Diagnosing migraines proves to be a headache

Washington -- Only about half of the millions of people who have migraine headaches are properly diagnosed as migraineurs, a rather elegant name that belies the intensity of the malady some liken to an ice pick to the head.

This misdiagnosis is shaping up to be a major public health problem, said Mark W. Green, MD, director of Columbia University's Headache Center in New York City.

The debilitating headaches affect about 20% of the U.S. population, said Dr. Green, who spoke Nov. 10 at the AMA's 24th annual Science Reporters Conference in Washington, D.C.

Whenever a patient enters a physician's office complaining of a disabling headache, the chances that the patient is a migraineur are nine out of 10, said Robert Kaniecki, MD, director of the headache center at the University of Pittsburgh, in a separate interview. "But you'll find that five are correctly diagnosed with migraine, two with sinus headaches, two with tension headaches and one with something else."

People may also walk out with a diagnosis of five different headache types. But what they all have are migraines, which are very much a brain problem, Dr. Green said.

The brain, like the heart, can refer pain to various parts of the body. The heart, of course, can refer pain to the arm, chest or jaw. But there is just one diagnosis -- heart attack -- rather than several different types of heart attacks, noted Dr. Green.

For some people with migraines, though, there is not just one answer. Their complaints of jaw pain are diagnosed as TMJ. Others who have pain in the area around the eyes are diagnosed with sinus headaches. However, the experts say most likely have migraines.

Although sinus headaches exist, they are a symptom of sinusitis and are not likely to be the problem that brings people to their physicians. "When you have a sinus infection with pus coming out of your nose, and fever, you have a sinus headache," said Stephen Silberstein, MD, professor of neurology at Thomas Jefferson University in Philadelphia and president of the American Headache Society, in an interview.

Still, one in four patients who sees a primary care physician for headaches will be told that sinus headaches play some role, said Dr. Kaniecki. One in eight who sees a neurologist will receive a similar message.

The acceptance of sinus headaches is likely due to an extremely successful ad campaign begun decades ago to promote a range of over-the-counter pain relievers, said Robert Shapiro, MD, PhD, associate professor of neurology at the University of Vermont College of Medicine in Burlington, who also is a migraineur.

Migraine dangers

The sinus headache diagnosis has gone on to achieve widespread acceptance. It may have served as an easy out for physicians reluctant to tell patients that they had migraines, as the diagnosis once carried the stigma of mental illness, said Dr. Kaniecki. "If you had a family member or colleague come in with headaches and you didn't want to imply they had any psychological problem, you could say, 'Oh, it's got to be your sinuses.' "

The fact that many sinus-related medicines provide relief for migraineurs' symptoms is another driving factor behind the widespread belief in sinus headaches.

The anti-inflammatory component of most over-the-counter pain medications helps relieve pain, and the decongestant acts as a vasoconstrictor that controls swollen blood vessels, said Dr. Kaniecki. "The sinus drugs are really pretty good migraine drugs."

While sinus headaches are few and far between, tension headaches are more frequent. They are the average headache, without the throbbing intensity of the migraine headache, said Dr. Kaniecki.

The jury is still out on whether tension headaches are a less severe migraine or a totally different type of headache, said Dr. Shapiro, in an interview.

A more troubling issue arose from a study published last year suggesting that migraines may cause brain damage. "Migraine is a progressive disorder, and we believe that undertreating migraines may have serious consequences," said Dr. Green.

Others disagree.

"While we do understand migraine as a chronic disease with episodic exacerbations, progressive implies you will be an invalid," said Dr. Kaniecki. "Our migraine clinics aren't filled with people with dementia in wheelchairs. Migraine actually gets better when people are in their 50s and 60s. It declines after age 40. People grow out of them."

But before people age out of migraines, treating their headaches early and correctly seems to provide great relief. Taking medication before the pain begins is the best way to beat a migraine, said Dr. Green.

Many people can predict the onset of a migraine by an "aura," flashing lights or another vision change.

"If an individual suddenly feels an eyeball, it could be a sign of an oncoming migraine," Dr. Green said.

Triptans are the most common type of migraine medication, stimulating the nervous system to send out inhibitory signals to ease the pain. However, the medication delivery system of triptans, generally in pill form, can cause trouble for migraineurs who experience nausea and vomiting with their headaches.

Newer treatments in the form of injections and inhalers may be more helpful.

Physicians may also recommend lifestyle changes including getting a full night's rest, reducing stress and anxiety and altering birth control regimens, all of which can help.

"Eventually, our hope is that a patient can build up a resistance to migraine triggers and eliminate, or at least reduce, their migraine pain," said Dr. Green.