Probably one of the commonest predisposing conditions in migraine is stress-anxiety, or tension. There are now many tranquillizing drugs which act to relieve these states and, in doing so, prevent migraine attacks. The most widely used group are the benzodiazepines, of which Valium and Librium are the best known and perhaps over-used. Tranquillizers exert a calming effect by acting on those structures in the brain concerned with emotion. (Apart from this effect on the specific receptors in the brain, Valium relaxes skeletal muscle, which is helpful in muscle-contraction headaches.) The soothing effect of these drugs on anxiety or agitation also makes people less likely to react to external stress and, because of this, it can be very effective in reducing the frequency of headaches.Small doses are prescribed so that untoward effects, such as drowsiness, should not occur; other unwanted effects of Valium such as depression, apathy, and loss of muscle tone are also avoided. With chronic high dosage more serious effects are personality changes, such as sudden rages and irritability (similar to those experienced by people addicted to alcohol). Suddenly stopping these drugs can result in acute episodes of anxiety. These serious side-effects are infrequent and Valium is a remarkably safe and very useful medicine. Other substances in this group include Ativan, Librium, and Nobrium.Equally important in increasing the frequency of migraine is depression and this too is eminently remediable by antidepressant drugs.Of the three main types, the most commonly used are the tricyclics, e.g. Tryptizol (amitryptiline). These work by increasing the level of noradrenalin in the brain and so control mood. As the drug accumulates in the blood, it may take up to two weeks before its antidepressant effect is noticed. Because these drugs antagonize the neurotransmitter acetylcholine, which helps to produce saliva, a common side-effect is dryness of the mouth. As acetylcholine is the transmitter of the parasympathetic nervous system, its other side-effects include speeding up the heart rate.The tricyclics are surprisingly effective against migraine even in sufferers who are not depressed, possibly because the two conditions are related biochemically. If the migraine is aggravated by depression, treatment with tricyclics is particularly rewarding. Similar to the tricyclics but with fewer side-effects are the new tetracyclic antidepressants; although their value in migraine has not been fully assessed, they have the advantage that they exert their effects almost at once.A second group of antidepressants act as inhibitors of the enzyme monoamine oxidase (MAO). This enzyme breaks down amines, active substances that play a part in the transmission of nervous impulses (neurotransmitters). MAO inhibitors are also effective in the treatment of migraine and their usefulness again is not confined only to patients who are depressed. This is paradoxical because the level of MAO is low during an attack of migraine; in this situation it is difficult to know in which way MAO is having its effect. However, there are several forms of MAO and more specific inhibitors, which inhibit only one variety, are now being tested.Patients taking MAO inhibitors should not eat food containing tyramine (such as cheese) since they may develop reactions such as episodes of high blood pressure. Because of these reactions, the use of these drugs is limited to more serious cases of depression and they are not usually prescribed simply for migraine.
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