Those of us with migraines are all too aware that a migraine consists of much more than just head pain. There are a number of other symptoms that many of us experience to one degree or another. These may include light and sound sensitivity, cognitive fog, fatigue, dizziness, _ aphasia, neck pain, and motor weakness. (For a more comprehensive list of symptoms, see _ Anatomy of a Migraine.) However, I have to admit that the one that I dread the most is that green monster - nausea. To be honest, sometimes I'm not sure what's worse - the pain or the nausea. I'm sure you can relate to that sense of queasiness - the rolling of the stomach, the sense that everything you've eaten for the last 24 hours is gathered in a lump in your throat, the chills that run over your body, the sweat on your forehead, the tinny, metallic taste in your mouth, the rush of saliva or bile to your mouth, and the diarrhea. It's not a pretty picture, is it? And it's a horrible experience - one where you are afraid to be too far away from the porcelain throne. How many hours have I sat on the floor of my bathroom praying for some kind of relief?
Along with the profound sense of illness is the inevitable internal debate. Do I take my migraine abortive now, or will I just throw it up? If I do throw it up, will I have wasted my precious, carefully allocated mediation? Will it work or do I need to re-dose? (See Teri's article, Nausea, Vomiting, and Migraine Medications - Risk of Fatal Overdose.) If I don't throw it up, is it just going to make my nausea more intense? Even the thought of taking oral medication for nausea can be overwhelming. I'm generally a very compliant patient, but I have to admit that there are times when I avoid my medication because of my fear of making the nausea worse. The nausea keeps me constantly off kilter, frantically trying to gain some equilibrium. It's difficult to speak with others, to read or to think as I ride the virulent waves of queasiness. Chief in my mind is how far I am from the bathroom should I need to make that mad dash. Yes, nausea is very unpleasant, but it is also very disabling. Let's face it - there are just not many productive things that can be done while in the grips of nausea. While society is very aware of the disabling nature of nausea for those who are pregnant or are receiving chemotherapy, I doubt it's one of the first things that comes to mind when one hears the word migraine.
Migraine research can be undertaken for a variety of reasons. One primary reason is to better understand the nature of the disease and how it affects the person with migraines so that more effective treatment can be developed. A large national study was undertaken to identify the prevalence of migraines, as well as means to prevent or treat them. This study, the American Migraine Prevalence and Prevention (AMPP) Study, is a longitudinal study of 24,000 adults over the age of 18 who self-identified as having severe headaches. The AMPP took place over the course of six years and looked at a wide array of issues pertaining to migraines, as well as a number of specific research goals. More information about the AMPP can be found at this
article, Understanding Research.
One issue that was studied as a part of the AAMP was the impact of nausea on migraineurs, their treatment, and the quality of their life. The results were published in an article in the journal Headache.
The Study:** Premise of the Study:**
- "Nausea is both a defining feature of migraine and a major challenge in its clinical treatment. Individuals with migraine-associated nausea may delay or avoid taking oral medication with a resultant loss or reduction of therapeutic efficacy."
- "Besides affecting medication-taking behavior, nausea-and migraine-associated gastroparesis may delay drug absorption. Vomiting can render oral medication completely ineffective."
- "Nausea is a potential barrier to effective migraine treatment."
Goal of the Study:Data from the American Migraine Prevalence and Prevention (AMPP) Study was used to determine _the frequency and** burden** of migraine-associated nausea in persons with episodic migraine._
- This was a longitudinal study conducted between 2004 and 2009. A longitudinal study is a study that observes the same variables or characteristics in the same people over an extended period of time.
- A 2004 screening survey was given to 24,000 adults over the age of 18, followed by annual questionnaires from 2006 to 2009. 6,488 survey respondents with episodic headaches and nausea were included in this specific study on nausea.
- The questionnaire obtained employment status and sociodemographics (including annual household income, race, population density, and geographic census region).
- Respondents were 77.9% female; 89.3% white; and 78.3% were 40 years of age or older. Respondents were evenly distributed across other sociodemographic lines.
- Respondents had an average of 2.6 headache days a month.
- Headache symptom data was obtained which assessed frequency, location and symptoms of headaches.
- In order to assess the frequency and functioning of those with severe headaches, a 6 item Headache Impact Test (HIT-6) was administered.
- Respondents were also asked about their perceptions of headache medications. They were presented with statements such as "My headache medication(s) interfere with my ability to function at work or school." Respondents answered using a 5-point scale ranging from 1=strongly agree to 5=strongly disagree.
- Respondents were divided into three nausea frequency groups.
- The nausea absent group were those who reported never or rarely having nausea.
- The second group reported having nausea less than half of the time but more than rarely.
- The final group reported having nausea half of the time or more.
- 49.5% reported high-frequency nausea (greater than 50% of the time).
- 29.1% reported low-frequency nausea (less than 50% of the time).
- 21.4% reported never or rarely having nausea.
- High frequency nausea is more common in women.
- High frequency nausea is 28% more common in Native Americans than whites.
- African Americans were half as likely as whites to report high frequency nausea.
- High frequency nausea is uniform across the 9 regions of the United States with a marginally significant increase in the East South Central region of the US.
- There were no differences relative to age, income or population size of the area from which the respondent came.
- "While headache days per month was not predictive of reporting nausea less than half the time, every additional day per month of headache was associated with a 5% increase in the odds of reporting nausea half the time or more." (Note: This would suggest that while these results are specific to episodic migraine that they are also applicable to chronic migraine.)
- Attitudes about pharmacological treatments varied according to nausea status. Specifically, the high frequency nausea group felt more financially burdened by their medications, worried more about running out of medications, felt that their medications interfered with work or school, the ability to complete housework and to engage in family, social and leisure activities.
- "Other headache symptoms occurred with higher frequency in the groups with more frequent nausea." These included increased frequency of one-sided pain, throbbing pain, moderate or severe pain intensity, pain increased by routine activities, phonophobia and photophobia.
- "High frequency nausea compared with no/rare nausea group was associated with a substantial increase in the relative odds of occupational disability or being on medical leave."
- "Headache pain severity and impact were also found to increase with nausea frequency."
- Of all the measures assessed on the HIT-6, "nausea is the strongest predictor of headache impact and disability."
- "Respondents with episodic migraine and high frequency nausea fared significantly worse than respondents with headache and less frequent nausea on measures of migraine symptom burden and the impact of headache on their lives."
- "Frequent nausea appears to be an independent contributor to the disability and life impact observed among these study respondents."
- "The high rates of frequent nausea among episodic migraineurs and its links with impairment indicate that nausea is an important target for monitoring and treatment in the management of these individuals."
- "Effective management of nausea via the use of therapies less likely to produce nausea, the use of non-oral routes of administration where feasible, and the early introduction of anti-emetic therapy could reduce the burden of headache amongst those with episodic migraine."
- "The presence, frequency, and severity of nausea, is too often assessed only as part of headache diagnosis, and should also be monitored as part of ongoing care of persons with migraines.
From My Perspective
So why are the findings of this study so important? You know, it is easy for people to understand just how disabling nausea is for chemotherapy patients and pregnant women. However, the public, doctors and patients alike sometimes underestimate the significance of nausea on migraineurs. It not only affects how we feel but also impacts our level of disability and productivity. While many can understand the impact of vomiting since it frequently leads to dehydration and electrolyte imbalances, we frequently aren't as sympathetic, tolerant or even as aware of the burden associated with nausea. However, one of the most compelling and startling conclusions of this study is the statement that nausea is the "strongest predictor of headache impact and disability." If this is indeed the strongest predictor of headache impact and disability, then it is essential that it be thoroughly discussed with one's doctor.
I know that as much as I hate to be nauseous, I also tend to blow off the nausea, accepting it as a "normal" part of my migraines. I rarely write it down as something I want to discuss with my doctor even though I've already told you that it is one of the most difficult and dreaded aspects of my migraines. However, even though migraine doctors and migraineurs alike are quick to say that migraine is more than a headache, we still seem to place a significant amount of focus on the number of days with pain and the intensity of the pain. Yet, if I take the findings of this study to heart, it is essential that I look at the relationship among migraines, pain, nausea and daily functioning (disability). If I'm to be an effective partner in my treatment, I need to be more specific about my experience with nausea and how it impacts my life. I need to know what to do when my nausea is so severe that I just can't stand the thought of taking them. What is my plan B? Is there an alternative to my oral medication? What do I do if I throw up my oral medication? Should I re-dose? Can I take it again later in the week?
Ironically, when I did discuss these things with my doctor, he helped me develop a game plan and suggested that I use an injectable form of my anti-emetic
(medication taken to reduce the effects of nausea and to stop vomiting). This was a good solution for me as I don't mind injecting myself. However, the insurance company was quick to turn down the request for injectables. There were a number of reasons for this, but one significant one had to do with the cost. This was another clear example of a lack of understanding of the impact of nausea on the migraineur and how important viable treatment options are. Maybe if I had this article at that time and had sent it with my appeal, the research may have made a difference in helping the insurance company to understand the medical necessity of controlling nausea in the most effective form.
Secondly, I think the information from this study is important for drug manufactures to take into consideration. If nausea is a significant factor that prohibits us from taking our medication, then maybe it is time to look at other delivery systems. The typical medication delivery systems at this time are oral, injectable, inhaled, transdermal and suppository. Inhaled agents frequently have a taste associated with them that can also increase nausea. Some people are very fearful about injecting themselves and have no one available to do it for them. Some doctors even require that all injections be done in the office which does little good when the patient is in immediate need. Transdermal systems have limitations due to the skin's low permeability. A suppository, frankly, just isn't the easiest or most pleasant of delivery systems. This is particularly true when one is dealing with chronic nausea and accompanying diarrhea. Obviously, delivery systems need to be developed that bypass the gastric process and effectively deliver the medicine to the blood stream.
So, do the findings of this research study ring true for you? Is nausea a significant burden for you? Does it impair the quality of your life? Do you dread it as much as I do? If so, please take this as an opportunity to talk with your doctor about your nausea and to develop a game plan for how to deal with it.
___________ource:** Lipton, Richard B., MD; Buse, Dawn C., PhD; Saiers, Jane, PhD; Fanning, Kristina M., PhD; Serrano, Daniel, PhD; Reed, Michael L., PhD. "Frequency and Burden of Headache Related Nausea: Results from the American Migraine Prevalence and Prevention AAMP) Study." Headache 2013;53:93-103.**
Wishing you health, hope & happiness,
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