“You Have a Sensitive Brain”
My migraine patients always want to know why they have migraines. It has taken me a long time to understand this desire, but I have learned that they believe that finding out the why is key to finding the “fix.” Often, when evaluating a patient with headaches, physicians order a scan of the brain, either CT or MRI. Most migraine patients have normal scans because their abnormality is in the physiology (function), not the anatomy (structure), of the brain. As a neurologist, I always hope the scan will be normal. Initially, I could not understand patients’ disappointment when I told them, “Great news! Your MRI is normal.” Years of caring for patients have given me insight into this reaction: They are hoping to find something that can be fixed and end their suffering. In the same way that I prepare a patient with an abnormal neurological exam for what I expect to be a bad result, I have learned to prepare my migraine patients that I expect them to have a normal scan, even though I understand they may hope that I find something wrong. I know they may be thinking, “I hope she finds a tumor. Then it can be taken out and my headaches will go away!”
When the imaging comes back normal and I need to explain why, I like to tell my patients that the reason for their migraines is that they have a sensitive brain. Often this sensitivity is hard-wired into their brains, with family history of migraine playing a strong role. In some patients, an event such as a head injury or severe stress turns on a migraine generator. Sensitive migraine brains react to triggers like hormones, stress, lack of sleep, food, motion, the weather, caffeine, and alcohol (among many other triggers).
Recognizing and accepting this sensitivity are key factors in managing migraine. For example, many patients need exercise to feel good and handle stress. However, it is necessary for them to exercise in a way that works for their body. Many patients tell me, “I keep my tension in my neck.” This tension seems to have both emotional and physical origins. Yes, stress makes our necks tight. But sitting at the computer all day does, too. Many of my patients are of slender build with long, thin necks. Simple physics says that the muscles holding their head and arms in place work harder than those of a thick-necked football player. Most of these patients will not do well with high-resistance exercises that increase tension in the neck, such as weights over the head and planks. Sometimes the solution can be as simple as reducing the weight or number of reps, but often those exercises need to be avoided completely. Patients who want to tone their arm muscles and achieve abs of steel are not happy when I tell them these exercises need to go.
Early in my practice, I did not like to focus on migraine triggers because I felt doing so placed too much blame on my patients for their migraine attacks. I have learned over time, though, that recognizing and managing triggers is an important part of coping with having a sensitive brain. Still, migraine attacks may come without apparent trigger, with a trigger that is out of our control such as the weather, or with a complex stacking of triggers that is impossible to control. For these migraine attacks, I believe it is helpful to recognize and accept, “I’m sensitive.”