Migraine

Migraine is a complex and debilitating condition that affects individuals of all ages, with a higher prevalence among women. The recurrent episodes of severe headaches can significantly impact a person's quality of life, leading to missed work days, reduced productivity, and strained relationships. Understanding the causes, triggers, and available treatments for migraines is crucial in managing this neurological disorder effectively.

What is a Migraine?

A migraine is a type of headache caused by nerve activity in the blood vessels of the brain. This leads to a throbbing pain, often on one side of the head, that can range from moderate to severe. The pain can last anywhere from 4 to 72 hours. Along with the headache, people with migraines may also experience symptoms like sensitivity to light, sound, and smells, nausea, vomiting, and visual disturbances like flashing lights or blind spots. These symptoms can make it difficult to perform everyday activities during a migraine attack.

Migraines can be broadly classified into two main categories: migraine with aura and migraine without aura.

1. Migraine with Aura

Migraine with aura is characterised by visual disturbances and other neurological symptoms that appear 10 to 60 minutes before the onset of the headache. These auras may include flashing lights, zigzag patterns, blind spots, numbness, tingling, and weakness on one side of the body.

2. Migraine without Aura

On the other hand, migraine without aura is the more common form, where the headache pain occurs without any warning signs. The pain is usually felt on one side of the head and is accompanied by symptoms such as nausea, confusion, blurred vision, mood changes, fatigue, and increased sensitivity to light, sound, or noise.

3. Chronic migraine

Chronic migraine is a type of migraine headache that occurs on 15 or more days per month for at least three months, with at least eight of those days being associated with a migraine. The intensity and duration of the headaches can vary, and individuals may experience a combination of other symptoms such as nausea, light sensitivity, and visual disturbances. Chronic migraines can significantly impact a person’s quality of life and often require long-term management strategies.

4. Basilar-type migraine

Basilar-type migraine, also known as brainstem migraine, is a rare and severe form of migraine that affects the brainstem or the base of the brain. It often presents with symptoms such as vertigo, double vision, difficulty speaking, and loss of coordination, along with the usual migraine headache. This type can be particularly concerning due to the neurological symptoms it causes. It mostly occurs in young women and can sometimes lead to more serious complications, requiring immediate medical attention.

5. Status migrainosus

Status migrainosus is a prolonged and severe migraine attack that lasts for more than 72 hours despite treatment. This type of migraine can be extremely debilitating and may require hospitalisation for proper management. In addition to the intense headache, individuals with status migrainosus may experience persistent nausea, vomiting, and light sensitivity. It can significantly impact daily life and may require stronger medications or treatments to alleviate the pain and symptoms.

In addition to the common types of migraines, there are several other forms that individuals may experience:

• Menstrual Migraine: Linked to the menstrual cycle, usually occurring 2 days before and 3 days after menstruation.
• Silent Migraine: Characterised by aura symptoms without a headache, often accompanied by nausea and other migraine symptoms.
• Hemiplegic Migraine: A rare and severe form that causes temporary paralysis on one side of the body, often accompanied by vertigo, pricking or stabbing sensations, and problems with vision, speech, and swallowing.
• Abdominal Migraine: Affects young children, characterised by moderate to severe pain in the abdomen, often accompanied by nausea, vomiting, and diarrhoea.
• Retinal Migraine: Characterised by attacks of visual loss or disturbances in one eye, often accompanied by migraine headaches.

Recognising the various types of migraines is essential for accurate diagnosis and tailored treatment plans. By understanding the specific symptoms and triggers associated with each type, individuals can better manage their condition and work with healthcare professionals to find the most effective migraine therapies.

The symptoms experienced during a migraine can vary widely among individuals, but there are some common signs and symptoms associated with each phase:

1. Prodrome Symptoms

• Mood changes (e.g., irritability or euphoria)
• Food cravings
• Neck stiffness
• Increased thirst and urination
• Frequent yawning
• Constipation or diarrhoea

2. Aura Symptoms

• Visual disturbances (zigzag patterns or blind spots)
• Sensory issues (pins and needles or numbness)
• Speech or language difficulties

3. Attack Symptoms

• Throbbing or pulsating head pain (often on one side)
• Sensitivity to light and sound
• Nausea and vomiting
• Blurred vision
• Lightheadedness

4. Postdrome Symptoms 

• Feeling drained or fatigued
• Confusion or difficulty concentrating
• Elation or mood changes
• Body aches and dizziness

Knowing these various migraine symptoms can aid in getting an accurate diagnosis and finding the most effective treatments and therapies to manage the condition.

Migraines typically progress through four distinct phases, each with its own set of symptoms. Understanding these phases can help in managing and treating migraines more effectively.

• Prodrome phase: This early warning stage occurs one or two days before the migraine, with symptoms such as constipation, depression, drowsiness, food cravings, and irritability.
• Aura phase: About 20-30% of migraine sufferers experience an aura, which includes reversible symptoms of the nervous system like visual hallucinations, zigzag lines, blind spots, tingling, numbness, and difficulty speaking.
• Attack phase: Characterised by throbbing, pulsing head pain on one side of the head lasting 4 to 72 hours, along with sensitivity to light, sound, and sometimes smell and touch, as well as nausea and vomiting.
• Postdrome phase: After the migraine attack, individuals may feel drained, confused, and washed out for up to a day, with some reporting feeling elated. Sudden head movements might briefly bring on pain again.

The exact cause of migraines is not fully understood, but it is believed to involve a combination of changes in the nervous system and blood vessels in the brain. Some common triggers for migraine headaches include:

• Genetics, as migraines tend to run in families
• Hormonal changes, particularly in women during menstrual cycles, pregnancy, and menopause
• Emotional triggers, such as stress, anxiety, depression, and excitement
• Environmental factors, including weather changes, bright or flickering lights, strong smells, and loud noises
• Dietary triggers, such as alcohol, caffeine, chocolate, aged cheeses, and additives like MSG and aspartame
• Sleep disturbances, including too much or too little sleep, and jet lag
• Physical exertion and changes in physical activity levels
• Neurological Imbalances:
  An imbalance in brain chemicals such as serotonin, which helps regulate pain signals, may contribute to migraine development. Fluctuations in serotonin levels can trigger migraines by affecting blood vessels and nerve signaling.
• Medication Overuse:
  Overusing pain relievers or specific medications for headaches can lead to rebound headaches, which may escalate into chronic migraines.
• Dehydration:
  Inadequate fluid intake can lead to dehydration, a well-known trigger for migraines, as it affects blood volume and brain function.
• Sensory Overload:
  Extended exposure to high sensory input, such as prolonged screen time or exposure to high-decibel sounds, can overstimulate the nervous system and trigger a migraine.
• Underlying Medical Conditions:
  Conditions like hypertension, sleep apnea, or temporomandibular joint (TMJ) disorders can act as secondary triggers or exacerbate migraine symptoms.
• Immune System Reactions:
  Inflammatory responses to infections or autoimmune conditions can lead to migraines, as inflammation affects the brain's blood vessels and nerves.
• Altitude Changes:
  Sudden shifts in altitude, such as during air travel or mountain climbing, can disrupt oxygen levels and trigger migraines in sensitive individuals.

Migraine is a complex neurological disorder influenced by various risk factors, including genetic, hormonal, lifestyle, and environmental factors. Understanding these risk factors can help individuals take steps to manage and prevent migraine headaches.

• Genetic predisposition: Having a family history of migraine significantly increases the likelihood of developing the condition, with a 50% chance if a parent or sibling has migraine.
• Hormonal fluctuations: Particularly fluctuations in estrogen levels during menstrual periods, pregnancy, and menopause can trigger migraine attacks.
• Age and gender: Women are three times more likely to experience migraines than men, and the condition typically begins during adolescence and peaks in the 30s.
• Lifestyle factors (smoking, caffeine, sleep disorders): Lifestyle factors such as smoking, caffeine misuse, body weight gain, and sleep disorders are associated with an increased risk of developing migraines.
• Underlying health conditions (depression, hypertension, head trauma): Certain underlying health conditions, including depression, hypertension, head trauma, and epilepsy, can also increase the likelihood of developing migraines.
• Environmental triggers (light, noise, smells, weather changes): Environmental factors like bright lights, loud noises, strong smells, changes in weather or barometric pressure.
• Certain foods and substances: Certain foods like aged cheeses, processed foods, aspartame, and MSG can trigger migraines. Skipping meals can also lead to a migraine.

Migraines are not just debilitating headaches; they can lead to several complications that significantly impact various aspects of an individual's life.

• Economic and social impact (work, school, relationships): The economic and social impact of migraines can be substantial, affecting work and school activities, family relationships, and financial stability. The economic burden includes direct costs such as healthcare expenses and indirect costs like lost productivity.
• Mental health issues (depression, anxiety): Migraines can also lead to mental health issues, including depression and anxiety, which can further exacerbate the condition.
• Medication overuse headaches: In some cases, chronic migraines can result in medication overuse headaches, where the frequent use of pain relief medications paradoxically worsens headache frequency and intensity.
• Rare complications (migrainous infarction, persistent aura, vertigo): Rare but serious complications of migraine include migrainous infarction (stroke), persistent aura without infarction, and migraine-associated vertigo.

Migraine prevention aims to reduce the frequency, severity, and duration of migraine attacks. Preventive strategies can be both pharmacological and non-pharmacological.

• Medications used for migraine prevention include beta-blockers (propranolol, metoprolol), antidepressants (amitriptyline, venlafaxine), anti-seizure medications (topiramate, valproic acid), and CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab).
• Lifestyle modifications such as maintaining a regular sleep schedule, eating regular meals, staying hydrated, exercising regularly, and managing stress can help prevent migraines.
• Identifying and avoiding migraine triggers like certain foods, bright lights, loud noises, strong smells, and hormonal changes can be beneficial.
• Supplements such as riboflavin (vitamin B2), coenzyme Q10, and magnesium may help prevent migraines in some people.
• Botulinum toxin (Botox) injections are FDA-approved for preventing chronic migraines (15 or more headache days per month).
• Neuromodulation devices that deliver electrical or magnetic pulses, and single-pulse transcranial magnetic stimulation (sTMS), can be used for migraine prevention.

Diagnosing migraine involves a comprehensive evaluation by a healthcare professional, typically a neurologist or headache specialist.

• Medical history and symptom evaluation: The diagnostic process begins with a thorough medical history, including a detailed description of headache symptoms, frequency, duration, triggers, and family history.
• Physical and neurological examination: A physical and neurological examination is performed to rule out other potential causes of headaches.
• International Classification of Headache Disorders (ICHD) criteria: ICHD provides standardised criteria for diagnosing migraine, which include having at least five attacks lasting 4-72 hours, with specific characteristics such as unilateral location, pulsating quality, moderate to severe intensity, and aggravation by physical activity. Additional symptoms like nausea, vomiting, and sensitivity to light and sound are also considered.
• Imaging tests (MRI, CT) if needed: In some cases, imaging tests such as MRI or CT scans may be ordered to exclude other underlying conditions.
• Headache diary: Keeping a headache diary can help identify patterns and triggers, aiding in diagnosis and treatment planning.

Key diagnostic criteria for migraine include having at least five attacks lasting 4-72 hours with at least two of the following characteristics:

• Unilateral location
• Pulsating quality
• Moderate to severe pain intensity
• Aggravation by physical activity

The attacks must also be associated with at least one of the following:

• Nausea and/or vomiting
• Sensitivity to both light and sound

An accurate diagnosis is essential for determining the most appropriate migraine treatments and management strategies for each individual patient.

Acute Treatment

Acute treatments are designed to stop or reduce the symptoms of a migraine attack once it has begun. Some common acute treatments include:

• Over-the-counter (OTC) pain relievers such as ibuprofen and aspirin. Combination of aspirin, acetaminophen, caffeine and isometheptene, dichloralphenazone, acetaminophen may also be effective.
• Prescription triptans like sumatriptan, rizatriptan, and others that block pain pathways in the brain. These are available in pill, shot, or nasal spray forms.
• Ergots such as dihydroergotamine and ergotamine tartrate can be helpful for longer-lasting migraines.
• Newer CGRP antagonists like rimegepant, ubrogepant, and zavegepant that target calcitonin gene-related peptide (CGRP) receptors.
• Anti-nausea medications such as metoclopramide and prochlorperazine can help with nausea and improve gastric motility during migraine attacks.

Adjunctive Therapies

In addition to pain relief, other treatments can help manage associated symptoms of migraines.

• Antiemetics can be used to treat nausea and vomiting.
• Resting in a quiet, dark room and staying hydrated can also help alleviate symptoms.
• Small amounts of caffeine can enhance the pain-reducing effects of other medications and relieve early-stage migraine pain.

It is important to consult a doctor if you experience frequent, severe, or disabling migraines that significantly impact your quality of life. Seek immediate medical attention if you have a sudden, severe headache accompanied by fever, stiff neck, confusion, seizure, double vision, weakness, numbness, or difficulty speaking, as these symptoms may indicate a more serious condition. If your migraine patterns change or if you experience new symptoms, it is also advisable to consult a healthcare provider. They can help identify potential triggers, rule out underlying conditions, and develop an effective treatment plan tailored to your specific needs.

• Migraine management involves a combination of acute treatments to stop a migraine once it starts and preventive strategies to reduce the frequency and severity of attacks.
• Acute treatments include NSAIDs, triptans, antiemetics, ergots, CGRP antagonists, and medical devices.
• Preventing migraines involves lifestyle modifications and pharmacological prophylaxis, including beta-blockers, antidepressants, anticonvulsants, and CGRP monoclonal antibodies.
• Non-pharmacological approaches, such as relaxation techniques, biofeedback, and cognitive-behavioural therapy, can also be beneficial in preventing migraines.
• Consult a doctor if you experience frequent, severe, or disabling migraines that significantly impact your quality of life or if you have any concerning symptoms.