As they went from doctor to doctor, chronic sufferers of migraine headaches once got little more than pills and sympathy. Their pain was often dismissed as a "tension headache" not worthy of attention, even as it turned their lives upside down with misery.

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Migraine treatment has become far better in the last decade. Expert treatment can eliminate or reduce migraines so people can once again get on with their lives.

The most severely afflicted can now get relief through new therapies such as dental splints, exercise, better drugs and even Botox injections. When migraines become emergencies, they can now be stopped in minutes. Prevention of migraines has also become much more efficient, allowing incipient attacks to be shut off quickly.

More knowledge, and some luck, is responsible for these improvements. Doctors have learned much more about how migraines are caused. They've also discovered that migraines have been greatly underdiagnosed.

Migraines don't have to come with the flashing lights and nausea they're classically associated with. About 30 million Americans suffer from migraines, according to the National Headache Foundation.

However, patients dealing with severe or intractable migraines must see an expert to take full advantage of these new treatments, and ones still being tested. Here's a look at the treatments, doctors and patients at one such place, The Headache Center of Southern California.

More than just a headache

Headaches are not migraine. They are a symptom of migraine. It's a disease that abnormally heightens one's senses. Muscles in the jaw, face, neck and shoulders tense. Nerves that control sensation in the head are overstimulated. Because the senses are so acute, subtle shifts such as a change in humidity can trigger attacks.

Migraine pain can be a dull ache and sense of unease, a background distraction that makes it hard to concentrate. Or it can be an blinding misery that sends the sufferer to bed in a dark, quiet room, unable to function or think of anything else.

The harm to quality of life is severe, said migraine patient Carole Felker as she was being examined recently by Dr. Andrew Blumenfeld, a neurologist and director of The Headache Center.

"It's horrible. It spoils everything for you," said Felker, who lives in Oceanside. "You can't enjoy anything. You can't enjoy being with friends, you can't even enjoy eating a meal. And you're always worrying if it's going to happen to you on a day that's important, like your daughter's wedding."

Jennifer Capuzelo, another migraine patient of Blumenfeld's, said she's lived with chronic migraines since she was 10 years old. The Carlsbad resident says the attacks begin with a vague, background pain that escalates in half an hour into a full-blown headache.

"It's difficult to describe, because it hurts in so many different places. . . . It's usually one side of my head, and it radiates down the side of my neck into my shoulder, and it switches sides depending on the day," Capuzelo said.

"It was in my early teens I realized that I had a problem, but it was hard to articulate. I had it every day, and was almost used to it, although it was so bad," she said. "Doctors didn't take it seriously. They said it was tension but didn't get into the diagnosis."

Capuzelo said her pain has dramatically lessened with the treatments so far. She now wears a dental splint, a small device worn between the teeth at night to reduce jaw-clenching.

Seeking relief

The stories of Felker and Capuzelo are typical, said James Boyd, a dentist and director of temporomandibular disorders at the center. Many patients have suffered for years.

"You don't see a patient in this clinic who's just started having headaches this past year," Boyd said. "When neurologist Blumenfeld sees a new patient - she's not new - not new to migraine."

Blumenfeld said the center's strategy is to look at all the ways migraines can be triggered, and devise short-term and long-term solutions to stop the pain and prevent it from occurring.

Neck and shoulder muscles are involved in migraines, so they receive attention. Some patients get the dental splints. And for immediate relief, nerve blocks deaden nerves implicated in migraine, such as the occipital and trigeminal nerves. Respectively, these nerves are at the back of the head and near the ears.

Felker's treatment regimen includes arm exercises, medication and Botox injections. The Botox, which paralyzes muscles where it's injected, deadens muscle and nerve activity, reducing migraines. This was discovered accidentally in patients who received Botox for cosmetic reasons, Blumenfeld said, and reported relief from headaches.

Part of Felker's problem is postural, Blumenfeld said, as he prepared to give her a Botox injection.

"Her head is jutting forward, which puts a lot of pressure on her neck and shoulder muscles. So what we want to do is take some of the pressure out with the Botox in the spasm areas between her shoulder blades," Blumenfeld said.

Another patient, Gwen Suennen of Rancho Penasquitos, said the intensity of her migraines went down significantly after receiving Botox.

"It was three weeks to the day," when the relief kicked in, Suennen said to Boyd, as he prepared a dental splint for her.

Suennen said she often ends the day with virtually no pain now. The tension she once experienced in her shoulders and neck is gone.

"Botox enhances what I do," Boyd told her.

The cost of Botox is about $350 per treated area. Typically, relief lasts about three months. Botox has not been approved for migraine relief, so getting insurance coverage can be difficult. Clinical trials are under way to prove Botox works with migraines.

Easy on the meds

A large and growing number of medications provide relief from migraines, but many come with unwanted side effects, Blumenfeld said. Nondrug methods such as the dental splint reduce nerve activity and may allow patients to reduce their use of painkillers.

Suennen has been taking Topamax, a prescription anti-convulsant medication often used in migraine therapy. However, Topamax can interfere with concentration. It also causes weight loss, which had put Suennen underweight. She's decreased her Topamax dosage, and her weight has since stabilized.

"She's also been relying on Imitrex to treat these, and she's been taking one to three Imitrex tablets per day. Each of those tablets runs between $15 to $20," Blumenfeld. "In addition she'd supplement once a week with an Imitrex nasal spray, and that costs about $50 per treatment. … The Botox costs, although high, are actually relatively small compared to the Imitrex costs. Because we've been able to control her headaches now, we've actually saved her health care dollars."

Emergency treatment

Migraines can spiral out of control. The pain can trigger more nerve and muscle irritation, along with inflammation. This makes the pain even worse, said Dr. Jack Schim, another neurologist with The Headache Center. That's when desperate people head for a hospital emergency room, which Schim said can be "the worst experience of their life."

Emergency rooms are brightly lit and often noisy. That's hell for those with migraines, because the jarring sensations make the pain harder to bear. And because migraine patients are not obviously ill, they may wait a long time before getting attention. And when they do get treated, it may just be a generic shot of some painkiller. The patients get relief for a few hours, but then the pain starts all over again.

Patients who go to The Headache Center for urgent migraines care are handled far differently, Schim said.

"What we do is bring them into the office - quiet, calm environment - turn the lights down, put an intravenous line in so we can give them hydration if necessary, and then start off with blocks to turn off overactive nerve impulses," he said.

"Typically that will entail injection across the back of the head at what's called the greater occipital nerve and lesser occipital nerve. Those are nerves that are responsible for sensation across the back of the head," Schim said.

"By injecting a combination of an anesthetic and a steroid-type medicine, we can get people pain relief in 10 to 15 minutes, without giving them narcotics that would be sedating or increase nausea," Schim said.

The anesthetic lasts about six to eight hours, Schim said. The steroid kicks in after about six to 12 hours and lasts for days. That's enough to break the cycle of pain and inflammation.

After business hours, migraine patients in an emergency can get migraine-specific care at Scripps Hospital in Encinitas, Schim said.

The care is given "in an environment where the people who are managing their headache problem actually understand headache, and not just being fitted in among someone with belly pain or a sore shoulder," Schim said.

Contact staff writer Bradley J. Fikes at (760) 739-6641 or bfikes@nctimes.com.

Many doctors and speciality centers offer migraine and headache treatment. Some of the local clinics include the following:

The Headache Center of Southern California

http://www.the-headachecenter.com/

(760) 631-3000

La Jolla, Encinitas and Oceanside

San Diego Headache and Facial Pain Center

http://www.sdheadache.

com/

(760) 436-6365 or (800) 400-4552

La Jolla, Encinitas and Oceanside

Coastal Neurological Medical Group Inc.

http://www.coastalneurological.com

(858) 453-3842

La Jolla

Dr. Eric Austad

http://www.draustad.com

(760) 635-2448

Encinitas

NeuroCenter Medical Clinic Inc.

http://www.neurocen

ter.org

(951) 696-1818

Murrieta

For more information

Migraine Awareness Group

http://www.migraines.org

(703) 349-1929