MIGRAINES may be right up there with root canals and childbirth as one of life's more painful experiences. But unlike childbirth or dental surgery — the pain of which can be dulled with standard medications — migraines are notoriously tricky to treat.
Those who suffer from these disabling headaches often try a dozen or so medications before they find something that works. What's more, many migraines do not get properly diagnosed, according to the doctors and researchers I spoke with. That can lead to a lot of extra pain — and expense — for the afflicted.
A reason migraines are so maddeningly elusive is that they are not simply bad headaches. They stem from a genetic disorder (yes, you have your parents to blame) that afflicts 36 million Americans and manifests as a group of symptoms that besides head pain may include dizziness, visual disturbances, numbness and nausea.
Some of the symptoms resemble those from other disorders, like sinus headaches, epilepsy, eye problems or even strokes. And to further complicate matters, sufferers react in varied ways to medications.
"What might be a miracle drug for one person could be a dud for another," said Dr. Joel Saper, director of the Michigan Headache and Neurological Institute, a treatment and research center in Ann Arbor. "There is no universally effective therapy."
If that sounds murky, one thing is not: early intervention is important. If you get a migraine every few months and can cope by taking an over-the-counter med, great — you've got the problem somewhat under control. But if recurring pain is not responding to your own efforts, seek expert help.
"Some early data suggests that if you let headache pain go without treatment it can lower your threshold for pain down the line," Dr. Saper said. In other words, untreated headaches can make you more vulnerable to pain.
On the other hand, if you are taking over-the-counter or prescription painkillers two to three days a week for months on end, the medications you are taking to dull pain could worsen your condition. You may then start to experience medication-overuse headaches — a risk for migraine sufferers.
Researchers are learning that pain and the medications used to treat pain can potentially change the biology of the brain.
Receiving good treatment can help you function more effectively, and will probably also save you money over the long term. And if you have health insurance, it should cover most of the relevant medical evaluations and treatments.
Here are suggestions for getting help.
EVALUATION If you have chronic or disabling headaches that your primary care physician has not been able to manage, see a neurologist who has expertise in treating headaches.
Be sure to ask beforehand about that expertise. Not all neurologists have experience treating migraines.
You might want to see a certified headache specialist. Doctors with this new certification have passed board exams in their area of specialty as well as one on headaches. You can find a list of the approximately 200 certified headache doctors on the Migraine Research Foundation's Web site.
Before you make an appointment, ask your potential doctor's assistant, by phone, a few key questions. Find out about the doctor's experience. And be sure to ask how long the first meeting will last.
"A good doctor will spend at least an hour with you," said Dr. David W. Dodick, a neurologist at the Mayo Clinic in Arizona.
It's important for a doctor to take time to listen to your issues, said Claire Louder, 44, who has had migraines since she was 12. She said she has seen a half-dozen doctors over the years.
"The best ones pay attention to what you say," said Ms. Louder, who is a chamber of commerce executive in Maryland. "One doctor I saw had a treatment plan in mind before I'd said a word. Then she kept telling me my migraines were due to stress, which was an oversimplification."
A good doctor should be creative and willing to try a variety of treatments.
At your first visit, the doctor will make sure that your headaches are not caused by an underlying illness, like Lyme disease or a brain tumor. Once the doctor is satisfied that your condition is indeed what are called primary migraines, the doctor will ask you detailed questions about your attacks, take a thorough medical history and probably have you keep a diary of your migraine patterns.
STRATEGIES VARY Be prepared for a multi-tiered approach.
Doctors typically prescribe a triptan drug or an ergot-related drug to help people control infrequent migraine attacks. Both of these drug types influence brain cell reactions that are part of the migraine process.
There are seven types of triptans. Ms. Louder tried five before she found one, rizatriptan — sold under the brand name Maxalt — that worked for her. The best-seller Imitrex (sumatriptan) is available in an affordable generic version.
Triptans are far more popular, but many people who do not respond well to triptans do well with the ergots, such as D.H.E. (dihydroergotamine), Dr. Saper said.
If you have migraines at least weekly your doctor may prescribe a preventative medicine to reduce their frequency of attacks.
"Prescription preventatives are grossly underutilized," Dr. Dodick said. "They can be extremely effective for some people."
Preventive medicines, taken every day, include antiseizure drugs, beta blockers and tricyclic antidepressants. Ms. Louder started taking Topomax (topiramate), an antiseizure drug, five years ago and says it has helped to reduce the frequency of her migraines from once a week to once a month.
Your doctor might suggest some natural remedies too — like vitamin B2, coenzyme Q10, magnesium or butterbur, an herb that is sold under the name Petadolex — which some specialists say can help reduce both the frequency and intensity of your headaches. These supplements are not covered by insurers but all are relatively inexpensive.
LIFESTYLE CHANGES "Migraines are built into the biology of the brain," Dr. Saper said.
Sufferers inherit a hypersensitivity to physical and emotional events — like stress, noise, certain foods and even bad weather. Learning to identify the circumstances that can set off an attack is important in migraine management.
Dr. Dodick said, "Recognizing triggers can prevent attacks from occurring." After keeping a diary, Ms. Louder learned, for instance, that low-pressure storm systems, meats with nitrates and many other preservatives induced her migraines.
"Migraine patients don't respond well to change," Dr. Dodick said.
Sometimes just keeping one's patterns and habits predictable can reduce attacks. Lack of sleep, erratic schedules and lots of plane rides are disorienting for even the hardiest people, but they can literally send migraine sufferers to their beds, or worse, to the E.R.