MIGRAINE HEADACHES are very common and account for a considerable amount of temporary disability. They are much more common in women, but men can get them too. Although they can occur in children, migraine headaches typically start in the teens, get worse in the twenties and thirties, and then gradually get better. However, migraines sometimes will get worse for no clear reason.

Not all headaches are migraine. One common type is tension or muscle-contraction headaches, which result from spasm of the muscles at the back of the neck and sides of the head. Because these muscles hold our heads up against gravity, they do not get much chance to rest during the day. When they contract, the headache can be quite painful. While muscle-contraction headaches are related to stress, they do not necessarily occur on the most stressful days.

While sinus problems are often blamed for headaches, most headaches -- including those on the forehead -- are not due to sinus problems. Temporomandibular joint (TMJ) problems also are not a common cause of headache.

Some people get headaches nearly every day. While migraine can be a factor in these chronic daily headaches, they are not the primary cause. Understandably, people suffer from these frequent headaches take pain relieving medications like acetaminophen or ibuprofen on a continuing basis, but this may perpetuate the problem by lowering the pain threshold. Migraine measures may help somewhat, but do not usually completely solve the problem.

The symptoms of migraine are caused by changes in the blood vessels in the brain. The vessels first contract, then expand. The pain is due to the expansion of the vessels, which stretches their walls. The earlier contraction results in decreased blood flow and is the cause of the aura (a subjective sensation -- as of voices, colored lights, or crawling and numbness) that many people experience before a migraine attack: the most common form is a change in vision. As the vessels expand, the aura goes away and the headache begins. An aura lasting longer than one hour may indicate a more serious condition. Migraine is usually one-sided, but not invariably. The pain can lead to muscle contraction as described above, so that two types of headache may be present at the same time.

Hormones clearly play a role in migraine. Commonly migraines are triggered by a certain phase of the cycle. The most common time is just before or at the beginning of menses. Estrogen levels are falling then, and this may be what sets off the headache. Estrogen is a vasodilator and the fall in estrogen may trigger the blood vessel changes that lead to migraine. The exact role is not completely worked out, however. Some women's migraines occur at a different phase of the cycle and some get the headaches without any apparent relationship to their cycle. Usually hormones are not very successful in treating migraine: birth control pills sometimes help, but are equally likely to make it worse.

There are two aspects of migraine treatment: preventive and abortive. Preventive treatment consists of taking a medication daily to prevent the headaches from starting in the first place. Abortive treatment consists in using medications to take away the headache after it has started. Many women with migraine need both. The main classes of medications used for prevention are beta-blockers such as propranolol (Inderal¨), atenolol (Tenormin¨) and nadolol (Corgard¨). These are taken daily and often reduce the frequency and severity of migraine attacks by up to 50 percent. My preference is for calcium channel blockers -- such as verapamil (Calan SR¨) or amlodipin (Norvasc¨) and others -- because they seem to have fewer side effects. Many migraine sufferers do quite well with beta-blockers however. It is sometimes necessary to try several medications in these classes before you find one that works for you. Occasionally, other medications such as the anti-convulsant carbamazepine (Tegretol¨) are used for migraine prevention.

There are now several medications, which help end the migraine attack. This is an area which has advanced considerably in recent years. The first fully effective drug was sumatriptan (Imitrex¨). This is available in oral, injectable, and nasal spray forms. The nasal acts almost as quickly as the injection and faster than the tablets, and consequently is often the first choice. Other newly introduced medications for aborting attacks are dihydroergotamine nasal spray (Migranal¨) and zolmitriptan (Zomig¨) which is a tablet. Sumatriptan lasts for a few hours. For migraine sufferers whose headaches usually last longer, an alternative is naratriptan (Amerge¨) which lasts for about 24 hours. All these medications work by causing blood vessels in the brain to constrict and so it is important to not take them more often than recommended. Sometimes sumatriptan is used to stop the headache, and naratriptan is taken an hour or two later to prevent it from coming back. Naratriptan is very useful for menstrual migraine when the attack often lasts for two or three days. Patients must be very sure they fully understand their doctors' instructions before using these medications and should not make changes without his or her advice.

With these approaches to migraine treatment, most who suffer from it can get considerable relief. It does take time and patience to work out the treatment that is best for each individual, so you should not be discouraged if the first medication tried does not work completely.