottschalk, before puberty, boys experience migraine at a higher rate than girls. At menarche, a girl’s first period, migraine prevalence flips and is more common in females.

Menarche and menstruation

One-third of women with migraine say that they experienced their first migraine around the time of their first period. From then on, a woman is more likely to experience a migraine around her period, as estrogen levels routinely fall before menstruation. Some women experience pure menstrual migraine, a migraine that only occurs during days 1-3 of a period (plus/minus two days), due to this estrogen fall.

Hormonal birth control usage

Over 9 million American women use oral contraception. The birth control pill can actually relieve migraine or make them less painful by stabilizing estrogen levels. Yet, if you have migraine with aura, hormonal birth control increases the risk of ischemic stroke six-fold. Dr. Reshma Narula, an Associate Professor of Neurology at Yale School of Medicine, shares that the full effect of using oral contraceptive pills (OCPs) as someone who suffers from migraine with aura still needs to be explored.

“If someone has a migraine with aura, the question is do we [as neurologists] tell our patients not to use OCPs? I don't know that we've made that jump yet,” she says. “I think you can tell people what the data is, which is that people that have migraine with aura are at higher risk for having a stroke. Yet, we don't know why, and we don't know what the cause is.” It is clear that more research is needed, especially because so many women of reproductive age suffer from migraine.

Pregnancy

Estrogen quickly rises during pregnancy and stays stable throughout gestation. Consequently, many pregnant women stop experiencing migraine after the first trimester. However, women with migraine have a higher risk of developing gestational hypertension, preeclampsia, or vascular complications related to pregnancy.

Migraine typically returns soon after delivery, exacerbated by increased stress, lack of sleep, and changes in eating habits— all common experiences during postpartum. Half of women say that their pre-pregnancy migraine patterns return within a month or less of delivery. Despite this, breastfeeding has a preventative effect, which is believed to be due to the release of oxytocin that women experience while breastfeeding.

Perimenopause and menopause

During perimenopause, the two to eight years leading up to a woman's last period, 1 in 5 women experience migraine for the first time. Perimenopause is a stage where estrogen fluctuates, so migraines often become more frequent and more painful. Furthermore, women with a history of migraine are more likely to experience hot flashes, palpitations, and night sweats during perimenopause. After menopause, migraine frequency improves for most women.

According to a study that used news articles to measure the stigma attached to over 100 health conditions, migraine is more stigmatized than obesity, HIV/AIDS and tuberculosis. Migraine-related stigma affects a quarter of people with Episodic Migraine and half of people with Chronic Migraine. This stigma can be devastating, as there is evidence that stigma decreases the quality of life for people with migraine and increases their risk of developing a psychiatric condition such as anxiety and depression. According to the American Migraine Foundation, there are two types of migraine-related stigma: internalized and enacted stigma. Internalized stigma is when a person believes they have less value due to their migraine symptoms, and enacted stigma is when a person receives negative attitudes from others due to their migraine.

“People are stigmatized. They are blamed for their own problem. Because of this, [migraines] are not taken seriously,” Dr. Gottschalk expressed.

Because of migraine’s higher prevalence in women, there have been misconceptions that migraine is a result of psychological fragility. Women with migraine are often seen as hysterical and hormonal. This stereotype hurts men too, as they are believed to be less masculine if they suffer from chronic pain. Dr. Jaskiran Vidwan, a headache specialist at Duke University School of Medicine, says men are less likely to go to the doctor regarding migraine because it is seen as a “woman’s disease,” and they do not want to be perceived as weak.

Migraine-related stigma also pervades doctor’s offices. Migraine is invisible to medical tests; there is no evidence of pathology when imaging is performed. As a result, neurologists struggle to treat migraine, and patients often feel unheard or unbelieved. A study in Spain revealed that 30% of people with migraine do not seek medical care due to a belief that their symptoms are not serious enough or because they fear not being taken seriously by medical professionals.

The workplace is another area that is rife with migraine-related stigma. A survey of 2,000 employers who did not experience migraine showed that 31% of them believed that their employees used migraine as an excuse to avoid work and 27% believed that migraines were used as a way to get attention. These attitudes reflect a misunderstanding of migraine by the public. There is work to be done as a community to increase awareness and decrease stigma about the condition.

Dr. Gottschalk shared an important perspective: “Migraine patients tend to be the strongest people that we meet. These are people who have dealt with intermittent, partial, or complete disability for years, and somehow they get through it… If we would just shift our view to, ‘wow, these are people who are dealing with about as bad a problem as you could possibly have, how can we help?’ it would change the lives of these patients overnight.”

Migraine headaches can be extremely painful, but there are therapies that can stop them— sometimes before one even starts. Triptans are a class of drug that 78% of people with migraine find helpful. I take a triptan called eletriptan, and my migraine typically subsides within an hour. People with migraine find triptans to be almost twice as effective as ibuprofen or acetaminophen, both of which have a 42% and 37% approval rating, respectively. Additionally, doctors often employ preventive measures for people with Chronic Migraine. These prophylactics are often medications that have other purposes such as treating depression or high blood pressure, but they are also effective in preventing migraine. If you suffer from migraine symptoms, make an appointment with your doctor. Although migraine is still not fully understood, there are medicines that can provide relief.

Dr. Narula emphasizes that if you have a headache that feels different than what you normally experience, it is cause to seek emergency care.

“I would never hesitate to get checked out emergently, because there are a lot of things that can mimic migraine headaches that have more sinister long-term implications,” she explains. “I would listen to your body and listen to yourself. If something feels abnormal to you, go to the emergency room and get checked out.”

Similar to my experience writing the preeclampsia article for Why Didn’t I Know This?, I found that there is not nearly enough research on migraine, especially considering the large number of people who are debilitated by the condition. Scientists remain unsure about what overactivates the trigeminal nerve, what causes an aura, how estrogen influences migraine, and the way in which OCPs increase stroke risk in people with migraine.

“There are good things happening in migraine research,” Dr. Gottschalk asserts. “It's just sad that there's only five or six labs in the world that are conducting large-scale migraine studies instead of 500.”

It’s time to invest time and energy into learning about the headaches that affect one in ten of our fellow citizens. We would be a more prosperous society because of it — potentially to the tune of $12 billion or more.