Why do my hemiplegic migraines worsen with stress?

Stress as a Trigger for Hemiplegic Migraines

Stress is a significant trigger that worsens hemiplegic migraines by increasing cortical spreading depolarization susceptibility, particularly during stress relief periods such as weekends or holidays. 1

Understanding the Stress-Hemiplegic Migraine Connection

Hemiplegic migraine (HM) is a rare subtype of migraine with aura characterized by transient hemiparesis (one-sided weakness) during attacks. The relationship between stress and hemiplegic migraines follows specific patterns:

1. Stress Relief Phenomenon: Research shows that relief following chronic stress (rather than the stress itself) significantly increases susceptibility to cortical spreading depolarization (CSD) - the electrophysiological substrate of migraine aura - in genetically susceptible individuals 1

2. Stress as a Trigger: Stress is the factor most frequently reported by migraine sufferers as triggering their attacks 2

3. Vicious Cycle: Migraine attacks themselves can act as stressors, potentially leading to a cycle of increasing migraine frequency 2

Physiological Mechanisms

The worsening of hemiplegic migraines during stress involves several mechanisms:

• Genetic Susceptibility: If you have familial hemiplegic migraine (FHM), you likely have mutations in ion channel genes (CACNA1A, ATP1A2, or SCN1A) that make your brain more susceptible to cortical spreading depolarization 3

• Stress-Induced Changes: Stress triggers biochemical changes related to the physiological stress response, including the release of corticotrophin releasing hormone 2

• Reduced Treatment Efficacy: High stress levels are associated with poor outcomes of acute migraine treatment, creating a compounding effect 4

Management Strategies for Stress-Triggered Hemiplegic Migraines

Acute Treatment Options

1. First-line medications:

   • Acetaminophen and NSAIDs (ibuprofen, naproxen sodium, diclofenac potassium) 5, 3
   • Note: Use these early in the headache phase for best effectiveness 5

2. Important caution: Triptans and ergotamine are contraindicated in hemiplegic migraine due to pathophysiological concerns 6

Preventive Treatment

Consider preventive treatment if:

• Attack frequency exceeds 2 per month
• Attacks are severe and significantly impact quality of life 3

Options include (in no strict order):

• Flunarizine
• Sodium valproate (500-1,500 mg/day)
• Lamotrigine
• Verapamil
• Acetazolamide 3

Stress Management Strategies

Since your individual response to stressors is the critical factor in the stress-migraine interaction, acquiring effective stress management skills can significantly reduce migraine impact 2:

• Identify stress patterns: Keep a headache diary that includes stress levels and potential triggers 5
• Stress reduction techniques: Implement regular relaxation practices
• Lifestyle modifications: Improve sleep quality and physical fitness, as poor sleep and fitness are predisposing factors for migraine attacks 5
• Avoid weekend/holiday triggering: Be especially vigilant during periods of stress relief, as this is when attacks are most likely to occur in genetically susceptible individuals 1

Important Caveats

1. Medication overuse risk: Limit acute medication use to avoid medication-overuse headaches 5

2. Realistic expectations: Understand that effective treatment aims to reduce attack frequency, duration, and intensity rather than completely cure the condition 5

3. Weekend/holiday vulnerability: Be particularly careful during transitions from high stress to low stress periods, as this is when your hemiplegic migraines are most likely to be triggered 1

4. Individualized approach: Hemiplegic migraine treatment often involves a trial-and-error strategy due to its rarity and lack of specific clinical trials 3

By understanding the unique relationship between stress and hemiplegic migraines, particularly the vulnerability during stress relief periods, you can better manage your condition through appropriate medication and targeted stress management strategies.