A migraine is a headache with throbbing pain that is usually worse on one side of the head. The pain is often severe enough to hamper daily activities and may last from four hours to three days if untreated. More than one in 10 Americans, including one in 6 women, have migraines, but many have been told mistakenly that they have a sinus or tension headache. Foods, stress, and hormones can be migraine triggers.

About 20% of people who suffer from migraines will have an aura about 20 minutes to an hour before the pain. They may see flashing lights, wavy lines, or dots, or they may have blurry vision or blind spots. These are called “classic migraines.”



Throbbing pain typically occurs on one side near the temples, forehead, and eyes. Migraines can make you very sensitive to light, sound, or mild exertion, such as climbing the stairs. Many people have nausea, vomiting, or vision problems. The pain can be disabling, forcing people to miss work or other activities.

Some people may have a change in mood before a migraine begins. They may become more excitable or irritable or depressed. Others may detect a sensation, such as a funny smell or taste. They may feel more fatigued, yawn frequently, or experience muscle tension. About 1 in 4 people experience this prodrome phase, which can occur as early as 24 hours before any head pain.



Migraines may be set off by some specific cause, such as flickering lights. This could be a reflection from snow or water or from fluorescent bulbs or television or movie screens. Wearing polarizing sunglasses outside and using daylight spectrum fluorescent bulbs inside may help.




An Advantage of Aging

Migraines most often strike in the prime of life – between the ages of 20 and 60. While elderly people still get migraines, they often decrease in severity and frequency as we age, or even disappear entirely. Good management of migraines may help you get rid of your migraines for good.




Migraine Miseries Push Patients to Ways of Coping



Graphic: Stuart Bradford




The New York Times, July 26, 2011, by Tara Parker-Pope  —  The news that the presidential candidate Michele Bachmann suffers from severe migraines has touched off a national discussion about a surprisingly common disorder that is little understood and often undertreated.

Migraine patients are coming forward with their stories. And while each one is different, they have two common threads: suffering and trying to cope.

For some, a migraine represents throbbing head pain and nausea so severe they retreat to a darkened room for a day or more. For others, it’s about a scary moment, driving on the highway when a migraine-induced aura or vision change forces them to pull over.

“Imagine someone having driven a nail straight through your head,” said Craig Partridge, 50, chief scientist for a high-tech research company in East Lansing, Mich., who began having migraines in his late teens. “And then they periodically tap on it to remind you it’s there. It’s that painful.”

More than 10 percent of adults and children suffer from migraine — which is three times as common in women and girls as in men and boys — and the Migraine Research Foundation reports that nearly a quarter of households are affected. The World Health Organization ranks migraine among the top 20 most debilitating health conditions; more than 90 percent of sufferers are unable to work or function normally during an attack, which can last for hours or even days.

Some migraine sufferers say the attacks are so debilitating they couldn’t imagine taking on a job with significant responsibility. But others note that years of experience and new drug treatments have helped them find ways to cope. Some say the condition forced them to take better care of themselves and adopt healthful behaviors, like getting enough sleep and learning to manage stress.

Mr. Partridge has learned to avoid caffeine and bright lights, and is vigilant about wearing sunglasses in strong sunlight. Years of taking ibuprofen to treat headaches led to an ulcer. Eventually, he learned that a magnesium supplement reduced the frequency of his headaches, and now he gets only about three a year.

“As far as I can tell, everyone is a little different,” he said. “Some people have auras, but I never had auras. I get tunnel vision. My tongue starts to get heavy and I have trouble talking.”

Kat Smith, a 47-year-old mother of three in Bryn Mawr, Pa., remembers her teenage brother suffering terribly from migraines, but she never experienced them until a bike accident in her 20s. Then, after the birth of her son, she had migraines “regularly and fiercely” about 12 times a month. She discovered that small amounts of alcohol and vigorous physical activity acted as a trigger.

“I was a fairly carefree person, but I became rigid, very disciplined with myself,” she said. “It seemed I had to eliminate things that other people associated with joy. I had to reconstruct my life as a person of migraine after accepting that these weren’t going to go away.”

She adapted, giving up ice hockey and aerobics and switching to yoga. But sometimes she pushes her limits. This weekend she took part in a vigorous dance class and was punished with a migraine.

“I’ll do something incredibly vigorous and physical, and it will feel so good,” she said. “That night I will get a massive migraine.”

For many patients, including Ms. Smith, a class of migraine drugs called triptans have been a godsend, helping to cut short the pain. Triptans work by causing blood vessels in the brain to constrict and change blood flow, and can often stop a migraine completely or reduce its severity if taken in the early minutes of an attack.

Other patients take daily treatments to prevent migraine from setting in. Barbara Thompson, a 59-year-old communications specialist in Manhattan, uses Topamax, a seizure drug that has been shown to prevent migraine. An attack sometimes “breaks through” despite the daily dose, and on those days she uses a triptan drug.

“Often I get them when I’m at work,” she said. “I find that I get more quiet, and I have to focus more intently on what I’m doing. It’s a more internal day — I don’t have a better way of putting it.”

In a video that went viral, the television reporter Serene Branson babbled gibberish last winter during a live report from the Grammy Awards. At first, it seemed as if she were having a stroke on live television, but her doctor later concluded that a complex migraine had rendered her unable to form words.

Some migraine sufferers, including Ms. Bachmann, experience pain so severe they go the emergency room. But a recent review of emergency room doctors in Ontario found that patients were rarely treated with the proper drugs for migraine, according to a report last month in the journal Pain Research & Management.

The data suggests that more education is needed.

“If it’s not well controlled with the right combination of preventative or acute therapy, it can be very disabling,” said Dr. Satnam Nijjar, the study’s lead author and an assistant professor of neurology at the Johns Hopkins Headache Center. “It’s probably the most common cause for time missed from work in the U.S.”

Robert Dalton, executive director of the National Headache Foundation in Chicago, says that while migraines can be impairing, the larger problem is that many sufferers aren’t getting proper medical care.

“What we want to make sure people understand,” he said, “is that it’s a debilitating disease when it’s not managed properly.”



Alternative Therapy: Biofeedback

Biofeedback and relaxation training can give you relief that is similar to the help you get from medications. Biofeedback uses a monitor to train you to recognize the onset of muscle tension and changes in body temperature that are signals of stress.




Lung Cancer Slowed by First-Line EGFR Inhibition

By Charles Bankhead, Staff Writer, MedPage Today

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner




July 26, 2011  —  Patients with advanced lung cancer had a threefold improvement in progression-free survival with first-line erlotinib (Tarceva) instead of chemotherapy, final results of a randomized trial showed.


The erlotinib group had a median progression-free survival of 13.1 months versus 4.6 months for those treated with a standard chemotherapy doublet. The difference represented an 84% reduction in the hazard for progression or death, Chinese investigators reported online in The Lancet Oncology.


The results constitute “conclusive evidence that erlotinib provides superior overall response rate and progression-free survival versus platinum doublet-chemotherapy as first-line treatment in Asian patients whose tumors harbor activating mutations of epidermal growth factor receptor (EGFR),” Caicun Zhou, MD, of Tongji University in Shanghai, and co-authors wrote in conclusion., “The results of this study have practice-changing implications and provide justification for widespread implementation of routine EGFR mutation testing in advanced non-small cell lung cancer (NSCLC).”

The findings corroborate the initial report last year at the European Society for Medical Oncology meeting.

EGFR mutations occur in a substantial proportion of NSCLC tumors, ranging from about 8% in white populations to 30% of Asian patients (N Engl J Med 2009; 361: 947-957, J Natl Cancer Inst 2005; 97: 339-346, J Thorac Oncol 2007; 2: 430-439).

The frequency of EGFR-mutant tumors provided a rationale for treatment with EGFR inhibitors, which include erlotinib. The rationale was borne out in a phase III trial that demonstrated improved overall survival with erlotinib in patients with previously treated NSCLC (N Engl J Med 2005; 353: 123-132).

Whether EGFR inhibition offered a survival benefit as first-line therapy was the question posed by Zhou and co-investigators in the OPTIMAL trial, conducted at 22 centers in China.

Eligible patients had newly diagnosed stage IIIB-IV NSCLC with confirmed activating mutations in EGFR.

Patients were randomized to first-line chemotherapy with gemcitabine and carboplatin or to erlotinib.

Patients in the chemotherapy arm received a maximum of four cycles of therapy. Those randomized to erlotinib continued treatment until disease progression, development of unacceptable toxicity, or withdrawal from the study.

Investigators screened 549 patients and randomized 165. The final analysis involved 82 patients in the erlotinib arm and 72 in the chemotherapy arm. The primary endpoint was progression-free survival.

When the trial ended, the erlotinib group had an 8.5-month improvement in progression-free survival, which translated into a hazard ratio of 0.16 versus chemotherapy (P<0.0001).

Erlotinib was also associated with a more favorable safety profile.

Grade 3-4 toxicity in the chemotherapy arm included neutropenia in 30 patients (42%) and thrombocytopenia in 29 (40%); none of the patients in the erlotinib arm developed neutropenia or thrombocytopenia.

The most common grade 3-4 toxicity with erlotinib was elevated alanine aminotransferase (in three patients) and skin rash (in two).

Serious adverse events occurred in 10 patients (14%) in the chemotherapy arm versus two (2%) in the erlotinib group.

Similar trials involving the EGFR inhibitor gefitinib (Iressa) resulted in a median progression-free survival of 10.4 and 9.2 months.

Given those results, the median progression-free survival of 13.1 months with erlotinib “is amazing,” Tetsuya Mitsudomi, MD, of Aichi Cancer Center Hospital in Nagoya, Japan, wrote in an accompanying commentary.

Although no trial of first-line EGFR inhibition in NSCLC has demonstrated a benefit in overall survival, “failure to translate extended progression-free survival into increased overall survival is accounted for by the substantial crossover of treatment after progression of disease,” Mitsudomi wrote.

“Yet, this crossover should not lead to underestimation of the power of EGFR tyrosine kinase inhibitors (TKIs) in patients with EGFR mutations.”

“EGFR TKIs are undoubtedly key drugs for patients with EGFR mutations and should be used early in treatment,” he added. “However, when EGFR test results cannot be obtained in a reasonably short time frame, first-line chemotherapy and second-line EGFR TKI after progression is a reasonable option if the patient is later shown to be EGFR mutation-positive.”

Preliminary data from a randomized European trial has also demonstrated a significant progression-free survival advantage in favor of first-line erlotinib versus chemotherapy in patients with EGFR-positive tumors.

The OPTIMAL trial was supported by F Hoffmann-La Roche China and the Science and Technology Commission of Shanghai Municipality.

Zhou disclosed relationships with Roche, Roche China, and Eli Lilly China. Co-author Yi-Long Wu disclosed relationships with Roche, Eli Lilly, Pfizer, and AstraZeneca. Co-author Jie Wang disclosed relationships with AstraZeneca, Eli Lilly, and Roche. Co-author Li Zhang disclosed relationships with Lilly, AstraZeneca, and Roche.

Mitsudomi disclosed relationships with Pfizer, Boehringer Ingelheim, Chugai Pharmaceuticals, Eli Lilly, and AstraZeneca.

Primary source: The Lancet Oncology
Source reference:
Zhou C, et al “Erlotinib versus chemotherapy as first-line treatment for patients with advanced EGFR mutation-positive non-small cell lung cancer (OPTIMAL, CTONG-0802): A multicenter, open-label, randomized, phase III study” Lancet Oncol 2011; DOI: 10.1016/S1470-2045(11)70184-X.

Additional source: The Lancet Oncology
Source reference:
Mitsudomi T “Erlotinib, gefitinib, or chemotherapy for EGFR mutation-positive lung cancer?” Lancet Oncol 2011; DOI: 10.1016/S1470-2045(11)70194-2.