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All you need to know: Migraine headaches
Sat, 14 Jun 2008 17:13:57
By Patricia Khashayar, MD., Press TV, Tehran
Migraine is a severe throbbing headache, commonly on one side of the head, which may or may
not be accompanied by nausea, visual disturbances among other symptoms.
Epidemiology
Migraine is a common condition, which typically begins in adolescence or early adulthood,
affecting 12-28% of 15- to 55-year-old individuals worldwide.
The disease is more prevalent in women until menopause thereafter the number of male and
female sufferers becomes equal.
More than 80% of migraineurs have a positive family history of the disease, suggesting a genetic
component for the disease.
Pathophysiology
The exact cause of migraine headaches is unclear, but experts have announced a complex
process involving excessive dilation and contraction of cerebral blood vessels, the release of
certain inflammatory chemicals or inflammation of the brain membranes are responsible for the
disorder.
Signs and symptoms
Migraines usually cause episodes of moderate to severe headaches (often one-sided and
pulsating), which last for several hours and their frequency varies from person to person.
These headaches often worsen with physical activity and interfere with daily activities. They are
often accompanied by nausea, vomiting, diarrhea, photophobia (increased sensitivity to bright
lights) and hyperacusis (increased sensitivity to noise).
Visual changes (blurred vision or blind spots, zigzags of light or light flashes), fatigue, confusion,
nasal congestion, feeling cold or sweating, neck stiffness, restlessness, lightheadedness and cold
hands and feet are other accompanying factors.
Migraine attacks consist of four phases which are not necessarily experienced by all migraineurs.
1. Prodrome phase
A variety of warning signs including mood changes (euphoria, irritability or depression), a subtle
change in sensation (a funny taste or smell), fatigue, yawning, excessive sleepiness, craving
certain foods (chocolate), stiff muscles (especially in the neck), constipation or diarrhea,
increased urination and other vegetative symptoms may precede the headache phase of the
migraine attack by several hours or days.
2. Aura phase
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Aura precedes or accompanies the attack in 20-30% of migraineurs. These focal neurological
phenomena gradually appear over 5 to 20 minutes and generally last for less than 60 minutes.
Symptoms of migraine aura can be visual, somatosensory or motor in nature.
- The visual aura is typically a slowly expanding area of blindness surrounded by a sparkling edge
that increases.
Some migraineurs develop blind spots (scotomas), geometric patterns or unformed flashes of
white and/or black or rarely of multicolored lights (photopsia), formations of dazzling zigzag lines
(scintillating scotoma or fortification spectra or teichopsia), blurred, shimmering or cloudy vision
or lose vision on one side (hemianopsia).
- The somatosensory aura includes paresthesia, feeling pins-and-needles in the hand and arm as
well as in the ipsilateral nose-mouth area.
- The motor aura typically presents as muscular weakness on one side of the body.
3. Pain phase
Migraine can occur at any time of the day, though it often starts in the morning. The typical
migraine headache is unilateral, throbbing and moderate to severe.
The pain may be bilateral at the onset or start on one side and become generalized. The onset is
usually gradual. The pain peaks and then subsides, usually lasting between 4 to 72 hours in
adults and 1 to 48 hours in children.
The frequency of attacks is extremely variable, from a few in a lifetime to several times a week;
the average migraineur experiences from one to three headaches a month.
4. Postdrome phase
The pain may persist for some days after the main headache has ended; during this time, the
patient may feel tired, irritable or listless and may even experience impaired concentration, scalp
tenderness or mood changes.
Some people feel unusually refreshed or euphoric after an attack, whereas others note
depression and malaise. Often, some of the minor headache phase symptoms such as appetite
loss, photophobia and lightheadedness continue after the headache has ended.
Migraine symptoms in children
In children, migraines tend to last for a shorter period. The pain is bilateral, often disabling and
accompanied by more severe symptoms. The frequency and intensity of attacks reduces as they
grow older.
Children may also have all of the signs and symptoms of a migraine without the headache. This
condition known as 'abdominal migraines', is difficult to diagnose.
Childhood headaches can also be indicators for more serious problems such as depression.
Classification
According to the International Headache Society, migraines are classified in various subtypes:
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- Common Migraine (migraine without aura)
This kind of headache accounts for about 80% of migraines and is accompanied by symptoms
such as nausea and vomiting. These migraineurs may develop aura in later attacks.
- Classic Migraine (migraine with aura)
Individuals suffering from this type of headache experience an aura, generally in the form of
visual disturbance before their headaches.
- Basilar type migraine
BTM is an uncommon complicated migraine resulting from brainstem dysfunction. Serious BTM
episodes can lead to stroke, coma and death.
- Familial hemiplegic migraine
FHM is a migraine with a possible polygenetic component. These migraineurs experience typical
migraine headaches preceded and/or accompanied by reversible limb weakness on one side as
well as visual, sensory or speech difficulties.
- Abdominal migraine
This migraine, which mainly afflicts children, is characterized by moderate to severe central
abdominal pain that last 1-72 hours.
- Acephalgic migraine
This migraine is a neurological syndrome in which the patient may experience aura symptoms in
the absence of any headache.
- Menstrual migraine
Some 50% of female migraineurs claim their attacks are aggravated right before, during or after
their periods, suggesting that hormones also trigger the condition. Migraines usually disappear
during pregnancy in a substantial number of sufferers.
- Status migrainosus
This type of migraine is characterized by severe headaches which last for over 24 hours and do
not go away without intervention. There are rare cases in which an aura occurs, but not a
headache.
- Hemiplegic migraine
Muscular weakness or partial paralysis, lasting less than an hour characterize this type of
headache.
- Ophthalmoplegic migraine
This type of headache involves temporary eye dysfunction such as droopy eyelid or pupillary
changes which last from several days to weeks.
Triggers
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The major triggers responsible for migraine attacks include allergic reactions, bright lights, loud
noises, certain odors or perfumes, physical or emotional stress and anxiety, changes in sleep
patterns, smoking or exposure to smoke, weather changes, skipping meals, dehydration, alcohol,
caffeine (in excess), hormonal changes during the menstrual cycle and tension headaches.
Consuming special foods such as chocolate, nuts, peanut butter, avocado, banana, citrus, onions
and dairy products as well as foods containing tyramine (aged cheese, smoked fish, chicken
livers, figs and some beans), monosodium glutamate or nitrates (canned and preserved meats)
are also considered migraine triggers.
Medications such as nitroglycerin, lithium, certain anti-hypertensive, anti-inflammatory,
bronchodilating drugs and hormone-related medications can increase migraine risk.
Diagnosis
There are no tests available to diagnose a migraine accurately. Diagnosis is based on the findings
of physical examination and medical and family history.
Neurological examination is usually performed to rule out other headache causes including
stroke, tumor, meningitis and sinusitis.
Treatment
Migraine treatment is more an art than science. A drug that works well for one migraineur may
not provide any relief for another. A combination of different medications is sometimes required
to treat resistant headaches.
Although there is no cure for migraine, numerous interventions may help restore the quality of
life in migraineurs.
Prophylactic therapy is the best way to prevent migraines. This method includes eliminating
controllable triggers as well as improving the patient's physical, mental and emotional health.
Migraineurs should adopt a diet that is low in simple carbohydrates and high in protein. The diet
should also be rich in almonds, almond milk, watercress, parsley, fennel, garlic, cherries and
fresh pineapple.
Such individuals should eat small meals along with nutritious snacks between meals. They should
avoid foods containing tyramine, salt and acid-forming foods (meat, cereal, bread and grains).
Self-Care at Home
Most migraineurs can manage mild-to-moderate attacks at home with the strategies including
using a cold compress on the pain area, resting with pillows supporting the head or neck in a
room with little or no sensory stimulation (light, sound and odors), withdrawing from stressful
surroundings, drinking moderate amounts of caffeine and taking certain over-the-counter
headache medications.
Medical Treatment
Migraine treatments are directed at preventing attacks (prophylactic or preventive therapy) and
alleviating them when they occur (abortive therapy). Many people with migraine use both forms
of treatment.
1-Abortive Therapy
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This method aims to prevent migraine attacks or to stop them once they start using Nonsteroidal
anti-inflammatory drugs (NSAIDS) such as aspirin, acetaminophen (Tylenol), ibuprofen (Advil,
Motrin), naproxen (Naprosyn), naproxen sodium (Anaprox), ketoprofen (Orudis) and ketorolac
(Toradol).
Taking NSAIDs with acetaminophen have an additive effect in treating migraine. Moreover,
acetaminophen or ibuprofen plus sleep are effective enough to stop mild headaches.
Other over-the-counter painkillers including Excedrin Migraine (containing acetaminophen and
aspirin combined with caffeine) are also approved for use with migraine.
Serotonin receptor agonists (triptans) are effective in certain patients; however, individuals with
basilar, hemiplegic and ophthalmoplegic migraines should not use such medications.
Prochlorperazine (compazine) and promethazine (phenergan), mainly used for nausea, have an
abortive or preventive effect on headaches as well.
Due to the habit-forming effects of butalbital compound (fioricet, fiorinal) and acetaminophen
codeine, they should be reserved for resistant cases.
2- Prophylactic Therapy
This type of treatment is considered when migraines occur on a regular basis and migraineurs
experience more than one attack per week. This treatment aims to lessen the frequency and
intensity of attacks rather than eliminate the headache.
In order to be effective, these medications must be taken every day, in the presence or absence
of a headache.
- Medication used to treat high blood pressure including Beta-blockers, and calcium channel
blockers.
- Tricyclic antidepressants and newer antidepressant drugs including the selective serotonin
reuptake inhibitors.
- Antiepileptics such as Gabapentin (Neurontin), valproic acid (Depakote), topiramate
(Topamax).
- Some antihistamines and anti-allergy drugs including diphenhydramine (Benadryl) and
cyproheptadine (Periactin)
Alternative methods
Biofeedback is shown to be effective in some migraineurs. In this method, individuals learn to
control and lessen their bodily reaction to stress.
Massage, acupuncture and relaxation can also help relieve stress. Counseling is also effective if
the migraine is depression- or anxiety-related.
Botulinum toxin (BOTOX) injection is another effective alternative in certain migraineurs.
Herbs effective in treating migraine include bio-rizin, cordyceps, feverfew, ginkgo biloba, clued
cayenne, chamomile, fumitory, ginger, peppermint, rosemary, valerian, willow bark and
wormwood.
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