Migraine headaches are often disabling and caused by abnormal brain activity—many nerve pathways and neuropetides are involved in activating nerves that affect sensory tracts in the brain.
While migraine headaches are thought to be caused from a dilation of blood vessels along the path of the fifth cranial nerve (trigeminal nerve) the actual chain of events still is not clear. Imaging studies taken during migraine headaches suggest a failure of normal sensory processing.
The most important consideration in life underwriting is determining the diagnosis and understanding the radiologic testing that may appear quite striking and associated with more disabling disease.
Migraines are classically associated with a pattern familiar to most sufferers. Most of those affected get an aura of symptoms that are a warning sign preceding the severe headache. These symptoms—which can occur a few minutes to several hours before the headache—include nausea, vomiting, light sensitivity and visual disturbances. These headaches may become throbbing and can affect sense of taste, smell and vision in addition to the characteristic pain. Disturbances of neurologic function may accompany the headaches and are thought to be caused by constriction of branches of the internal carotid artery. Visual disturbances may take the form of light flashes, hallucinations, and changes and narrowing of the visual fields. Numbness, tingling, as well as problems with speech and balance may also occur during the course of an attack.
The headache itself is usually pulsatile, one-sided and very severe. Alcohol, anxiety, stress or even bright lights may begin an attack. Other triggers can be smoke, low blood sugar, changes in sleep patterns, physical stress or even certain foods. The most common include those with added MSG; those that contain tyramine, such as cheese, red wine and smoked fish; chocolate; nuts; or fruits.
Migraines are more common in women than men, can begin as early as adolescence, and may appear later in life, sometimes after age 40. They have an increased occurrence within families, and pregnancy appears to decrease the incidence in known sufferers.
Most physical exams show little during a migraine attack. The diagnosis of migraine is made by establishing the typical pattern of pain and evolution of symptoms. Severe headaches such as cluster headache, post trauma head pain and other neurologic causes have to be ruled out. Medications to treat migraines start with simple over-the-counter medicines when the attack is mild, to narcotic pain relievers, anti-nausea medicines and those that treat blood vessel dilation when it is severe Some necessitate trips to the emergency room for acute pain relief.
While disabling when present but with a return to normal between attacks, what makes migraine headache difficult to underwrite?
First, migraine may be confused with other more serious entities, such as brain tumors, cerebral hemorrhage or narrowing of important blood vessels in the brain. Migraine headache is a risk factor for stroke in both men and women, especially in those where an aura is prominent. Those who have other stroke risk factors, such as hypertension, smoking or women on birth control medications are particularly prone to problems. Dependence on pain medications and narcotic overuse are also concerns.
Most of those with controllable and non-disabling migraines are underwritten at standard and even preferred rates when cases are non-complicated. Those whose migraines are prolonged, have neurologic compromise, show residual abnormalities after imaging such as CT or MRI, or who have other complicating risk factors for stroke are considered individually and constitute more serious risk.
Robert Goldstone, MD, FACE, FLMI
Goldstone, board certified internist and endocrinologist, is vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1990. Goldstone can be reached by telephone at 949-420-8390. Email: firstname.lastname@example.org.