Migraines and Auras

Many of us can cite a special person as the inspiration for our choices and achievements in life. For Sheena Aurora, MD, that person is her mother, Jasbir Kaur.

As a young woman in rural 1960’s Punjab, India, Kaur had wanted to be a doctor. But that wasn’t possible, Dr. Aurora explains, because “During that era in India, girls were not encouraged to go into medicine.” When Dr. Aurora realized she wanted to pursue medicine, she had her mother’s whole-hearted support. By becoming a doctor, Dr. Aurora achieved not just her own dream, but her mother’s as well.

In 1994, during her residency, Dr. Aurora was home visiting family when one day her mother suddenly said, “I can only see half the dog.” While the episode was unnerving for her mother, Dr. Aurora thought she knew what was going on.

After checking one of her medical books, she explained to her mother that she was experiencing a migraine with aura, an unsettling but harmless condition that comes and goes, often causing obscured vision and even bright, flashing rainbows of color.

“The experience was very alarming to my mom,” Dr. Aurora says. “This was 20 years ago, and there weren’t really any imaging studies yet on migraine with aura.

”Once again, Jasbir Kaur served as inspiration for her daughter: at that moment, young Dr. Aurora decided she wanted to learn more about — and treat — this mysterious condition.

In medical school, she became fascinated with migraines, which she describes as “different from all other pain.” She says, “With migraine, patients can be sensitive to light, sound, smell, touch and heat.” The mysteries of the brain continued to intrigue Dr. Aurora. When she was doing her first neurology rotation at age 19, she encountered a 19-year-old patient in a coma. “I knew the brain was different from other organs in that it can’t repair itself,” Dr. Aurora recalls.“ But when I saw this young patient — the same age I was — I thought, ‘That could be me.’ I wanted to try to figure out why the brain can’t repair itself.”

LEADING THE WAY; UNLOCKING THE MYSTERIES OF MIGRAINE

Twenty years later, Dr. Aurora is now a clinical associate professor of neurology at Stanford University’s School of Medicine and one of the nation’s leading migraine pain researchers. Dr. Aurora’s research is based in the idea that the best migraine pain management is learning to prevent them rather than treating them after the fact.

In 1997, she first proposed that BOTOX® might be used as a preventive treatment.

In 2008, she served as the lead investigator for the PREEMPT-1 trial, which in October 2010 led to FDA approval of BOTOX to treat chronic migraine, a debilitating condition characterized by 15 or more headaches a month, with headaches lasting four hours a day or longer, with half those headaches being associated with migraine. The BOTOX regimen Dr. Aurora developed is not a reaction to a headache at its onset but is preventive in nature: adult migraine sufferers are injected to prevent headaches.

During the 15-month trial, patients were injected in seven muscle groups in the head and neck area every three months. “They got better and better,” Dr. Aurora reports. “More than 80 percent of trial participants had migraine reduction of more than 50 percent, both in terms of frequency and severity.”

A typical candidate for BOTOX, says Dr. Aurora, suffers from headaches at least half of every month, with headaches lasting four or more hours a day. “There is no proven efficacy in episodic migraines experienced fewer than 15 days each month,” she says.

While pain-free migraine does exist, Dr. Aurora says it’s more common for migraines to be accompanied by pain. Some people suffer from chronic migraine pain, but episodic pain — the kind that comes and goes — is more common, though less debilitating.

KNOW YOUR TRIGGERS

When Dr. Aurora first began her career, little was known about what caused migraines — to say nothing of how to treat them effectively. The field has come a long way in a short time.

“We now know that migraines happen in the part of the brain that’s hyper-excitable,” she says. “Migraine is a genetic disorder. You’re born with the tendency.”

Once the brain prone to migraine meets the right triggers, it’s like kindling, explains Dr. Aurora. Those triggers vary from person to person. “Red wine, chocolate and aged cheese are all popular culprits,” she says. “Those who suffer from migraines have to know their triggers and try to avoid or reduce contact with them.”

Dr. Aurora recommends keeping a journal to help track what you have consumed and whether it had an impact. This is a good first step to knowing what you’re dealing with and how to work around it.

People who live with migraines will be happy to know that Dr. Aurora doesn’t recommend completely foregoing red wine, chocolate or cheese — rather, developing a plan to minimize their effects. Dr. Aurora notes that she treated one migraine sufferer who learned to grow his own grapes so he could remove the tannins, enabling him to create a migraine-free red wine.

KEEP DRINKING YOUR COFFEE

But you need not go to those lengths. Dr. Aurora had a patient who loved coffee but was worried about her in-take, so she tried to cut back on her daily habit. She drank coffee on workday mornings but went without it on weekends. As soon as she began her coffee-free weekends, she started getting Saturday headaches. The practical Dr. Aurora advised her to enjoy her coffee every day of the week. The weekend headaches stopped.

“I worked in Seattle for 12 years,” she says. “I am not going to ask people to give up their coffee.“

I try to work with patients,” she continues. “I’m not going to say, ‘Lead a dietarily boring life.’ Many patients worry they’re going to have to subsist on stale bread and water to avoid headaches, but that’s just not the case. There are creative workarounds.”

TO STRESS OR NOT TO STRESS: THAT IS THE QUESTION

Stress is another migraine trigger. But curiously, so is a lack of stress. Dr. Aurora cites the “honeymoon headache” as a classic example. “After all the stress and busy-ness of wedding planning has passed, and you’re finally married and on your honeymoon, the lack of tress can trigger a serious headache.”

Dr. Aurora has seen it happen with patients who are high-flying Silicon Valley entrepreneurs, too. “They’re running on lack of sleep and adrenaline as they work toward a big deadline,” she explains. “And as soon as they’ve met the deadline, a stress migraine kicks in.”

BREATHE (AND USE BIOFEEDBACK)

Just as some people are predisposed to migraine, some people are predisposed to having stress as a trigger. “Biofeedback works remarkably well for this type of patient,” Dr. Aurora says. “It re-trains the brain not to go into that reaction mode. It teaches patients how to breathe their way through stress.”

The noninvasive therapy involves electrodes being placed on the muscles around the stomach and chest. The doctor uses guided imagery to talk the patient through some exercises and monitors the patient’s pulse and heart rates. Biofeedback helps patients use their minds to control how they feel physically. The process recognizes the mind-body connection and uses one to benefit the other.

“Sometimes patients get results from biofeedback after just two or three sessions,” Dr. Aurora says. “Other times, it may take five or six.”

Biofeedback is only one of the tools in Dr. Aurora’s tool kit. Although one treatment may work on its own, she suggests an integrative approach for managing migraines. She prefers to customize a treatment plan for each patient, but almost all treatments involve one or more of these:

•  Acute medication (taken when a migraine is just coming on)

•  Prevention, including injectables like BOTOX

•  Biofeedback

Dr. Aurora also reassures patients of something her mother (and others) weren’t aware of 20 years ago: There is a biological basis for migraine.

“When I first chose this as a career, people asked,‘Why would you want to go into a field no one understands?’ Now, we understand the causes — and the treatments — so much better than we did even a few years ago.” {PP}

Sheena K. Aurora, MD, has built a career on researching and developing novel treatments for migraine and other primary headache disorders. A graduate of Christian Medical College in Punjab, India, Dr. Aurora is clinical associate professor at Stanford University and member-at-large on the Board of Directors and fall symposium co-director of the American Headache Society.

Dr. Aurora served as director of the headache clinic at Henry Ford Hospital for four years before becoming co-director of the Swedish Headache Center at the Swedish Neuroscience Institute in Seattle, Washington. From 2001–2012, she served as an adjunct assistant professor in the department of neurology at the University of Washington in Seattle.

Voted one of the area’s best doctors in Seattle Magazine’s “Seattle Best Doctors” in 2010, 2011 and 2012, she was also awarded the Harold G. Wolff Award for Research in Headache by the American Association for the Study of Headache in 1999, 2001 and again in 2007.

Dr. Aurora currently serves in professional societies including the NIH Headache Task Force, Clinical Research Committee and Clinical Research Trial; American Academy of Neurology; Migraine Research Foundation Medical Advisory Board; National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements; and the American Headache Society.