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Migraine

Overview

Migraine is a common neurological disorder in which throbbing headaches of varying intensity occur on one side of the head, which may or may not be preceded by Aura. These episodes are recurrent, lasting 12 – 72 hours, and are provoked by stressors like insufficient sleep, hunger, sunlight exposure, hormonal changes, stress, etc. The migraine headache might be severe enough to hamper daily routine and is usually associated with nausea, vomiting, photophobia (increased sensitivity to light), phonophobia (increased sensitivity to sounds).  It is more common in females and tends to run in families. Migraine headaches are treated with abortive medicines (pain killers), and prophylactic medication prevents future episodes.

Cause

The exact cause of migraine is not well established until now. Both genetic and environmental factors are responsible for migraines. Your chances of having the disorder are more if you have a family member who suffers from migraine.
Two possible theories have been proposed at the disease level, one involving the blood vessels and the other involving the nerves. There are different chemicals called neurotransmitters in your brain, which affect your blood vessels, causing them to constrict (become narrow) or dilate (become wider), which causes pain. Some other chemicals work on the nerves causing alterations in their functions, affecting the blood vessels ultimately causing pain. One vital neurotransmitter is serotonin that is especially important in causing headaches. A class of medicines used to abolish migraine headache, called Triptans, exert their effects by blocking receptor (gate) for serotonin.

Types

Migraine is classified into different types based on the clinical symptoms. You may not have all the symptoms, and you might be suffering from one type or the other.

  • Migraine With Aura: In this type, headache is preceded by Aura (sensation), which can be:
  • Visual (flashing lights, central visual loss, arc of shimmering zig-zag lines)
  • Sensory (feeling numbness)
  • Motor (heaviness in limbs, blurring of speech)
  • Migraine Without Aura: there is no aura before the headache
  • Aura Without Headache: in this type, you may feel Aura, but there is no headache after it.
  • Chronic Migraine With Analgesic Overuse: you may have this type if you often use painkillers to abort the headaches. Instead of providing relief, the painkillers can worsen your disease, so it is advised to be cautious with the overuse of pain medicines.
  • Pediatric Migraine: this type occurs in children.
  • Hemiplegic Migraine: this type is very rare in which you may feel weakness in any of your limbs or body part on one side of your body.

Epidemiology

Migraine headaches are a widespread problem worldwide, but they are more prevalent in white Americans as compared to African Americans and Asians. They are more common in females than in males.

Risk Factors

 Having these characteristics makes you more susceptible to migraine;

Apart from these risk factors, some things can act as triggers to initiate the pain, which may be;

  • Sleep deprivation
  • Hunger
  • Exposure to sunlight
  • Physical or mental stress
  • Extremes of weather
  • Hormonal changes
  • Certain types of food and drinks like aged cheese, alcohol, caffeine

Signs And Symptoms

The signs and symptoms are described as follows:


Prodrome: Some people might feel the following symptoms hours to days before actually having the headache. They might not be the same for everyone but are usually fixed for the person who experiences them.

  • Mood swings (depression or euphoria)
  • Irritability
  • Food cravings
  • Constipation or diarrhea
  • Increased urination
  • Feeling more or less hungry than usual
  • Intolerance to bright lights or loud sounds

Aura: they may or may not precede the headache and may even occur without a headache.

  • Start to develop in 5-20 minutes and may last for 60 minutes
  • They may be visual, sensory, or motor
  • Visual auras are more common and feel like flashing lights, central visual loss, an arc of shimmering zig-zag lines
  • Sensory auras may feel like numbness or needle-like sensations on the body
  • Motor auras may feel like weakness of any part of the body, slurring of speech.

Pain: The pain of migraine has the following characteristics;

  • Throbbing or pulsatile
  • May increase on physical movements and may cause neck pain
  • It lasts for about 12- 72 hours
  • Occurring on one side of the head but maybe bilateral
  • Associated with nausea, vomiting. Often accompanied by increased sensitivity to light, sound, smell.

Postdrome: After the headache, you may feel;

  • Tired
  • Feeling sore at the site of pain
  • Depressed or euphoric
  • Feeling hungry
  • Usually, migraine headaches follow a pattern, but this may not be the case for everyone. 

Diagnosis

The diagnosis of migraine is usually clinical. The headache has to be typical, as described above in the symptoms.
To rule out other neurological disorders, your doctor may advise you to undergo a few tests like ESR, CRP (blood tests), or CT or MRI scan of the brain.

Differential Diagnosis

Some other disorders can mimic the presentation of migraine headaches, which should be considered while diagnosing. They are;

  • Cluster headaches
  • Exertional headaches
  • Brain tumor
  • Space occupying lesion in the brain
  • Brain hemorrhage
  • Temporal/Giant Cell Arteritis

Treatment

While having an episode, you should seek a quiet place with low lights and less noise. Two groups of medicines are given for the treatment of migraine. Abortive drugs that aim to stop the headache and prophylactic drugs whose function is to prevent future episodes.

Abortive Medicines: They include;

  • Analgesics like ibuprofen, acetaminophen, NSAIDs, etc.
  • Triptans: sumatriptan, naratriptan, zolmitriptan are the medicines that block serotonin receptors and so abolish the pain
  • Ergot derivatives: ergotamine tartrate, dihydroergotamine are the medicines that should be used soon after the commencement of headache. However, they should not be used by cardiac patients.
  • CGRP receptor antagonists: Ubrogepant, Rimegepant are oral medicines that are recently approved for migraine.
  • Anti-emetics: chlorpromazine, promethazine is used to control the symptoms of nausea and vomiting

Prophylactic Medicines: Your doctor may prescribe you these if you have more than two attacks per month, each lasting for more than a day, compelling you to use an excessive amount of abortive medicines and putting you at risk of developing chronic migraine due to analgesic overuse. They include;

  • Antihypertensive: they include Beta-blockers (most effective) like propranolol, metoprolol, calcium channel blockers like verapamil.
  • Anticonvulsants: valproate, topiramate. These are contraindicated in pregnant women
  • Antidepressants: tricyclic antidepressants like amitriptyline.

 

Prognosis

Migraine is a chronic condition. It may be remitted wholly or partially in some people, while others may continue to have it for life. Usually, the intensity and recurrence of episodes diminish as a person ages. In some people, headaches affect their quality of life. In some research studies, migraine is also linked with ischemic brain strokes.

Lifestyle Changes

People are usually aware of the typical triggers of their headaches. By maintaining a daily routine and avoiding those triggers, they can prevent an attack.

  • Maintain a healthy routine for eating and sleeping
  • Perform some physical activity and relaxation exercises
  • Stay hydrated
  • Use sun shields
  • Avoid the foods and drinks that trigger headache

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