Interview With
Dr. David Sudderth

I contacted David B. Sudderth, M.D., co-author of Migraine: What Works, and asked him if he'd be willing to participate in an e-mail interview and share some of his insights on migraines. So here it is, straight from the neurologist's mouth..err..keyboard.

    Imitrex is undoubtably the most exciting development in treating migraine in recent years. It has really changed the lives of many people by giving them more control and predictability for themselves and their families. The injections are safe, quick and the injector can be carried by the patient at all times. Recently it has become available in a tablet form which in my experience is not as effective but still helps many people who are afraid of needles. Dihydroergotamine (DHE) was expected to be available as an inhaler but was withdrawn from approval by the manufacturer because of various obstacles. One inhaler that clearly helps many people is Stadol. People often complain of getting "a buzz" but many feel it is very helpful. Unfortunately we still don't have the perfect drug.

    There is no specific blood or other diagnostic test to make the diagnosis. A history consistent with migraine and a normal neurological examination are the cornerstone of the diagnosis. Usually there is a family history of migraine. The typical migraine involves an intense, unilateral, throbbing head pain accompanied by irritability, increased sensitivity to light and sound, and often intense nausea with vomiting. Often there is a prodrome, i.e. a vague sense of unwellness, fatigue and lassitude. An aura, usually visual in the form of flashing lights or wavy lines, precedes an attack of classic migraine. It is possible to have migraine with bizzarre symptomatology such as strange behaviour or even halucinations with or without the actual headache phase. Lewis Carrol's strange descriptions of disproportionate body parts well known from Alice in Wonderland are thought to be his own experiences during migraine attacks.

    I truly doubt if the incidence of migraine is on the rise. The American public is becoming increasingly knowledgeable about all medical problems including migraine. This trend is likely to continue as it becomes harder and harder to get access to a relevant specialist. While information and education are good in many cases, I feel that some patients will experiment with their health in an unsafe manner. This is a sad consequence of managed care.

    The best treatment for migraine is the one that works. The happiest migraine sufferer is the one who identifies his or her trigger and successfully avoids it. This is not always possible but should remain a lifetime goal for anyone with migraine. As a traditional M.D. I tend to use prescription drugs but have also used feverfew and other so-called natural remedies. However just because a drug is not controlled by the FDA does not mean it's safe. Melatonin is said by some to help with migraine. This is quite unclear at the moment, and the long term side effects are equally unclear. A health scepticism is often a good thing. It is very important in migraine to keep an open mind and not give up. The more dogged the patient is the more likely an effective treatment can be found. A migraine sufferer should learn to keep a good and accurate diary which should include a description of attacks as well as other facts including meals, exposures, activities, sleep, etc. A careful list of all medications including the dose and effect/side effects as well as test results and if possible actual imaging studies, i.e.MRI's/CT's should accompany a migraineur when he or she visits a doctor.

    The classic migraine (about 10%)is preceded by an aura while the common (about 90%) migraine is not. Migraines are considered chronic if they occur frequently.

    Migraines can affect individuals at any age. It is not uncommon for migraines to present in childhood in the form of cyclical vomitting or abdominal discomfort. Usually the first attack occurs in the teens while about 90% have had their first attack by the age of 40. A new headache syndrome in a patient over 40 should be of great suspicion to the treating physican, and mor e serious problem should be considered. The attacks tend to lessen in terms of severity and frequency in later years although some unfortunate individuals my actually get worse as they get older.

    Any frequent headaches should be evaluated by a neurologist. A neurologist with a special interest in migraines would be the logical choice. Any neurologist will have access to relevant diagnostic studies. The main advantage to a headache center is really geographical. Many individuals live far from neurologists and a visit to a headache center provides the opportunity for one-stop shopping. Headache centers are often involved in research protocols and for this reason can provide new treatments not available to other physicians and their patients. At least at a headache center one can be reasonably sure of finding a physician with a special interest in headaches.


    As noted above, migraines typically improve with age.

    Biofeedback is an exciting form of therapy for headaches and many other conditions including ADD (attention deficit disorder). Unfortunately it is labor intensive for the patient and health care provider and is often not covered by insurance plans. It is probably most effective in headaches related to stress. Stress is actually the single most commonly identified trigger of migraine attacks. I expect biofeedback to be more important in the future especially if a home program can be made widely available.

    Diet is of the greatest importance in triggering migraine. Many food items are notorious for inducing migraines in susceptible individuals. The usual suspects would include chocoloate, citrus, aged cheese, red wine, MSG, certain preserved foods etc. However more unusual suspects can also bring on an attack and can only be identified by careful record-keeping by the patient. The situation is made more complex, however, by the fact that triggers may not invariably lead to an attack in a given individual. We really have a lot to learn about migraine.

    Yes, I have one very important tip! Educate yourself. Go to the library and read books, articles, etc. about migraine. And then there is the Net. There is a lot of good information out there provided by physicians and more importantly by actual patients with migraine who freely share their experiences relative to medication, doctors, family, etc. The Internet is a valuable resource for anyone with a chronic medical problem! Ronda, your Web page is a great example! Self-education will also help you meet your doctor in a prepared manner which will pay off in increased efficiency of you consultations.


    Migraines are not an isolated series of painful episodes. Migraine is a syndrome that affects the entire family as well as co-workers. The family can play a large role in helping migraine sufferers. I instruct family members in the following ways:

  1. Leave the migraineur alone during an attack unless specifically requested to do otherwise. People having an attack are not themselves. Even breathing can hurt! Stay away!
  2. Always be aware that the migraineur will blame himself or herself if a family outing, etc. is cancelled or affected by an attack. Try to be reassuring and reduce the tension in any possible way. The migraine sufferer oftens feels burdensome and this can lead to depression and other problems.
  3. Help the migraineur to avoid triggers such as offending foods, odors (including tobacco smoke), changes in sleep patterns, etc.
  4. Remind the migraneur to take medications along on outings etc.
  5. Help in finding educational material and get involved in the disease as much as possible. The support is usually but not always appreciated.
  6. Help in identifying triggers and in record keeping.
  7. Have one responsible family member go along to doctor visits. This really pays off as it can be very difficult to remember everything, particularly if you are nervous!
  8. Migraine: What Works by David Sudderth, M.D. and Joseph Kandel, M.D is a book I own and would recommend as a great source of information on medications, diet, and support. It is available at bookstores or by calling 1-800-844-7880.

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