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Stop that splitting headache

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About once a month, usually around my period, I start feeling sort of…off. My neck gets tight and achy, and I can't think as clearly as usual, like my mental gears are gummed up. That slow-brain feeling, I've learned over the years, is not a good sign. It means I'm about to get a migraine. It's my cue to be careful—to steer clear of red wine and sugar, two sure triggers when I'm in that sensitive state, and to get enough rest since lack of sleep can tip me over the edge, too.

Even so, if anything in my routine is out of whack—if I don't eat often enough, or if I become overly stressed—I can count on one or two days of misery. Head-pounding, nauseated, verge-of-tears misery.

Sound bad? Compared to many of the 30 million migraine sufferers in the U.S., my experience is fairly mild. Several years ago, the massive American Migraine Prevalence and Prevention Study found that half of those who struggle with migraines can't do household chores and a third forgo family or social activities. That's a whole lot of agony, and it affects three times as many women as men, largely because the ups and downs of our hormones seem to make us more susceptible, according to Dr. Andrew Charles,  professor and director of the UCLA School of Medicine's Headache Research and Treatment Program.

A migraine isn't just a headache; it's a neurological disorder, often inherited, in which triggers ranging from stress to certain foods to even changes in the weather set off a chain reaction in the brain that results in intense pain. Most migraine sufferers are between the ages of 20 and 50—women in full-speed-ahead career/family/juggling mode. We're talking about multitaskers who definitely can't afford a day or two (or more) of feeling cruddy. And yet most don't get effective treatment, even though there are plenty of options. 

"Many people still don't know what migraines are or that there's good help available," said Dr. Stewart Tepper, a headache specialist at the Cleveland Clinic's Center for Headache and Pain.

In fact, many women don't even realize that they've got migraines in the first place. The truth is, most bad headaches—the ones that make getting through the day a chore or make you feel nauseated or sensitive to light—are the Big M. 

"They're more common than we used to think," Charles said. "Nearly 48 percent of all women will have a migraine at some point in their lives." Although tension headaches affect more people, they're far less debilitating and easier to deal with. Studies have found that most people who complain to their doctors about headaches have migraines—as do nearly 90 percent of people who think they have sinus headaches.

That's why it's so important to understand migraines—why we get them, what triggers them, how to prevent them, and the most effective ways to treat them at every stage.

Pre-headache: Prevent it

The best migraine defense is a good offense—stopping it before it starts. "One of the most effective things you can do is maintain regular habits and try to keep your life on an even keel," said Dr. Peter Goadsby, director of the University of California–San Francisco Headache Clinic.

Eat, sleep, and exercise regularly (studies have shown that both cardio and stretching are effective at reducing headaches), and try to control your stress, since that is the number-one migraine trigger.

Lifestyle changes. Two options proven to help: biofeedback and cognitive behavioral therapy. With biofeedback training, technicians attach electrodes to your head and neck to measure muscle tension and relaxation, so you not only learn to recognize those states but to control them. And in cognitive behavioral therapy, you learn relaxation strategies, like meditation.

"You get about a 55 percent reduction in headache frequency, on average, with behavioral approaches," said Donald Penzien, director of the Head Pain Center at the University of Mississippi Medical Center, "so long as you make an effort to put the techniques into practice."

Training costs between $70 and $250 a session, but it's usually covered by insurance. And when Penzien and his colleagues studied the cost of behavioral therapies a few years ago, they found that most people learn the techniques in just a few sessions.

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Supplements. Consider taking a supplement as a preventive measure if your headaches are disabling—even if you only have one or two a month. Since different options work for different people, you may need to try several before finding the one that's most effective for you:

Butterbur (or Petasites root) is an herb that can help reduce the frequency of attacks, possibly by reducing inflammation. Researchers at Albert Einstein College of Medicine found that people who took 75 milligrams twice a day had about half as many migraines as usual over a four-month period.

Vitamin B2, or riboflavin, reduced headache frequency from four per month to two in a German trial—possibly because it speeds up brain metabolism, which seems to be beneficial for those with migraines. "The effective dose is 400 milligrams per day," Goadsby said.

Coenzyme Q10 is a vitamin-like substance found in meats and seafood. It, too, may boost the brain's energy metabolism. Research shows a dose of 100 milligrams three times a day can decrease the frequency of headaches by about 50 percent.

Magnesium is an element that's involved in a variety of bodily functions, and there's some evidence that low levels can trigger migraines. "A dose of 300 to 500 milligrams a day might help," Charles said.

Medication. "If you have several disabling attacks a month, and you can't control the pain, talk to your doctor about using preventive medication on a daily basis," Goadsby said. Options include:

Beta-blockers normally used to treat high blood pressure, such as propranolol (sold as Inderal) and timolol (sold as Blocadren), help prevent headaches likely because they help improve blood flow.

Antiseizure drugs topiramate (sold as Topamax) and valproic acid (sold as Depakote) may reduce your migraines because epilepsy and migraines are caused by similar reactions in the brain.

Tricyclic antidepressants such as amitriptyline are used for migraine prevention because they regulate levels of the feel-good chemical serotonin in the brain, and it's believed that serotonin may play a role in the development of migraines.

Botox injections are approved for use in people with chronic migraines (headaches more than 15 days a month). They help people have fewer headaches and less painful headaches, possibly because Botox affects the facial nerves that play a role in migraines, according to Goadsby.

As it starts: Nip it in the bud

Sometimes, catching an attack in the pre-head-pain phase, known as prodrome, can prevent a full-blown headache. Not everyone has early-warning symptoms, but a 2004 study at the Headache Center of Atlanta found that about a third of people experienced signs like feeling tired and moody or having diarrhea and neck pain about eight hours before their migraine set in.

Lifestyle changes. Because stress is the most common migraine trigger, you might be able to stave off a headache by taking a few minutes to decompress, Penzien said. Try five minutes of diaphragmatic breathing: Lie on your back with a pillow beneath your head and another under your knees, so your legs are slightly bent. (You can also do this sitting in a chair.) Put your right hand on your upper chest and your left just below your rib cage. Breathe in slowly through your nose so your stomach pushes up against your left hand. Then, as you exhale, blowing out through pursed lips, tighten your stomach muscles and let them fall inward. Your right hand should remain as still as possible through the inhale and exhale.

Medication. A pair of recent studies looked at treating migraine during the pre-headache stage and found it was at least moderately effective in heading off an attack, so it makes sense to talk to your doctor about taking a triptan, such as Imitrex. These drugs (if appropriate for you, your doc will give you an Rx and determine the best dose) reduce inflammation and constrict blood vessels in the brain. You can also try an over-the-counter pain med such as ibuprofen (400 to 600 milligrams).

During the migraine: Treat it

Though it's better to prevent a headache than try to get rid of it, that's not always possible. Fortunately, there are good options for managing the pain when you're hit by a migraine.

Medication. "All medications work better when you take them early in the attack—within 30 minutes of when you feel the headache coming on, whether you're actually feeling pain yet or not," Tepper said. "Also, you have to be careful not to use any medications more than 10 days a month, because you run the risk of transforming your periodic headaches into a chronic condition."

OTC nonsteroidal anti-inflammatory drugs like naproxen and ibuprofen inhibit blood vessel inflammation, so they can reduce the pain, as can simple analgesics like aspirin or acetaminophen.

Another good option: drugs (like Excedrin) that combine acetaminophen and aspirin with caffeine, which narrows blood vessels and increases the effectiveness of pain relievers.

Triptans are the best prescription option for treating migraines, but because they constrict blood vessels, you can't use them if you have a history of heart attack or stroke.

Dihydroergotamine (sold as Migranal) is a new Rx nasal spray or injection that tightens blood vessels in the brain. Studies show it reduces nausea and sensitivity to light and sound as well as pain.

Lifestyle changes. Rest. If you can do it, relax in a dark, quiet room at the first sign of a headache—either during the aura phase or the second the pain hits.

Stretch your neck by tilting your head gently to one side for 10 seconds, then the other. "Neck tightness and discomfort are common symptoms, so stretching might provide a little relief," said Charles.

Relax. Try yoga or progressive muscle relaxation (in which you tighten, then relax one group of muscles at a time, starting at your calves and working up to shoulders). Because of the connection between migraine and stress, relaxing can make a big difference.