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doi: 10.1097/01.NNN.0000383092.54638.51
Features: Cindy Mccain

Cindy's Campaign

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For more information on migraine and stroke, see RESOURCE CENTRAL on page 37.

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Abstract

Straight talk from Cindy McCain about her stroke and migraines.

Cindy McCain was the picture of sophistication and self-confidence as she traveled the country supporting her husband, Sen. John McCain, 73, in his bid for the 2008 presidency. Yet behind McCain's smile and ever-present sunglasses, the mother of four was often fighting horrendous migraines, a condition that has plagued her for 15 years and counting.

In the past year, McCain, 55, has opened up about her ongoing battle with migraines—a medical condition that she candidly refers to as “a disability.” According to the American Migraine Foundation, 36 million Americans experience migraines, and women are affected three times more often than men.

A successful businesswoman and philanthropist in her own right, McCain serves as chairman of her family's business, Hensley and Company, one of the largest Anheuser-Busch distributors in the country. She also advocates for children's health care organizations around the world, including HALO, Operation Smile, and the World Food Program.

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GOING PUBLIC WITH HER PAIN

Taking her condition public signified a monumental step for McCain, who didn't even tell her husband about her migraines until 10 years ago.

“John was commuting from Arizona to Washington, D.C., at the time, and I didn't want to ruin our times together,” she says. “I didn't really tell a lot of people. I now have a close-knit group of friends who know about my migraines. They understand if I have to cancel plans at the last minute because I'm in pain.”

Like many people with migraines, McCain found early on that doctors failed to take her severe headaches seriously. As part of her mission, she hopes to promote migraine education to emergency room physicians in small hospitals and other health practitioners who may not fully understand the symptoms.

“I wasn't accurately diagnosed with migraines until I was 40,” McCain says. “Prior to that, I saw many doctors who seemed condescending and wrote me off as being ‘a neurotic senator's wife.’ Their advice was to go home, relax, and have a glass of wine.”

McCain knew her debilitating headaches were more than just the result of a busy life. It wasn't unusual for her to feel excruciating pain accompanied by auras, ringing in her ears, nausea, and temporary loss of sight. A migraine is a severe headache usually described as throbbing or pulsing. It most commonly occurs on one side of the head and is felt to be coming from behind the eye, temple, or ear. Migraines can last anywhere from four to 72 hours. According to David Dodick, M.D., professor of neurology at the Mayo Clinic in Scottsdale, AZ, some of the most common symptoms associated with migraines include sensitivity to light (photophobia) and/or sound (phonophobia), nausea, and vomiting.

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“If I—as a prominent person—was being brushed off by doctors, what about the mother of four in a small rural community whose migraines are never taken seriously?” McCain says.

“Medicine has long considered migraine and other headache disorders to be predominantly psychological afflictions of women, which is why many women have felt their symptoms weren't taken seriously,” says Dr. Dodick, who is McCain's personal physician. “Anyone who believes she is experiencing migraines should ask her physician for a referral to a headache specialist or neurologist who is skilled at diagnosis and management of patients with headache disorders. If the person has trouble finding such an individual, she should turn to the American Headache Society (AHS) or American Council on Headache Education (ACHE) for advice and guidance on specialists in their area.” (You can reach AHS at americanheadachesociety.org or 856-423-0043, and the ACHE at achenet.org. You can search online with the American Academy of Neurology's “Find a Neurologist” tool at patients.aan.com/findaneurologist.)

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In order to determine whether a patient has migraines, doctors take what is called a “headache history,” which looks at frequency, triggers, severity and duration of pain, and what symptoms and warning signs occur with the headache. After obtaining the history, doctors typically perform a complete physical and neurologic examination to rule out any signs and symptoms of an illness or other neurologic disease that could be causing the headaches.

“I began keeping a diary of my headaches, listing what seemed to be triggering them and what symptoms I felt at the moment,” McCain says.

It wasn't until the Mayo Clinic opened in Scottsdale, AZ, that McCain was finally diagnosed as having migraines.

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INADEQUATE FUNDING

Dr. Dodick calls migraines one of the most misunderstood neurologic conditions. Both he and McCain hope to raise awareness about migraines and to see more federal money allocated for research.

“I don't think migraines are seen by many as a serious disorder, and that's a mistake,” Dr. Dodick says. “Headache is just one manifestation of migraines. It's a systemic illness.”

The World Health Organization estimates that migraines cause more lost years of healthy life in the United States annually than multiple sclerosis, epilepsy, ovarian cancer, and tuberculosis combined; however, the combined National Institutes of Health (NIH) research funding on those four disorders is more than 117 times greater than that of migraine.

“Right now, we receive one fiftieth of one percent of the NIH budget, an amount that is grossly disproportionate to the number of patients who have migraines,” says Dr. Dodick, who serves as president-elect for the American Headache Society.

Knowing the toll that migraines have taken on her own life, McCain hopes funding could ultimately provide better treatments for people with migraines, including those currently serving in the military. Experts estimate that 36 percent of Iraq War veterans who had never had migraines return home with them.

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“There have been days where I've missed an event that's been on my calendar for months because the pain and nausea were so bad,” McCain says. “I feel as if my children especially have taken a hit.”

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GENES, HORMONES, AND TRIGGERS

A mother of four (Meghan, 24, Jack, 23, Jimmy, 21, and Bridget, 18), McCain remembers her migraines taking root following a hysterectomy that she had when she was in her late 30s. Studies have shown that hormonal changes can bring on migraines, which may also explain why the condition affects more women than men.

“Fluctuations in hormone levels, particularly estrogen, which commonly occur during monthly menstrual cycles, pregnancy, the post-partum period, placebo week while on oral contraceptive pills, and menopause, can have a profound influence on the frequency and severity of migraine attacks,” Dr. Dodick says. “Indeed, before hormones begin to fluctuate (pre-puberty) and after hormones stop fluctuating (menopause), migraine is no more common in women than it is in men, but during this period of fluctuation, migraine is at least three times more common in women than men.”

In researching her condition, McCain learned that migraines may have a genetic component—and that her grandmother often had bad headaches. In 2002, UCLA geneticists discovered the first evidence that migraine with aura is a hereditary condition and reported their study in the March 1, 2002 edition of the American Journal of Human Genetics.

While specific migraine triggers can vary from person to person, McCain says her own triggers encompass everything from drops in barometric pressure to certain foods and perfume scents. “Red meat, wine, chicken, and chocolate can all pose triggers for me,” she says. “I'm also extremely sensitive to light, which is why I'm typically photographed wearing sunglasses.”

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CINDY'S STROKE

In retrospect, McCain's migraines may also have played a part in the stroke she suffered in 2004.

“A large body of evidence now indicates that women who have migraine with aura are at an increased risk of ischemic, but not hemorrhagic, stroke. The risk may be at least two-fold, and appears to be increased with the use of an oral contraceptive pill and smoking,” Dr. Dodick says. Ischemic stroke occurs when a blood vessel that supplies blood to the brain is blocked by a blood clot, while a hemorrhagic stroke occurs when a blood vessel in part of the brain becomes weak and bursts open, causing blood to leak into the brain.

“However, it's important to remember that the absolute risk of stroke [the numerical probability of a stoke occurring within a five-year period] in these women is still very low, and it's very rare for individuals with migraine with aura to experience a stroke during an aura or during the headache phase.”

While McCain made a miraculous recovery from her stroke, in part because of quick medical assistance, she still remembers the day six years ago when she began feeling ill while having lunch with friends in Phoenix.

“I tried to speak and found I couldn't talk or walk,” McCain recalls. Her friends rushed her to the hospital, where she was diagnosed as having a minor stroke. (See “Stroke Symptoms” box.) Several years earlier, doctors told McCain she had high blood pressure—the primary cause of strokes. She admits thinking that at 49 she was too young to need medication, and as a result didn't follow her doctor's orders and take her blood pressure pills.

While strokes typically affect those in their 50s and beyond, they can occur in younger patients.

“Potentially treatable risk factors for stroke include high blood pressure, high cholesterol, diabetes, sedentary lifestyle, obesity, obstructive sleep apnea, certain cardiac disorders, sickle cell disease, heavy alcohol use, illicit drug use, and cigarette smoking,” says Robert Brown, M.D., professor and chair of the Department of Neurology at the Mayo Clinic in Rochester, MN. “Other risk factors that are not treatable include age, a family history of stroke, and ethnicity.”

While you can't change some risk factors related to heredity, many of the risk factors for stroke can be modified with lifestyle changes.

The stroke served as a wake-up call for McCain, who decided to lose weight, start a regular exercise regimen, and give up salt, sugar, and caffeine. She also learned to manage stress better, and she shuns negative press and tabloid articles.

“They often don't make sense and just prove to be upsetting,” McCain says. “I'd rather concentrate on the things in life that are truly important, like my family.”

Today, McCain is in good health except for her recurring migraines. She says it's not uncommon to experience two horrible migraines in the course of a month.

“They seem to be more debilitating now for some reason,” she says. “Sometimes the only solution is a visit to the emergency room.”

McCain has found some relief using triptans, a class of drug used in the treatment of migraines and cluster headaches. However, she hesitates to talk about her specific medications because, she says, not all medications work well for everyone. Her neurologist, Dr. Dodick, prefers to take an individualized approach to choosing migraine medications and to involve each patient in the decision-making process.

“If the person has a pre-existing condition such as high blood pressure, it makes sense to select a medication that will also minimize blood pressure,” he says. “We also look at potential side effects from various medications. It's not uncommon for patients to try several different medications before we find the one that really makes a difference.”

Ultimately, McCain hopes that researchers will find a cure.

“Treatment for migraines has advanced significantly over the past 10 years, but there's still a long way to go,” she says. “But before you can receive appropriate treatment, a proper diagnosis has to be made.”

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Stroke Symptoms

Dr. Brown recommends that people of any age get prompt medical attention if they begin to experience these symptoms of a possible stroke:

Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body

Sudden confusion; trouble speaking or understanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination, and/or sudden, severe headache with no known cause

According to the National Stroke Association, women may report unique stroke symptoms including:

Sudden face and limb pain

Sudden hiccups

Sudden nausea

Sudden general weakness

Sudden chest pain

Sudden shortness of breath

Sudden palpitations

©2010 American Academy of Neurology

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