According to the “World Health Organization” (WHO), it is estimated that prevalence among adults of current headache disorder globally is about 50%. Half to three-quarters of adults aged between 18–65 years in the world have had a headache in the previous year and, among those individuals, 30% or more have reported migraine. A headache of 15 or more days every month affects 1.7–4% of the world’s adult population. Despite regional differences, headache disorders are a worldwide problem, affecting people of all ages, races, income levels and geographical areas.
There is still some dispute regarding the designation of a migraine. Some experts refer a migraine as a neurological disease, while others prefer to call it as a neurological disorder or condition.
Migraine attacks are categorized as primary headaches because another disorder or disease do not cause pain. Migraine attacks are often associated with symptoms other than a headache, including nausea, vomiting, sensitivity to light and sound.
What is a Migraine?
Migraine is a neurological condition characterized by severe head pain often accompanied by other symptoms such as nausea, vomiting, difficulty speaking, numbness or tingling, sensitivity to light and sound. Migraines are often hereditary and run in families. Migraines are often left undiagnosed in young children and can affect people of all ages.
The time duration of a migraine attack can vary from person to person. However, most migraine attacks typically last for at least four hours. If you encounter symptoms for more than three consecutive days, you should seek medical assistance as soon as possible.
Migraine attacks typically have four phases. However, there can be a migraine attack without having one or more phases. There is even a possibility to have a migraine attack without “a headache” phase at all. This type of migraine is referred to an “acephalgic” migraine which is also known as “silent” migraine.
What are the types of Migraine?
According to the “International Headache Society” ICHD-3 classification, there are seven types of migraine based on diagnosis and treatment.
The two important types of migraine are:
1. Migraine without Aura (previously known as a Common Migraine):
This type of migraine occurs most frequently, and symptoms include moderate to a severe pulsating headache that happens without warning and usually felt on one side of the head. It usually comes along or with nausea, blurred vision, mood changes, confusion, fatigue, and increased sensitivity to light, sound or smells. This type of migraine typically last for about 4-72 hours, and they occur a few times a year or a few times a week. Generally, movement makes this attack worse. Frequent use of symptomatic medication (such as NSAIDs like acetaminophen) makes this type of migraine even worse.
2. Migraine with Aura (previously known as Classic or Complicated Migraine):
This type of migraine involves visual disturbances and other neurological symptoms that develop about 10 to 60 minutes before an actual headache and normally last not more than an hour. You may temporarily lose a part or all of your vision. The aura may occur without a headache, which can strike at any time. Less frequent aura symptoms include an unusual sensation, a tingling sensation on the hands or face, numbness or weakness of muscles on one side of the body, difficulty in speaking and confusion.
Symptoms like nausea, loss of appetite, and increased sensitivity to light/sound/noise may lead to a headache.
Most of the patients who have migraine with aura also have migraine without aura and tension-type headaches, because of this reason, migraine with aura is challenging to diagnose as it does not fit precisely into one type.
The other five types of migraine are:
3. Migraine without Headache:
This type of migraine, which includes visual problems or other aura symptoms such as nausea, vomiting or constipation, but without headache. In other words, this can be called “Typical Aura” without headache. Some neurologists have suggested that fever, dizziness or unexplained pain in a part of the body could also be a possible type of headache-free Migraine. It is different from that of “Abdominal Migraine” and “Cyclic Vomiting Syndrome”, that usually occurs in children.
4. Migraine with Brainstem Aura (previously known as Basilar Migraine):
This type of migraine commonly affects children and teenagers, the symptoms are similar to Migraine with Aura that begins from the brainstem, but without motor weakness. This type of migraine is more prevalent in teenage girls and may have been associated with their menstrual cycles. Symptoms include dizziness and loss of balance (vertigo), partial or total loss of vision or double vision, slurred speech, poor muscle coordination, tinnitus (a ringing in the ears), and fainting. The throbbing pain can be felt on the both sides at the back of the head and may develop suddenly.
5. Hemiplegic Migraine (a sub-type of Migraine with Aura):
This type of migraine is rare but severe and may temporarily cause paralysis. Hemiplegic migraine can be felt on one side of the body, before or during a headache and can last up to several days. Symptoms such as vertigo, stabbing or pricking sensation, trouble in speaking or swallowing may begin before a headache and normally stop soon thereafter. It is also known as “Familial Hemiplegic Migraine” (FHM) if it is hereditary or runs in family.
6. Retinal Migraine:
This type of migraine is rare and involves an aura. A retinal migraine affects vision in one eye alone unlike most migraines with aura.
7. Chronic Migraine:
This type of migraine is distinct and recently defined sub-type of “chronic daily Headache”. According to the “International Headache Society”, chronic migraine is defined as more than fifteen days of headache per month, over a three month period of which more than eight days are migrainous, excluding medication overuse. The other migraine sub-type is the “Episodic migraine”, which is defined as less than 15 headache days per month.
What are the causes of Migraine?
The precise cause of a migraine is not known. However, genetics and environmental factors may play an important role.
Migraines may occur due to an imbalance in the brainstem and its interactions with trigeminal nerve, which is a major pathway of pain.
Although the role of serotonin is not fully established, scientists believe that the imbalances in brain chemicals such as serotonin, which helps regulate pain are also involved in causing a migraine. Scientists are still investigating the role of serotonin in migraines.
During a migraine attack, serotonin levels drop, which may stimulate the release of a substance known as neuropeptides from trigeminal nerves, which travel to the meninges (outer covering of the brain), which may result in a migraine. Other neurotransmitters may also involve in migraine pain.
Changes in estrogen levels may trigger migraines in many women. Most of the women with a history of migraines experienced an attack before their periods, because of the low estrogen levels before menstruation.
Some women have developed migraines during pregnancy or menopause.
Hormone replacement therapy and oral contraceptives may worsen migraines. However, some women say their migraines occur less frequent when they take these treatments.
Food can also trigger a migraine attack such as aged cheeses, processed foods, and salty foods. Irregular food habits or fasting can also trigger an attack.
Sweeteners such as aspartame and preservative like monosodium glutamate (MSG) may trigger a migraines attack.
Highly caffeinated beverages, alcohol, wine may trigger a migraine.
Any stress, depression or anxiety can cause migraines.
Bright lights, loud sounds, strong smells (perfume, paint thinner, smoke) can trigger migraines in some people.
Irregular sleeping habits may trigger migraines in some people.
Extreme physical exertion including sexual activity may initiate migraines.
A sudden change of weather can provoke a migraine.
Medications such as oral contraceptives and vasodilators (nitroglycerin) can trigger migraines.
You are at risk of developing migraines in the following cases:
Your chances of developing migraines increases if you have a family member with a migraine or a history of migraine.
Migraines often occur at the beginning of puberty. People with the age group of 30 years complained of more intense migraines attack.
Women are more prone to develop migraines compared to men.
Women experience a migraine attack shortly before their periods, because of the low estrogen levels before menstruation.
Some women experienced migraine attack during pregnancy, or their migraine became worst. For many, migraines didn’t occur during the last trimester of the pregnancy.
What are the complications of Migraine?
Sometimes methods adopted to suppress your migraine can lead to further complication. Such as:
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, ibuprofen, etc. may cause ulcers, abdominal pain, and other complications, especially if taken for a long period of time and larger doses.
Taking over-the-counter or prescription medications for a headache more frequently may trigger severe overuse headaches.
Medication-overuse headaches occur when you develop tolerance towards a pain medication, and the medication no longer relieves pain, and this leads to overuse of the pain relievers. This can cause a severe headache.
It is a rare but potentially life-threatening condition that occurs when your body produces an excess amount of chemical in the brain known as serotonin.
Taking migraine medications known as triptans like sumatriptan (Imitrex), serotonin and norepinephrine reuptake inhibitors (SNRIs) like duloxetine (Cymbalta) and venlafaxine (Effexor XR), antidepressants known as selective serotonin reuptake inhibitors (SSRIs) like sertraline (Zoloft), fluoxetine (Sarafem, Prozac), may increase the risk of serotonin syndrome. It is known that these medications, when taken in combination, may produce an excess of serotonin levels.
As these medications are taken in combination, it is very important to monitor symptoms of “serotonin syndrome”, such as mood changes and akinesia (involuntary muscle movements).
Some people also experience complications from migraines such as:
A chronic migraine:
If your migraine lasts for 15 or more than 15 days a month, and for longer than three months, this is considered as a chronic migraine.
If you have a severe migraine that lasts for 3 days or longer than 3 days, this is known as status migrainosus.
Persistent aura without infarction:
Usually, an aura subsides after a migraine attack, but sometimes it lasts for more than a week. A persistent aura may have symptoms similar to brain stroke (bleeding in the brain), but without signs of tissue damage, bleeding or any other problems inside the brain.
Aura symptoms lasting longer than an hour can indicate stroke (bleeding in an area of the brain) and should be examined immediately. Doctors can conduct tests like neuroimaging to identify bleeding in the brain.
What are the symptoms or stages of Migraine?
Migraines often develop during childhood, adolescence or at early adulthood. Migraines may progress through four stages:
3. Headache and
Some people may have a migraine without going through all 4 stages.
You may notice some changes that warn of an upcoming migraine. You may experience these changes one or two days before a migraine. These may include:
- Mood changes such as depression or anxiety or happiness
- Neck stiffness
- Food cravings
- Increased thirst and urination
- Yawning frequently
This phase may occur before or during a migraine. Most of the people do not experience this stage.
Symptoms of aura are usually visual changes, like flashes of light or wavy zigzag vision.
Some other symptoms are sensory (like someone is touching), motor (movement) or verbal disturbances (slurred speech).
Each of these symptoms may develop slowly, intensifies over several minutes and lasts for about 30 minutes to an hour.
Migraine with aura include:
- Visual problems, such as seeing various shapes, flashes of light, bright spots
- Temporary loss of vision
- Sensations of pins and needles on an arm or leg
- Numbness of the face or on one side of the body
- Speaking difficulty
- Hearing noises or ringing
- Uncontrollable movements or tremors
Migraine with aura is sometimes linked with limb weakness (such as hemiplegic migraine).
If untreated a migraine can last from about 4 to 72 hours, although this may vary from one person to another. Migraines may strike several times in a month. You may experience the following during a migraine:
- Unilateral location (pain on one side or both sides of the head)
- A throbbing or pulsing pain
- You may be sensitivity to sounds (phonophobia), light (photophobia) and sometimes touch and smell
- Blurred vision
- Nausea and with or without vomiting
- Dizziness and fainting
The final stage is also known as post-drome, usually happens after a migraine attack. This may last for about 24 hours, and you may also experience:
- Sensitivity to light and sound
What is the diagnosis of Migraine?
Diagnosis of migraine is important to rule out or exclude other possible causes of the symptoms, that is mistaken as migraine. Doctors have different criteria and tests for diagnosing a migraine.
Depending on your symptoms of migraine, doctors may consider a range of tests before diagnosing your migraine.
Some tests that are conducted to exclude other causes of the attacks are:
1. Magnetic resonance imaging (MRI):
MRIs are helpful in detecting the following that can be mistaken as migraine.
- Brain tumours
- Brain injuries
- Bleeding in the brain
- Fluid in the brain
- Spinal cord problems
- Eye disorders
- Ear disorders
For those with migraines, MRI can exclude the above problems – which helps to confirm the migraine diagnosis.
2. Computerized Tomography Scan (CT/Cat scan):
Computerized tomography scan (CT/Cat scan) can’t diagnose a migraine, and it can help rule out other causes of the migraine symptoms, such as:
- A brain tumour
- Fluid in the brain
- Infection in the brain (abscess)
- Sinus blockage
- Brain or head injury
- Skull fracture
- An aneurysm (bleeding in the brain)
3. Blood Chemistry and Urinalysis:
These tests are done to exclude the other possible symptoms:
Blood chemistry tests can detect:
- Blood clots or clotting problems
- Immune system disorders
- HIV and other sexually transmitted diseases
- Diabetes (or other blood sugar issues)
Urinalysis can detect:
- Thyroid problems
- Kidney disease
- Urinary tract infection, which causes frequent urination
- Blood in the urine
- Liver damage
Sinus X-Ray is done to detect any problem related to a sinus that causes a headache but mistaken as a migraine. Such as:
- Sinusitis—swelling or mucosal inflammation in sinuses
- Problems in bone structure
- Fluid in the sinuses
- Thickening of the mucous membrane
5. Electroencephalogram (EEG):
The electroencephalogram, or EEG, helps to detect electrical activity inside the brain. This test can detect or exclude other disorders that may cause migraine symptoms. Such as
- Epilepsy or other seizure disorders
- Brain tumors
- Brain injuries
- Dysfunctions in the brain
- Inflammation in brain
- Bleeding in the brain
- Sleep disorders
- Memory loss
6. Eye Examination:
Migraine symptoms usually involve vision changes like loss of vision, sensitivity to light (photophobia) or pain in the eye. An eye examination is done to detect other possible causes of vision changes such as:
- Diabetes-related nerve damage in the eye
- Eye infections
- Blocked tear ducts
- Nearsightedness, farsightedness or other sight problems
- Ulcers on the cornea
- Eye injuries
7. Spinal Tap/ lumbar puncture:
This test is performed after a CT scan, or CAT scan is used to detect cases of subarachnoid hemorrhage (bleeding into the space surrounding the brain).
What is the treatment of Migraine?
It is very important to have enough rest if you are suffering from a migraine. Enough sleep can abort almost all kinds of migraine attacks. This is a better alternative than using medications.
Analgesics and antiemetics:
Analgesics such as a non-steroidal anti-inflammatory drug (NSAID), like paracetamol 1000 mg, a large dose of dispersible aspirin of about 900–1200 mg, dissolved in water before ingestion, and taken as soon as a migraine appears to begin.
Antiemetics such as domperidone is prescribed to treat many migraines. Prokinetic antiemetics are given in case of gastric stasis (delayed gastric emptying) during a migraine. Domperidone has lesser side effects than other antiemetics and is easily available over the counter.
Opioid medications such as codeine, are sometimes recommended for the treatment of migraine, depending on the severity. Narcotic medication can develop addiction and are only used if no other treatments produce an effect and if the patient can not take triptans and ergots.
Triptans such as Sumatriptan (Imigran) acts by binding to serotonin receptors in the brain and thereby reduces the swelling of the blood vessels. Triptans are given alone or in combination with other drugs like nonsteroidal anti-inflammatory drugs (NSAIDs). They act very fast in migraine, usually about 2 hours. Not all respond very well to triptans. Triptans should be used to treat only moderately severe migraine, they should not be used during the prodrome stage, or during aura mistaken as a headache.
Ergot alkaloids such as ergotamine are used to manage an acute migraine. Ergots users may sometimes develop ergot dependency.
A glucocorticoid such as prednisone, dexamethasone may be used with other medications to increase the efficacy of pain relievers. Glucocorticoids shouldn’t be used frequently to avoid side effects.
Recurrence is a complex and poorly understood phenomenon: at the simplest level, ineffective treatment has zero recurrences. Triptans reach their site of action only when there is a migraine—so they terminate their own action after the migraine attack subsides. Some health practitioners reduce recurrence by combining NSAID with triptans, though there is no solid evidence.
Step care versus stratified care:
Step care means starting the treatment with simple analgesia, usually with an antiemetic and gradually increasing in one or more steps toward triptans.
Stratified care is where low impact migraine is treated with simple analgesic and an anti-emetic, but with high impact, migraine is treated first with a triptan. Stratified care has a significantly better clinical outcome than step care.
It is known that analgesic and antiemetic is effective to use at very early migraine attack, perhaps before pain intensifies—such as, during aura or prodrome phase, a stage when triptans are known to be inefficient.
Other acute rescue treatments:
Unlicensed options for refractory cases include high dose oxygen (100% if possible), parenteral steroids (such as dexamethasone 4mg injection), and parenteral phenothiazines (such as chlorpromazine 5–50mg injection).
How to prevent Migraine?
Preventive measures can help reduce the intensity and severity of headaches, reduces the frequency of migraines, helps shorten a migraine attack.
Beta blockers like propranolol (Inderal LA, Innopran XL, others), metoprolol (Lopressor) and timolol (Betimol) have proved effective for preventing migraines and may reduce the severity and frequency of migraines. You may take several weeks until you notice the full result.
Calcium channel blockers:
Calcium channel blockers like Verapamil (Calan, Verelan) are used to treat high blood pressure may be helpful in preventing migraines and relieving symptoms. They are used to prevent migraines with aura.
Angiotensin-converting enzyme inhibitor (ACE):
Angiotensin-converting enzyme (ACE) inhibitors lisinopril (Zestril) is used in reducing the length and intensity of migraines.
Tricyclic antidepressants such as amitriptyline is the only tricyclic antidepressant proved to be effective in preventing migraines. They are helpful in preventing migraines, even in people without depression. These antidepressants reduce the frequency of migraines by altering serotonin levels and other brain chemicals. Other tricyclic antidepressants are preferred because they have lesser.
Selective serotonin reuptake inhibitor (SSRI):
SSRI’s such as venlafaxine (Effexor XR), is the only medicine in this category which may be helpful in preventing migraines. Other SSRI’s are potentially harmful and can even worsen a migraine.
Anti-seizure drugs, such as valproate (Depacon) and topiramate (Topamax), may reduce the frequency of migraines attack. However, when these drugs are given in high doses, they may cause side effects like nausea, tremor, weight gain, hair loss and dizziness. Avoid valproate in pregnancy or if you are planning to become pregnant.
Nonsteroidal anti-inflammatory drugs like naproxen (Naprosyn), may help reduce the symptoms and prevent migraines.
Botox (Onabotulinumtoxin A):
Botox is effective in the treatment of chronic migraine in adults. In this procedure, onabotulinumtoxinA is injected into the muscles of the forehead and neck, and the treatment is usually repeated every 12 weeks.
This is a self-injected drug, which is taken once in a month. This is the first in a new class of drugs. It inhibits the activity of a molecule, which is known to play a role in migraines.
Clinical trials have found that acupuncture to be helpful for headache pain. During acupuncture, very thin needles are lightly inserted into your skin at defined points.
This therapy may reduce the frequency of migraines.
Cognitive behavioral therapy:
This type of psychotherapy teaches you how behaviors and thoughts affect how you perceive pain.
Herbs, vitamins and minerals:
Herbs like feverfew and butterbur may prevent migraines or reduce their severity, though studies are not fully established.
- A high dose of vitamin B-2 (riboflavin) may prevent or reduce the frequency of migraines.
- Coenzyme Q10 supplements may reduce the frequency of migraines, but further studies are needed.
- Magnesium supplements have been used in the treatment of migraines, but studies are not fully established.
Discuss with your doctor if these treatments are suitable for you.
Good lifestyle has a more significant impact on your wellbeing
Regular exercise, relaxation techniques may include progressive muscle relaxation, meditation or yoga.
Get the right balance of sleep each night and do not oversleep. Making sure to sleep early and wake up early.
Maintain a diary:
Maintain a record in your diary even after you see your doctor. This will help you learn more about your condition, what treatment is most effective and what triggers a migraine.
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