Migraines

Source: FAA Safety Briefing Jan/Feb 2019
By: Leo M. Hattrup, M.D.

A migraine is a type of recurring headache that affects about 12-percent of Americans. They are three times more common in women than men, and they tend to run in families. Although migraines can occur at all ages, they are most common between 30-39 years of age. Not all bad headaches are migraines, and not all migraines result in a bad headache. But the pain can range from distracting to debilitating. In fact, migraines are identified as one of the top 10 most disabling diseases. Migraines can impair a pilot’s ability to fly, causing a serious safety risk due to rapid onset and potentially incapacitating symptoms. Some complicated migraines have neurological aftereffects that can persist for hours to days, or even be permanent.

Approximately three out of four people who suffer from migraines get a warning 24-48 hours before the headache appears. This is the prodrome, and there are medications (triptans) that can be taken during the prodrome to end the migraine. Migraines can be divided into two major types: those with, and those without, aura, a more distinct warning sensation. About one-quarter of migraine cases are associated with an aura and are sometimes referred to as classic migraines. Aurae include visual (the most common and include blank spots or shimmering lights in the visual field), auditory, and other sensory disturbances as well as motor symptoms. Less common manifestations include difficulty with speaking, abnormal sensation, numbness or muscle weakness on one side of the body, a tingling sensation in the hands or face, and confusion. The aurae usually begin between 10 and 60 minutes before the headache, but can be coincident. The headache typically lasts an hour or less, but can be incapacitating. Clearly, either the aura or the headache can impair a pilot’s ability to maintain control of an aircraft. While some aura may occur without a subsequent headache, the safety concern remains.

Migraines without aura are called common migraines and are the more prevalent variant. Common migraines can occur without warning and are usually on one side of the head. They are associated with nausea, confusion, blurred vision, mood changes, fatigue, and increased sensitivity to light, sound, or noise.

A number of factors can trigger a migraine, including stress, bright flashing lights, loud noises, medicines, sudden changes in weather or environment, overexertion, tobacco, caffeine (or caffeine withdrawal), and even certain foods. This is not an exhaustive list and triggers may vary from person to person. Identifying a trigger which can be avoided is beneficial to the individual and a favorable factor for medical certification. A diary recording food, activities, and other pertinent events (weather, etc.) can be helpful in this identification.

There is no cure for migraines at present. If a trigger is not identified or avoidable, treatment focuses on symptom relief for the occasional migraine and preventive treatment for the more severe and/or frequent migraine. Different types of medicines used to treat migraines include over the counter (OTC) pain relievers such as aspirin, Tylenol (acetaminophen), or Motrin (ibuprofen), as well as prescription medications such as the various triptan drugs. Additional medications are used in the ER or Urgent Care to treat associated symptoms such as nausea or vomiting. In some cases, severe headaches may be given narcotics. For all medication use, there is a minimum grounding period before you can fly again. Regardless of the medication used, the headache and other symptoms should be completely resolved before you return to flying. In addition, for most triptans, you are grounded for 24 hours (talk to your AME about your specific medication): 24 hours for Zofran (ondansetron); 36 hours for metoclopramide (Reglan); and 96 hours for Phenergan (promethazine). Migraines severe enough to require the use of injectable medications or narcotics are not acceptable for the CACI (conditions AMEs can issue) program. For migraine prevention, both calcium channel blockers and beta-blockers are permissible.

All migraines are disqualifying and require FAA clearance. However, many of these migraines can be cleared by your AME if specific criteria outlined in the CACI are met. For the remainder, a special issuance is frequently possible after appropriate medical management.

Leo M. Hattrup, M.D., received a bachelor’s degree from Wichita State University, a master’s in public health from Harvard University, and a doctorate from Vanderbilt University. He is retired from the Air Force in which he spent the majority of his career in aerospace medicine. He is board certified in aerospace and occupational medicine. He is a certificated flight instructor and enjoys flying airplanes, helicopters, and gliders.