Migraine; Types, Causes, Symptoms, Diagnosis, Treatment

Migraine is a primary headache disorder characterized by recurrent headaches that are moderate to severe. Typically, the headaches affect one half of the head, are pulsating in nature, and last from two to 72 hours. Associated symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell.

Types of Migraine

There are several types of migraine, including

  • Migraine with aura – where there are specific warning signs just before a migraine begins, such as seeing flashing lights
  • A migraine without aura – the most common type, where a migraine occurs without the specific warning signs
  • Migraine aura without a headache, also known as a silent migraine – where an aura or other migraine symptoms are experienced, but a headache doesn’t develop.
  • Lower-half Headache or a Facial Migraine – The term applies to a common migraine that covers one-half of the face involving the nostril, cheek, and jaw.
  • Migraine Aura without a Headache – Where the headache of a migraine with aura may become less severe over the years or may not occur at all, the attacks are referred to as migraine aura without a headache.  It is rare for attacks to have always occurred without a headache and a doctor should be consulted if this develops for the first time when over 50.
  • Status Migrainosus – This term describes a migraine that may last longer than 72 hours.  Symptoms of nausea and light sensitivity resolve after a couple of days but a headache persists.
  • An abdominal Migraine (recurrent stomach pains in childhood) – Symptoms are periodic abdominal pains (experienced by about 20% of migrainous children compared with about 4% of children who do not suffer from a headache).
  • A symptom of basilar artery migraine -Symptoms include visual disturbances, giddiness, loss of balance, slurred speech followed by aching mainly in the back of the head.  Fainting can occur at the height of the attack.
  • A hemiplegic Migraine (with weakness on one side of the body) – Symptoms resemble a stroke and may progress until the arm and leg on one side are completely paralyzed for a few hours.  Repeated attacks may leave a residual weakness.  Familial hemiplegic migraine occurs where there is a family history of a hemiplegic migraine.
  • An ophthalmoplegic Migraine (with double vision) – Symptom is paralysis of one or more of the muscles moving the eyes resulting in the eyes moving out of alignment and the person seeing double.
  • A retinal Migraine (with loss of vision in one eye) – Symptom is a loss of sight in one eye and normal vision in the other.  The sight clears leaving an ache behind the eye or a generalized headache.
  • Migrainous Infarction – Symptoms range from permanent blind spots to a full stroke occurring during a typical migraine attack.  An infarct is the death of tissue due to an inadequate blood supply.

Causes of Migraine

Migraines may be caused by changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway.

Imbalances in brain chemicals — including serotonin, which helps regulate pain in your nervous system — also may be involved. Researchers are still studying the role of serotonin in migraines.

Serotonin levels drop during migraine attacks – This may cause your trigeminal nerve to release substances called neuropeptides, which travel to your brain’s outer covering (meninges). The result is migraine pain. Other neurotransmitters play a role in the pain of a migraine, including calcitonin gene-related peptide (CGRP).

A number of factors may trigger migraines, including

  • Hormonal changes in women – Fluctuations in estrogen seem to trigger headaches in many women. Women with a history of migraines often report headaches immediately before or during their periods, when they have a major drop in estrogen. Hormonal medications, such as oral contraceptives and hormone replacement therapy, also may worsen migraines. Some women, however, find their migraines occur less often when taking these medications.
  • Foods – Aged cheeses, salty foods and processed foods may trigger migraines. Skipping meals or fasting also can trigger attacks.
  • Food additives – The sweetener aspartame and the preservative monosodium glutamate (MSG), found in many foods, may trigger migraines.
  • Drinks – Alcohol, especially wine, and highly caffeinated beverages may trigger migraines.
  • Stress – Stress at work or home can cause migraines.
  • Sensory stimuli – Bright lights and sun glare can induce migraines, as can loud sounds. Strong smells — including perfume, paint thinner, secondhand smoke, and others — can trigger migraines in some people.
  • Changes in the wake-sleep pattern –  Missing sleep or getting too much sleep may trigger migraines in some people, as can jet lag.
  • Physical factors – Intense physical exertion, including sexual activity, may provoke migraines.
  • Changes in the environment – A change of weather or barometric pressure can prompt a migraine.
  • Medications – Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines.

Symptoms of a Migraine

Common symptoms include

Prodrome

One or two days before a migraine, you may notice subtle changes that warn of an upcoming migraine, including:

Aura

Aura may occur before or during migraines. Most people experience migraines without aura.Each of these symptoms usually begins gradually, builds up over several minutes and lasts for 20 to 60 minutes. Examples of migraine aura include:

Attack

A migraine usually lasts from four to 72 hours if untreated. The frequency with which headaches occur varies from person to person. Migraines may be rare, or strike several times a month. During a migraine, you may experience

Triggers 

Dietary Triggers

Common, well-recognised dietary triggers include:

  • missed, delayed or inadequate meals
  • caffeine (coffee and tea) withdrawal
  • certain wines, beers and spirits
  • chocolate, citrus fruits, aged cheeses and cultured products (chocolate and other sugar cravings may be prodomal not triggers)
  • monosodium glutamate (MSG)
  • dehydration.
Environmental Triggers

Environmental triggers include

  • bright or flickering lights, bright sunlight
  • strong smells, e.g. perfume, gasoline, chemicals, smoke-filled rooms, various food odours
  • travel, travel-related stress, high altitude, flying
  • weather changes, changes in barometric pressure (likewise, decompression after deep-sea diving)
  • loud sounds
  • going to the movies
  • computers (overuse, incorrect use).
Hormonal Triggers

Hormonal fluctuations – are implicated as a significant trigger for women as three times as many women suffer from migraine headaches as men, this difference being most apparent during the reproductive years,.  Hormonal triggers may be

Physical and Emotional Triggers

Physical and emotional factors include

  • lack of sleep or oversleeping – (even as little as half hour difference in routine, e.g. sleeping in on weekends)
  • illness –  such as a viral infection or a cold (if taken cold and migraine medication, remember that many cold remedies contain pain-killers)
  • back and neck pain – stiff and painful muscles, especially in scalp, jaw, neck, shoulders, and upper back
  • sudden, excessive or vigorous exercise (regular exercise can however prevent migraine, if migraine is triggered by a blow to the head a doctor should be consulted)
  • emotional triggers such as arguments, excitement, stress and muscle tension
  • relaxation after stress (weekend headache).

Diagnosis of Migraine

The diagnosis of migraine without aura, according to the International Headache Society, can be made according to the following criteria, the “5, 4, 3, 2, 1 criteria”

Five or more attacks—for migraine with aura, two attacks are sufficient for diagnosis.

Four hours to three days in duration

Two or more of the following:

  • Unilateral (affecting half the head)
  • Pulsating
  • Moderate or severe pain intensity
  • Worsened by or causing avoidance of routine physical activity

One or more of the following:

If someone experiences two of the following

Photophobia, nausea, or inability to work or study for a day, the diagnosis is more likely. In those with four out of five of the following: pulsating headache, duration of 4–72 hours, pain on one side of the head, nausea, or symptoms that interfere with the person’s life, the probability that this is a migraine is 92%.In those with fewer than three of these symptoms the probability is 17%.

Classification of  Migraine

Migraines were first comprehensively classified in 1988.The International Headache Society most recently updated their classification of headaches in 2004.A third version is in preparation as of 2016. According to this classification migraines are primary headaches along with tension-type headaches and cluster headaches, among others.

Migraines are divided into seven subclasses (some of which include further subdivisions)

  • A migraine without aura,  – a common migraine”, involves migraine headaches that are not accompanied by an aura.
  • A migraine with aura, or a classic migraine – usually involves migraine headaches accompanied by an aura. Less commonly, an aura can occur without a headache, or with a nonmigraine headache. Two other varieties are familial hemiplegic migraine and sporadic hemiplegic migraine, in which a person has migraines with aura and with accompanying motor weakness. If a close relative has had the same condition, it is called “familial”, otherwise, it is called “sporadic”. Another variety is a basilar-type migraine, where a headache and aura are accompanied by difficulty speaking, world spinning, ringing in ears, or a number of other brainstem-related symptoms, but not motor weakness. This type was initially believed to be due to spasms of the basilar artery, the artery that supplies the brainstem. Now that this mechanism is not believed to be primary, the symptomatic term migraine with brainstem aura (MBA) is preferred.
  • Childhood periodic syndromes –  that are commonly precursors of a migraine include cyclical vomiting (occasional intense periods of vomiting), abdominal migraine (abdominal pain, usually accompanied by nausea), and benign paroxysmal vertigo of childhood (occasional attacks of vertigo).
  • A retinal migraine involves a migraine – headaches accompanied by visual disturbances or even temporary blindness in one eye.
  • Complications of a migraine  – describe migraine headaches and/or auras that are unusually long or unusually frequent, or associated with a seizure or brain lesion.
  • A probable migraine – describes conditions that have some characteristics of migraines, but where there is not enough evidence to diagnose it as a migraine with certainty (in the presence of concurrent medication overuse).
  • A chronic migraine –  is a complication of migraines, and is a headache that fulfills diagnostic criteria for migraine headache and occurs for a greater time interval. Specifically, greater or equal to 15 days/month for longer than 3 months.

Treatment of a Migraine

Infrequent, less severe migraine may respond to over-the-counter medications such as

  • aspirin (not recommended for young children, some adults respond well to three tablets)
  • paracetamol
  • non-steroidal anti-inflammatory drugs such as ibuprofen , naproxen .
    Medications that may be prescribed for more severe migraine include
  • triptans such as sumatriptan, naratriptan, zolmitriptan that are based on the serotonin molecule
  • ergotamine compounds  that appear to provide relief by constricting cranial blood vessels
  • stronger non-steroidal anti-inflammatory drugs
  • stronger narcotic-type analgesics.
    Anti-emetic medications often prescribed with other forms of acute therapy to minimise the nausea that often accompanies migraine include
  • metoclopramide , prochlorperazine or domperidone  to increase absorption and reduce nausea.
  • Prescription medications used to relieve the pain of migraine include triptans (a class of drugs), for example:
    • Lifestyle changes like eating a healthy diet and getting exercise may help reduce the frequency of your attacks.
    • Try to avoid any foods that trigger your migraines. It also may reduce the frequency of attacks.
    • Some people find that exercises, for example yoga, promote muscle relaxation are helpful in managing severe pain.
    • Most people with migraines usually are able to manage their condition with a combination of medications and lifestyle changes.
    • Some people may need prescription medications to decrease the frequency of headaches.

Complementary Therapies of Migraine

Acupuncture

 Stimulating acupoints may ease pain by encouraging production of endorphins (natural painkillers).

Alexander technique

 Can help prevent tension headaches by relieving poor posture and pressure that results from it.

Aromatherapy

 Combines various scented oils and promotes relaxation and eases tension.

Biofeedback

 Can be used to treat tension-type and migraine headaches – patient learns to control blood pressure, heart rate, and spasms in the arteries supplying the brain through a sensory device.

Chiropractic Therapy

 Based on the theory that most diseases of the body are a result of a misalignment of the vertebral column with pressure on the adjacent nerves that may affect blood vessel and muscle function. Manual techniques purport to adjust the misalignment.

Homeopathy

 Uses active substances found in certain medications highly diluted.

Hydrotherapy

 Splashing your face with cold water before lying down for an hour can ease headache. Alternating hot and cold showers dilates then constricts the blood vessels, stimulating circulation. Ice pack on head is another option.

Hypnotherapy

 Can help sufferer deal with headache by altering the way the body interprets messages of pain.

Massage

 Can reduce muscle tension throughout the body, thereby reducing headache.

Meditation

 A recent study on migraine prevention through meditation has had very promising results, all participants reported less severe migraines.

Naturopathy

 Uses only natural substances in small amounts and aims to provide a healthier balance of bodily processes.

Osteopathy

 Manipulation of the neck or cranial, osteopathy may be used to correct misalignments of the vertebrae that can cause migraines.

Physiotherapy

 Treating muscle tension can release pressure that may lead to headache.

Relaxation Techniques

 Geared towards reducing pressure in the body and the level of stress chemicals that may worsen headache.

Shiatsu

 Combination of massage and pressure can restore the “energy balance” and induce relaxation.

Yoga

 Can relieve muscle tension in the back of the neck and correct posture.

Prevention of Migraine

Prophylactic/preventative medication is taken daily, regardless or whether a headache is present, to reduce the incidence of severe or frequent headaches. These include:

  • beta blockers such as propranolol (Inderal), timolol (Blocadren), atenolol (Tenormin) and metoprolol (Lopresor, Betaloc) that block the beta-receptors on which adrenaline works in the nervous system as well as on blood vessels
  • serotonin antagonists such as methysergide (Deseril),   pizotifen (Sandomigran) and cyproheptadine (Periactin)
  • sodium valproate or valproic acid (eg Epilim), an anti-epileptic drug shown to reduce the intensity of migraine
  • calcium-channel blockers such as verapamil (Isoptin) that stop the constriction of blood vessels by preventing the use of calcium necessary for this reaction
  • antidepressants such as amitriptyline  (eg. Tryptanol) have an action on headache that is independent of their antidepressant action
  • feverfew, a herbal remedy
  • riboflavin 200mgm twice daily has been reported as useful.
    All are effective.  All have side effects and, except feverfew and riboflavin, are prescription drugs.  Many were initially introduced for some other problem and were also observed to reduce a headache.

References

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