Overview
Migraine is a type of headache but isn’t the typical headache that most people experience. Migraine Headache occurs in recurrent attacks, involves one side of the head, and lasts from hours to days. The patient may experience a variety of symptoms before the attack (aura). In migraine attacks, the pain may be moderate or severe and interferes with life activities.
Migraine is a common condition; it affects about one billion people worldwide (about 15% of the population). It runs in families. It affects women more than men, but in some females, the condition gets better after menopause. It usually occurs between the age of 15 and 45 years.
Migraine has unclear aspects; scientists don’t know its exact mechanisms and causes. It has some risk factors and triggers, such as gender, family history, stress, physical activity, and hormonal changes.
Migraine symptoms differ from one patient to another. In the classic form, the attack occurs in 3 stages: aura, migraine attack, and postdrome. Aura symptoms usually involve the vision, such as flashes of light or other visual disturbances, but other symptoms may occur. Then, the patient experiences a migraine headache, which lasts up to 3 days in severe cases. The migraine headache has specific features that we will discuss later. After the attack, the patient may feel tired in a postdrome stage that may last a day after the attack.
Migraine has two major types: Migraine with aura (classic migraine) and aura (common migraine). We have other types of migraines that we will discuss below.
Diagnosis of migraine depends on the history of the symptoms that you will tell your doctor. The doctor can diagnose the migraine by your medical history and family history. Your doctor may need to do a physical examination and some investigations (CT or MRI) to exclude other conditions, such as stroke and tumors.
There is no curative treatment for migraine. Your doctor creates a management plan that aims to reduce the rate of attacks and treat the symptoms when the attack occurs. The management plan consists of lifestyle modifications, prophylactic drugs, painkillers, and self-care remedies.
In this article, we will discuss the migraine in detail; we will cover the following questions about them:
- What is the clinical picture of migraine?
- What causes migraine, and what are its risk factors and triggers?
- How can doctors diagnose this condition?
- Is it curable, and how do the doctors manage it?
The clinical picture of migraine
Migraine is a type of headache, but what occurs is not only a headache. Before the attack of migraine, prodromal symptoms may occur for one or two days before the attack. Prodromal symptoms include:
- Mood disturbances (depression or euphoria)
- Food craving
- Severe thirst and frequent urination
- Constipation or diarrhea
- Neck stiffness
- Frequent Yawning
- Fatigue
- Irritability and hyperactivity
- Sensitivity to smell, noise, or light
About 60% of migraine patients experience this prodromal stage of migraine, either their migraine is with or without aura.
After the prodromal stage, the attack occurs, and it starts with aura or pain, according to the type of migraine. About 30% of migraine patients experience this stage (aura) before the headache.
During the aura phase, the symptoms may be visual, sensory, or motor. The visual disturbances are more frequent, and some patients experience more than one type of symptom.
The aura symptoms may include:
- Seeing flashes of light, bright spots, different shapes, black dots, and wavy lines
- Visual hallucinations
- Tunnel vision
- Transient vision loss
- Tingling, numbness, weakness, heaviness that may involve a whole side of the body (face, arms, and legs)
- Difficult speaking and language disturbances
- Auditory and smell disturbances
The symptoms of aura start gradually over several minutes and last up to 60 minutes.
After or during the aura, the patient enters the stage of actual migraine headache. Migraine headache starts gradually, at one side of the head, and is dull-aching in nature. Then, the headache becomes pulsating (throbbing), more severe, and may involve the other side of the head. Migraine patients may have the following symptoms with the headache:
- Nausea and vomiting
- Sensitivity to light, sound, and odors
- Dizziness and fainting
- Nasal congestion
Physical activity
Physical activity worsens the headache, but physical exercise may have a prophylactic role in the attacks. Migraine attacks last from 4 hours up to 3 days in severe and untreated cases. The frequency of attacks varies among the patients; some patients may have few migraine attacks throughout their lifetime, and others may have several per week. Most patients have two or three migraine attacks per month.
After the attack, the patient enters the postdrome stage that lasts for one day. In this stage, the patient:
- feels tired, exhausted, or confused
- have muscle pain or weakness
- experience mood changes (unusually happy and euphoric or depressed)
Migraine symptoms vary among the patients; some patients may have an aura (classic migraine), some of them may not experience it (common migraine), and others may have an aural stage only without migraine (silent migraine).
- In addition to the common, classic, and silent types of migraine, there are other variants of migraine:
Vestibular migraine
It is a migraine that occurs with vestibular symptoms, such as vertigo and dizziness. It occurs in about 40% of migraine patients and those with a history of motion sickness.
- Menstrual migraine: It is a migraine that accompanies the menstrual period.
- Hemiplegic migraine: In this type, the patient feels paralysis or weakness in one side of the body (hemiplegia), and this is similar to the signs of a stroke, which requires emergent medical help.
- Ophthalmic (Retinal) migraine: In this type, there is a transient partial or total blindness in one eye, with a headache behind the eye. The patent may see blind spots or flashes of light.
- Status margins: This term describes a severe migraine that lasts for more than three days.
- Chronic migraine: Migraine becomes chronic when it occurs at a rate of 15 times per month for three months. Chronic migraine is more severe, disabling, and associated with other chronic pain (like arthritis) and other health problems (like hypertension).
Causes, risk factors, and triggers of migraine:
The exact causes of migraine are unknown. The scientists suggest that it occurs due to disturbances in the brain stem that affects the blood vessels, chemicals (serotonin), and nerve signals. The genetic factor may play a role; migraine runs in families. Although there are no definite causes of migraine, we know their triggers and risk factors.
Migraine Triggers
- Hormonal changes: Hormonal changes in women before, during, or after the menstrual period may trigger migraine (Menstrual migraine). Many women only have migraine attacks related to the menstrual period (2 days before up to 3 days after the period). Some women may experience improvement or worsening related to pregnancy and menopause. Also, oral contraceptives and hormonal replacement therapy worsen or improve the migraine.
- Emotional disturbances (like stress, anxiety, depression, and tension) may initiate changes in the brain’s blood vessels that lead to migraine.
- Intense physical activity, such as vigorous exercise and sexual activity
- Weather changes; severe hot or cold weather and humidity changes
- Bright light, loud sounds, and strong smells
- Abnormal sleep patterns; inadequate or too much sleep
- Medications that affect hormones, such as oral contraceptives, or blood vessels, such as Nitroglycerin (vasodilator)
- Skipped, delayed, or irregular meals
- Alcohol abuse and smoking
- Caffeine products, such as coffee and tea, may trigger migraine attacks; however, caffeine may treat acute attacks.
- Foods such as chocolate, citrus fruit, Aged cheese, cured meat, soy sauce
- Food additives, such as nitrates (in hot dogs and cured meat), monosodium glutamate, and aspartame (artificial sugar)
- Dehydration
Risk factors of migraine
- Family history: if you had one parent -or both- with migraine, you would be at increased risk of having a migraine.
- Sex: Women are at higher risk than men by three times.
- Age: Migraine affects any age, but it is more common between 15 and 45 years of age.
Diagnosis of Migraine
Diagnosis of migraine depends on your medical history that you will tell the doctor. Your doctor will ask you about the pain (side, character, and duration) and the associated symptoms before (prodrome and aura stages), during, and after (postdrome) the attack. Also, your doctor will ask if you have a positive family history of migraine.
It will be helpful if you make a diary of your symptoms and triggers that you notice over a few weeks, such as:
- What symptoms did you experience, and where did you feel these symptoms?
- When the symptoms occurred (for example, during the menstrual period or after stress)
- The frequency and duration of the attacks
- If you took any medications (long term use of painkillers may make the migraine hard to treat and may lead to a medication overuse headache)
The medical history may be enough to diagnose the migraine. But some cases may be unusual or complex and need to rule out other serious causes of headache, such as tumors, strokes, infections, and bleeding in the brain. To rule out these causes, your doctor will do a physical (neurological) examination and ask you to do brain imaging (CT scan or MRI) and blood tests.
Treatment of Migraine
Migraine has no curative treatment that can end it. The management of migraines aims to relieve the symptoms during the attack and prevent future attacks as possible. To achieve these purposes, we have relieving and preventive medications. Also, lifestyle modifications and home remedies have a role in the management. The management plan will depend on:
- The severity, frequency, and type of migraine that you have
- The associated symptoms, such as nausea, vomiting, visual disturbances, and other symptoms
- Your age
- Other health problems that you may have, such as hypertension and Diabetes Mellitus
- Relieving medications
The best use of these medications is at the first sign of a migraine attack possible. These medications include:
Pain killers
Over-the-counter (OTC) pain relievers like aspirin, paracetamol, ibuprofen, and diclofenac, can control mild to moderate symptoms. These medications take some time to enter the blood and start to work; thus, their best use is at the first of the attack as possible. They are present in many forms, tablets, effervescent, suppositories, and injections. Avoid prolonged use of these medications because they may worsen the migraine (medications overuse headache). Also, these medications have many side effects in prolonged use, such as peptic ulcers, bronchospasm, Rey’s syndrome (in children), and liver and kidney problems.
If you need these medications frequently, or if they become ineffective, you should talk to your doctor to stop them, replace them with other more potent painkillers, or add other medications to them.
Triptans (Sumatriptan, zolmitriptan, almotriptan, rizatriptan)
These medications are effective against moderate to severe migraine and mild migraine that doesn’t respond to the OTC drugs. They act on the blood vessels of the brain and pain pathways to reserve the changes of migraine. They are present in the form of tablets, injections, nasal sprays, and shots. They aren’t safe for patients with heart diseases or strokes.
- Ergotamines, such as Cafergot, are old migraine medications that are as effective as triptans, but they have many side effects and are unsafe for patients with heart diseases. They may be the best option for severe cases that last for more than one day.
- Lasmidtnanis a new oral drug for migraine that relieves pain, nausea, and sensitivity to light and sound.
- Other drugs, such as Ubrogepant and opioids, may help if the other medications failed to control the pain.
- Anti-nausea and Anti-vomiting medications help if there are nausea and vomiting with the migraine.
Preventive medications
These medications aim to reduce the frequency, severity, and duration of migraine attacks. Your doctor may prescribe them if you have frequent, prolonged, severe attacks that don’t respond to the relieving treatment.
These medications include:
Beta-blockers, such as propranolol and metoprolol, may help in migraine prevention. Calcium channel blockers, such as verapamil, are also helpful in migraine. Anti-depressants and anti-seizures also help in migraine prevention. Botox injections every three months may help in some cases. Also, calcitonin gene-related peptide (CGRP) monoclonal antibodies, such as Galcanezumab, may help.
The prescription and follow-up of these medications should be under the supervision of your doctor.
- Lifestyle and home remedies
During the attack, try the following:
- Close your eyes, rest, and sleep in a quiet and dark room.
- Apply a cold cloth or ice pack to your forehead.
- Drink fluids.
Between attacks, try to avoid the migraine triggers as possible. For example:
- Try stress-reduction techniques, such as biofeedback and meditation.
- Avoid alcohol, dehydration, and foods that trigger a migraine.
- Exercise
- Avoid too short or too long sleep patterns.