Migraine

Migraines are a type of headache characterized by intense, often debilitating pain. They are typically felt as a severe throbbing or pulsing sensation, usually on one side of your head, and can last for hours or even days. Migraine headaches are often accompanied by other symptoms such as sensitivity to light, noise, or smells, or nausea and vomiting. You may also experience visual disturbances known as aura before the onset of your headache, which can include flashes of light, blind spots, or tingling on one side of your face or in an arm or leg.

The exact cause of migraines is not fully understood, but they are believed to involve changes in your brain and surrounding blood vessels. Several factors can trigger migraines, including hormonal changes, stress, certain foods and beverages, bright lights, loud sounds, and changes in sleep patterns. Migraines are more common in women than men and often run in families, suggesting genetics may play a part.

Treatment for migraines can involve a variety of approaches, including medication to relieve symptoms and prevent future attacks, lifestyle adjustments to avoid triggers, and other therapies such as biofeedback or acupuncture.

There are several types of migraines with the most common being:

• Migraine with aura: This was once known as a classic migraine. Symptoms such as loss of vision, numbness or tingling, feeling dizzy, or difficulty speaking can occur up to an hour before the headache begins.
• Migraine without aura: This is considered a common migraine and is the more frequent type of migraine. Symptoms may include headache pain that begins without any warning signs and is typically felt on one side of your head, along with nausea, visual disturbances, mood changes, fatigue, and increased sensitivity to noise and light.

Some other types of migraines can include:

• Abdominal migraine (typically affects young children)
• Hemiplegic migraine
• Chronic migraine
• Menstrual migraine
• Retinal migraine (ocular migraine)
• Status migrainosus
• Migraine aura without headache (silent migraine)

The exact cause of migraines is not completely understood, but they are thought to result from abnormal brain activity affecting nerve signals, chemicals, and blood vessels in your brain. Some key factors that are believed to play a role in the development of migraines include:

• Genetics: Migraines have a strong genetic component, as they often run in families. Researchers are still studying specific genes involved in migraines.
• Neurological Factors: Changes in your brainstem and its interactions with the trigeminal nerve, a major pain pathway, may be partly responsible. Additionally, imbalances in brain chemicals — including serotonin, which helps regulate pain in your nervous system — might also be involved. Serotonin levels drop during migraines, which may cause your trigeminal nerve to release substances called neuropeptides, which travel to the brain's outer covering (meninges) and cause headache pain.
• Vascular Changes: Migraines were once thought to be primarily a result of changes in blood flow in the brain. While this theory has been largely discounted, it is believed that migraines may be related to wider changes in the brain, including vascular irregularities.

• Triggers:

  • Environmental: These include stress, changes in weather, exposure to bright or flashing lights, loud noises, and strong smells.

  • Dietary: Certain foods and beverages, such as aged cheeses, alcohol (especially red wine), caffeine, chocolate, and foods containing monosodium glutamate (MSG), can trigger migraines in some people.
  • Hormonal Changes: In women, fluctuations in estrogen, such as during menstruation, pregnancy, or menopause, can trigger migraines.
  • Physical Activity: Intense physical activity, including sexual activity, might trigger a migraine.
  • Medications: Some medications, like oral contraceptives and vasodilators, can aggravate migraines
  • Sleep Patterns: Both missing sleep and sleeping too much can serve as triggers.

Migraine symptoms will vary from person to person and can depend on which phase you experience. There are 4 phases of a migraine attack: prodrome, aura, headache, and postdrome. You may not experience all 4 phases. Only about 20% of people will have a migraine with aura. The most common symptoms include:

• Severe headache: The main symptom of a migraine is a severe, pulsing, or throbbing pain, typically on one side of the head. However, some people might experience head pain on both sides or pain that shifts from one side to the other.
• Aura: About one in five people with migraines experience aura, a series of sensory disturbances that precede the headache phase. These can include visual symptoms like flashing lights, zigzag lines, or temporary vision loss, as well as sensory changes like tingling or numbness in the face, body, or hands, and speech or language problems.
• Increased Sensitivities: Many people with migraines report increased sensitivity to light (photophobia) and sound (phonophobia). Some also have a heightened sensitivity to smells (osmophobia).
• Nausea and Vomiting: These are common and can be quite severe, significantly adding to the discomfort during an attack.
• Dizziness or Vertigo: Feeling dizzy or experiencing a spinning sensation (vertigo) can occur during a migraine.
• Cognitive Symptoms: Difficulty concentrating, feeling mentally foggy, or experiencing memory problems are also reported by some people during a migraine.
• Fatigue: Feeling unusually tired or weak can happen before, during, or after the headache.
• Mood Changes: You may experience mood changes such as feeling very happy or very depressed.
• Neck Pain and Stiffness: For some, neck pain or stiffness can occur either before a migraine or during the attack.

Symptoms can begin one to two days before the headache itself and can continue after your headache goes away, leading to what's known as the postdrome phase, where you often feel drained or washed out. Because symptoms can vary greatly and can mimic other medical conditions, migraines can sometimes be challenging to diagnose. Tracking symptoms and discussing them with your neurologist or healthcare provider can help in managing migraines more effectively.

Diagnosing migraines typically involves clinical evaluation, as there are no specific tests to definitively diagnose the condition. This can include:

• Medical History: The first step is a detailed medical history, where your doctor will ask about your symptoms, their frequency, duration, severity, and any known triggers. Information about your family history of migraines or other headaches is also crucial, as migraines often run in families.
• Symptom Description: You will be asked to describe your symptoms, including the nature of the pain (throbbing, pulsing), location, and accompanying symptoms such as nausea, vomiting, sensitivity to light, sound, or smells, and any visual or sensory disturbances (aura).
• Headache Diary: Keeping a headache diary can be very helpful. This diary should track the timing, intensity, and circumstances of your migraines, including what food you eat, weather conditions, emotional stressors, menstrual cycles for women, and how the headaches respond to medications.
• Neurological Exam: A thorough neurological examination is performed to check for any signs of other conditions that might cause your headaches. This includes testing your reflexes, muscle strength, muscle tone, senses of touch and sight, coordination, and balance. It can help determine if your headaches are due to things such as muscle tension, sinus problems, or a brain disorder.

• Ruling Other Causes: Since other conditions can cause symptoms similar to migraines, it is important to rule them out. This may involve:

  • Blood tests to rule out infections, thyroid disease, and other possible causes of headaches.

  • Imaging tests such as MRI or CT scans to look for tumors, strokes, or structural abnormalities in the brain.
  • Lumbar puncture (in some cases) to check for infections or other conditions affecting the brain and spinal cord.
• Diagnostic Criteria: Most doctors use the diagnostic criteria established by the International Headache Society, as outlined in the International Classification of Headache Disorders (ICHD). These criteria specify the characteristics and frequency of headaches needed to make a diagnosis of migraines.

By using these approaches, your doctor can usually diagnose migraines based on your pattern of symptoms, the absence of other neurological signs, and by ruling out other disorders. Treatment plans are then tailored to your symptoms and their severity.

Migraine treatment is typically a combination of medications, lifestyle adjustments, and sometimes alternative therapies. Treatment aims to relieve symptoms and prevent additional attacks. Some treatment options include:

These are taken during migraine attacks and are intended to stop or reduce the severity of your symptoms:

• Pain Relievers: Over-the-counter (OTC) pain relievers such as Advil (ibuprofen), aspirin, or Tylenol (acetaminophen) can help treat mild migraine symptoms. For more severe migraines, prescription nonsteroidal anti-inflammatory drugs (NSAIDs) or combination analgesics may be used.
• Triptans: These are commonly prescribed for migraine because they are effective in relieving the pain, nausea, and sensitivity to light and sound that are associated with migraines. Examples include Imitrex (sumatriptan), Maxalt (rizatriptan), and Zomig (zolmatriptan). To avoid medication overuse, triptans should be limited to less than ten days of use per month.

• Ergots: Less commonly used than triptans, combination drugs like Cafergot (ergotamine/caffeine) can be effective, particularly for pain that lasts for more than 48 hours.

• Anti-nausea Medications: These can help alleviate nausea and vomiting associated with migraines. Examples include Reglan (metoclopramide), Zofran (ondansetron), or Compazine (prochlorperazine).

• Ditans: A newer class of migraine medication that includes Reyvow (lasmiditan), is specifically designed to target serotonin without some of the heart side effects of triptans. It can be used if you have cardiovascular issues.
• Gepants: Another new class of medication that includes Ubrelvy (ubrogepant) and Nurtec (rimegepant), they block calcitonin gene-related peptide (CGRP), a molecule involved in migraine attacks.

If migraines are frequent, severe, or interfere significantly with your daily activities, preventive treatment may be recommended:

• Medication: Daily prescription medications can reduce the frequency, severity, and length of migraines and increase the effectiveness of symptom-relieving medicines used during migraine attacks. These can include blood pressure medications (beta blockers and calcium channel blockers), antidepressants, anti-seizure (epilepsy) drugs, and CGRP antagonists.
• Botox Injections: For those with chronic migraine, Botox (onabotulinumtoxin A) injections every 12 weeks can help reduce headache frequency.

Identifying and managing triggers is important in the prevention of migraines:

• Dietary Changes: Avoiding foods and beverages known to trigger migraines, such as alcohol, caffeine, and those high in histamine or monosodium glutamate (MSG).
• Regular Exercise: Exercise can help reduce the frequency and severity of migraines.
• Sleep Hygiene: Maintaining a consistent sleep schedule.
• Stress Management: Relaxation techniques such as yoga, meditation, and biofeedback can help manage stress.

Some people find relief with alternative approaches, though evidence can vary:

• Acupuncture: Some studies suggest that acupuncture can help reduce migraine frequency.
• Herbal Supplements: Magnesium, riboflavin (vitamin B2), and coenzyme Q10 are commonly used. Feverfew and butterbur are herbs that might reduce migraine frequency but must be used with caution.
• Essential Oils: Peppermint and lavender oil are popular for their potential soothing effects.

Cognitive-behavioral therapy can help manage the impact of migraines by changing the way you react to migraine pain. Everyones treatment plan will be different, depending on the frequency and severity of your migraines, your medical history, and your overall health. You need to work closely with your healthcare provider to determine the best treatment plan for you.

Sources

• What is Migraine? American Migraine Foundation. Accessed Apr. 17, 2024.
• Migraine Headache. National Library of Medicine. Accessed Apr. 17, 2024.
• Migraine. National Institute of Neurological Disorders and Stroke. Accessed Apr. 17, 2024.
• What is Migraine? JAMA Network. Accessed Apr. 17, 2024.
• Types of Migraine. The Migraine Trust. Accessed Apr. 17, 2024.