The Migraine: Doctors Differ on Causes, but Summer’s One

Driving in Southern California is tough. And what with the bright sun, harsh glare, smog and heat, commuting on a summer day can be a real headache.

Literally so, for Gerri Scharff.

“It gets so bad sometimes, if the sun is hitting just right,” said the Tustin woman, who can get a splitting headache from the summer light. “I find myself driving to work with one hand over my face, to avoid the glare.”

Summer may be the season of fun and sun for most people, but it can mean the makings of headache pain for migraine sufferers, according to a Tustin headache specialist.

“The normal person can go out in the sun and the glare and it won’t bother him,” said Dr. David E. Sosin, director of the Headache Treatment Center of Orange County in Tustin. But migraine sufferers, he said, have “an extreme sensitivity to internal and external stimuli. It’s like they have a hair trigger. They’re overly responsive to the environment.”

Wealth of ‘Triggers’

And summertime offers a wealth of environmental “triggers”--bright sunshine, glare, heat, vacations, smog and exercise, Sosin said. Beer and wine, popular summertime refreshments, are also possible headache triggers, he added.

“You tend to think of summer as a healthy time,” Sosin said, “but there are a number of forces out there to make headache sufferers worse.”

Not all physicians who treat headaches agree with Sosin’s summer migraine theory. Indeed, there appears to be a wide range of approaches to--and downright disagreement about--how to treat migraine headaches.

While some may dismiss migraine treatment as “full of witchcraft,” others note that light-sensitive headache sufferers can find glaring light on wintertime ski slopes and even in the office at computer terminals.

But Sosin’s patients say they are believers.

Summer, said one of his patients, means missing out on a suntan. And she really regrets having white legs beneath her summer shorts.

“But I can’t go out in the sun. No way,” said the 34-year-old woman, who has suffered from headaches since she was 18. “I don’t go to the beach and I don’t join in with the other summertime junk people do because it means a headache. And it’s just not worth it.”

Migraine headache sufferers usually feel severe, incapacitating pain on one or both sides of their head, often accompanied by nausea and intolerance to light and noise; attacks can last an entire day or longer. Some migraine sufferers report seeing spots of light or auras before the headache sets in.

Migraines occur, many headache experts believe, when blood vessels in the scalp dilate, hence the name vascular headache. Recent research has shown that the vessels are covered with a cobweb mesh of nerve fibers that produce the pain, Sosin said. But he added that just what causes the dilation is not completely understood.

There are environmental “triggers” year-around, Sosin said, but they are more pronounced in the summer. People who get migraines tend to be extra-sensitive to bright light, and although hats and sunglasses can help, moderation is the best precaution, he said. Continued exposure to heat “seems to be poorly tolerated,” and when heat is combined with vigorous exercise, a migraine is even more likely to follow, he said.

“Exercising in the face of bright light and heat is the coup de grace, “ he said. “Even walking around a swap meet on a sunny day can fire up a headache.” Another way to trigger a migraine, he said, is to garden in the hot sun, then cool off with a beer.

For migraine sufferers, taking a summer vacation to get away from stress may actually make things worse, Sosin said. In fact, any change of pace, even sleeping late, can set off a headache, he added.

“This is a paradox. You would think rest would be health-promoting. But migraine sufferers need a constant environment,” Sosin said. “I’ve had patients come back from their vacations and say, ‘I’m glad that’s over with.’ ”

In addition to having patients note the impact of diet and environmental factors on their headaches, Sosin also uses a variety of prescription medicines to get migraines under control. Biofeedback may also be prescribed.

Among the skeptics to Sosin’s approach is Dr. Stanley van den Noort, a UC Irvine neurology professor and former dean of the medical school. Treatment for migraines, according to van den Noort, “is full of witchcraft.

“Being an expert on migraine is like being an expert on the zodiac. It’s not very scientific,” he said.

‘Don’t Know Very Much’

There has not been much research into migraine headaches, van den Noort said. “And as a consequence, we really don’t know very much about it. . . . It’s a disease for which there is no good animal model. We don’t know how to produce headache in dogs and cats.”

There are lots of differing views and conflicting theories about what causes migraine, and the “triggers” seem to vary widely, he noted, adding that much of the information about causal factors is “circumstantial.”

As for the elements of summer provoking migraine headaches, van den Noort said: “Oh, maybe a little, but no big deal.”

Dr. William Bracciodieta, an associate professor of neurology at USC who sees patients at the Headache and Stroke Prevention Medical Clinic in Huntington Beach, agrees that bright light may be a trigger for some migraine sufferers.

“There are people who are (light sensitive), but that’s not peculiar to summer,” he said.

Bracciodieta has had a number of patients who suffer migraines in the middle of winter during a ski trip, possibly triggered by the bright glare off the snow, he said.

What’s more, a far more constant source of irritating light to migraine sufferers comes from the common fluorescent bulb. And further, neck and head position--especially for people working at computer consoles--is probably the No. 1 irritating factor for occupational headaches, he said.

The more seasonal headache, he said, is the “cluster headache,” a completely different headache that strikes mainly men. These severe headaches are felt mainly in one eye, which will get teary, and the nose will begin to run, he said. They strike mainly in the spring and fall, he said. “And nobody really knows why.”

Caffeine a Factor

There is the phenomenon, mentioned by both Bracciodieta and Sosin, of the vacation or weekend migraine. During the workweek, people tend to drink caffeine-loaded coffee and keep up a hectic pace, which pumps adrenalin into their systems, constricting the blood vessels.

“And as soon as the weekend comes, when the person doesn’t get as much caffeine and the adrenalin goes down because he or she is relaxing, bang, the migraine hits,” Bracciodieta said.

Dr. Donald J. Dalessio, chairman of the Department of Medicine at the Scripps Clinic and Research Foundation in La Jolla, said it would be difficult to blame migraines on the weather when “the weather is more temperate here than anywhere.”

Dr. Neil Raskin, a professor of neurology at UC San Francisco and secretary of the American Assn. for the Study of Headache, said he sees the issues of diet and weather in the treatment of migraine as “pretty trivial.”

“You can look around and see if doing those things (avoiding sun and eliminating certain foods) can modify things, but that hardly ever solves the problem. There’s no way short of taking medicine to deal with this. That’s the only thing that’s going to work,” he said.

He also discounted the theory that migraine pain is caused by dilation of blood vessels. Current research, Raskin said, is “making it abundantly clear” that there is an inherited factor that causes an “excitement” in the circuits of the nervous system, which then brings on the head pain.

Indeed, there are two schools of thought about what takes place in the body preceding the dilation of the scalp blood vessels, with one group studying the neurological changes, and the other focusing on the vascular changes, said Sosin, a member of the San Clemente-based American Assn. for the Study of Headache. As a result, he said, the body of research on migraine is growing.

Pain Not Taken Seriously

Sosin bristled at van den Noort’s skepticism about headache treatments. He contended that many in van den Noort’s specialty of neurology do not take the headache sufferer’s pain seriously.

Rather, they order expensive and extensive tests to search for brain tumors or other physiological abnormalities, and when they don’t find anything wrong--for such organic problems are rare--the specialists shrug off the patients’ complaints, Sosin said.

Because headaches do not show up on X-rays or laboratory workups, he said, patients are treated as if the pain is all in their head, pun intended.

Both Sosin and Bracciodieta advise their patients to avoid a number of foods that might trigger migraine headaches. They include chocolate, ripened cheeses, prepared meats such as bologna or pepperoni, and red wine.

“I have migraines myself, and I can’t go near red wine. Just wave it under my nose and I get a migraine,” Bracciodieta said.

Women make up the majority of migraine patients because estrogen appears to have a dilating effect on the blood vessels, Sosin and Bracciodieta agreed.

Many women are prone to headaches around the start of their menstrual periods, “and if they engage in certain activities or eat certain foods, they’re looking for trouble,” Sosin said. Women who suffer migraines, in most cases, should not take birth control pills, he said.

Sandi Bauernfeind, 45, of Tustin and a patient of Sosin’s, said she has had headaches since she was 10 and went from doctor to doctor, seeking relief. Her nauseating, incapacitating headaches used to last up to five days, striking three or four times a month. Now, with medication and by avoiding certain situations, she said she suffers only three or four a year.

During the summer, she knows to avoid exposure to the sun and heat, she said. If she gets too warm, she begins to feel nauseated, or if the sunlight seems to be piercing into her eyes, she knows a headache is on the way.

‘It Is Excruciating’

“If you’re watching a baseball game sitting in the hot sun, after 10 minutes, the migraine starts, with the light and the heat,” she said. “It’s an awful feeling. It’s a feeling like you can’t breathe. . . . You can’t fake that kind of pain. I’d rather have 10 kids than one migraine. It is excruciating.”

Another patient of Sosin’s--who asked not to be identified because of possible medical insurance problems--said she suffers from “mixed headache,” a syndrome in which the pain of migraine causes muscle tension that then produces a constant dull headache when the more piercing migraine subsides. She estimated that she used to have 25 headaches a month, before they were brought under control.

When she must go out during the summer, she wears large hats and makes sure she takes her medicine, she said. A jazz fan, she was thrilled to be able to sit through an entire day outside at the Hollywood Bowl for the Playboy Jazz Festival one year. “The year before, I had a rip-roaring headache, but because of the hat and the medication (the next year), I had a wonderful time. I just took my medicine and skipped the Cheddar cheese. It was great.”

Sosin said that avoiding the migraine triggers of summer does not mean missing out on seasonal fun. “It means not overdoing. It doesn’t mean a funless vacation,” he stressed.

Patient Gerri Scharff said she and her husband like to take “mini-vacations,” but she has learned to restrict her time out in the sun. Mountain trips have caused her problems because the altitude tends to set off a migraine, she said. There have been many trips to the emergency room of Big Bear’s hospital for a shot to kill the pain. “The headaches would get that bad,” she explained.

“I like summer for the warmth, but I don’t like it for the light,” Scharff said. “Even daylight savings time creates a problem in my family, because they can’t understand I can’t have all this light coming into the house. It really bothers my eyes.”

But by adapting her activities, she suffers less, she said.

Still, there’s that drive to work in Santa Ana every day, she said. In the morning, the sun hits her eyes hard. And although she can wear sunglasses and shield her face with her hand, “the sun comes over the way it comes over,” she said. “And you can’t change the direction of the sun.”

THE MIGRAINE HEADACHE

Migraine headaches were first described in the 2nd Century by Aretaeus of Cappadocia. Their symptoms: nausea, throbbing head, vomiting, diarrhea and blurred vision. While experts disagree on the causes and treatment of migraine headaches, the most widely held theory is that they are caused by the swelling of blood vessels in the head. Illustrated below are the mechanics and effects of migraine headaches based on the dilation theory.

HOW MIGRAINES WORK Arteries are elastic tubes that pump blood away from the heart to other parts of the body. Normally, they expand to receive blood and slowly contract as blood moves through. Migraines are thought to be caused by an abnormal dilation of the arterial blood vessels in the scalp. Some migraine sufferers report throbbing or pulsating pain, which it is believed, may be caused by the sensitivity of nerve endings on the dilated blood vessels.

Aged cheeses

Alcohol, especially red wine and champagne

Caffeine drinks in large amounts

Chocolate

Citrus fruit in large amounts

Monosodium glutamate in large amounts

Sausages and hot dogs

Bright sunlight and glare

Fatigue

Fluorescent lighting

Heat and physical exertion

High altitude

Interruption of daily routine

Menstruation

Pungent odors

Smog

Weather changes

SOURCE: The Headache Treatment Center of Orange County

WHO SUFFERS?

An estimated 18 million people in the United States suffer from migraine headaches.

79% women

21% men

75% say family members also get migraines

Of the 75% whose families suffer:

38% Mothers

18% Fathers

19% Sisters

13% Brothers

Source: National Headache Foundation WHAT MIGRAINES COST:

Migraines cost United States businesses $50 billion annually for missed days and medical benefits for employees.

The average migraine sufferer misses nine days from work each year.

In total, migraine sufferers missed an estimated 64 million days from work annually

Source: National Institutes of Health

FAMOUS HEADACHES

“I was suffering very severly with a sick headache,” Grant wrote. “ But the instant I saw the contents of the note, I was cured.”

Gen. Ulysses S. Grant, according to his journal, was cured of a severe migraine headache when Gen. Robert E. Lee sent word of his intent to surrender on April 9, 1865.

“You just can’t explain them to someone who doesn’t have them,” he said.

Los Angeles Laker center Kareem Abdul-Jabbar suffered six migraine attacks in nine days during the 1984 championship basketball series with the Boston Celtics.