MIGRAINE

A migraine is usually a severe headache felt as a throbbing pain or a pulsating sensation at the front or one side of the head. It is accompanied by nausea, vomiting and increased sensitivity to light and sound.

Migraine attacks can cause significant pain for hours to days and be so severe. Some migraines are preceded or accompanied by sensory warning symptoms (aura), such as flashes of light, blind spots, or tingling in your arm or leg.
Migraine is common. About 1 in 4 women and about 1 in 12 men develop migraine at some point in their lives. It commonly starts in childhood or as a young adult. Some people have frequent attacks - sometimes several a week. Some people may go for years between attacks. In some people, the migraine attacks stop in later adult life. However, in some cases the attacks continue throughout life.

CAUSES

The exact cause of migraine is unknown, but genetics and environmental factors appear to play a role. It is thought to be the result of temporary changes in the chemicals such as serotonin and blood vessels in the brain.
MIGRAINE HEADACHE TRIGGERS
Common migraine triggers include:

Ø Hormonal changes in women - Fluctuations in estrogen as seen in menstruation, pregnancy and menopause seem to trigger headaches in many women with known migraines.
Hormonal medications, such as oral contraceptives and hormone replacement therapy, also may worsen migraines.

Ø Diet -  Dieting too fast ; irregular meals; Foods containing tyramine (red wine, aged cheese, smoked fish, chicken livers, figs, and some beans), monosodium glutamate (MSG), or nitrates (like bacon, hot dogs).

Other foods are chocolate, nuts, peanut butter, avocado, banana, citrus, onions, dairy products and fermented or pickled foods.

Ø Drinks – Alcohol, especially wine, and highly caffeinated beverages

Ø Environmental - Bright lights, loud noises, flickering TV, smoking and smoky rooms and certain odors or perfumes

Ø Changes in sleep patterns or irregular sleep

Ø Physical or emotional stress ;including sexual activity

Ø Medications - Oral contraceptives; Hormone replacement therapy and vasodilators, such as nitroglycerin, and some sleeping pills can aggravate migraines.

Ø Psychological - Depression, anxiety, anger, tiredness, stress, etc. Some people with migraine cope well with stress but have attacks when they relax, leading to so-called weekend migraine.

RISK FACTORS

Several factors make you more prone to having migraines.

Ø Family history - If one or both of your parents have migraine, then you have a good chance of having migraines too.

Ø Sex- Women are three times more likely to have migraines. It tends to affect boys more than girls during childhood, but at puberty and beyond, more girls are affected.

Ø Age -  Migraines can begin at any age, though most people experience their first migraine during adolescence. By age 40, most people who have migraines have had their first attack.

Ø Hormonal changes – during menstruation, pregnancy and menopause

SYMPTOMS

Migraine can present in various ways which include –

Ø Migraine with aura (common migraine) – where there are warning signs before the migraine begins, such as seeing flashing lights.

Ø Migraine without aura(classic migraine) – where the migraine occurs without warning signs

Ø Migraine aura without headache(silent migraine) – where an aura or other migraine symptoms are experienced, but a headache does not develop

Migraines may progress through four stages, including prodrome, aura, headache and postdrome, though all stages may not be experienced.

Prodrome

This occurs one or two days before a migraine;subtle changes that signify an oncoming migraine may be noticed. These include-

Ø Constipation

Ø Depression

Ø Food cravings

Ø Hyperactivity

Ø Irritability

Ø Neck stiffness

Ø Uncontrollable yawning

Aura

Aura may occur before or during migraine headaches. Examples include:

Ø Visual phenomena, such as bright spots or flashes of light

Ø Vision loss

Ø Pins and needles sensations in an arm or leg

Ø Speech or language problems (aphasia)

Less commonly, an aura may be associated with limb weakness (hemiplegic migraine).

Headache phase

When untreated, a migraine usually lasts from 4 to 72 hours. During a migraine, the following symptoms are experienced.

Ø Moderate to severe pain, usually confined to one side of the head, but switching in successive migraines

Ø Pulsing and throbbing head pain

Ø Increasing pain during physical activity

Ø Inability to perform regular activities due to pain

Ø Nausea and vomiting

Ø Increased sensitivity to light and sound.

Postdrome

This is the final phase of migraine. It occurs after a migraine attack. During this phase you may feel drained and washed out, though some people report feeling mildly euphoric.

See your doctor immediately or go to the emergency room if you have any of the following signs and symptoms, which may indicate other, more serious medical problems:

Ø An abrupt, severe headache like a thunderclap

Ø Headache with fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or trouble speaking

Ø A chronic headache that is worse after coughing, exertion, straining or a sudden movement

Ø Headache after a head injury, especially if the headache gets worse

Ø New headache pain if you're older than 50

COMPLICATIONS

Ø Abdominal problems- Certain pain relievers called non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may cause abdominal pain, bleeding, ulcers especially if taken in large doses or for a long period of time.

Ø Medication-overuse headaches

Ø Serotonin syndrome. Serotonin syndrome is a rare, potentially life-threatening condition that occurs when the body has too much serotonin, which is a chemical found in your nervous system. It may occur with   migraine medications called triptans and antidepressants known as selective serotonin reuptake inhibitors (SSRIs)

Ø Chronic migraine -  migraine lasting for 15 or more days a month for more than three months

Ø Status migrainosus - migraine attacks that last for more than three days.

Ø Persistent aura without infarction.

Ø Migrainous infarction - Some people who have a migraine with aura may have aura symptoms that last longer than one hour. This can be a sign of bleeding in the brain (stroke).

TREATMENT

Migraines can't be cured, however medications used to combat migraines fall into two broad categories:

Ø Pain-relieving medications - Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms that have already begun.

Ø Preventive medications - These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.

Pain-relieving medications-include –

Ø Paracetamol

Ø Aspirin

Ø Non steroidal anti-inflammatory drugs(NSAIDs) – ibuprofen; naproxen

Ø Triptans – Sumatriptan, rizatriptan, zolmitriptan etc.They aren't recommended for people at risk of strokes and heart attacks.

Ø Ergots – Ergotamine; dihydroergotamine; combination of ergotamine and caffeine (CAFERGOT).

Ø Anti-nausea medications - chlorpromazine, metoclopramide or prochlorperazine.

Ø Opioid – codeine; Used especially in people who can’t take triptans or ergot

Ø Glucocorticoid –Prednisolone;dexamethasone;these may be used in conjunction with other pain relief medications

Preventive medications – include-

Ø Beta blockers-propranolol; metoprolol

Ø Calcium channel blockers – verapamil, nifedipine

Ø Amitriptyline

Ø Anti-seizure drugs – sodium valproate.

Ø Botulinum toxin - helpful in treating chronic migraine

Ø methysergide

LIFESTYLE AND HOME REMEDIES

Self-care measures can help ease the pain of a migraine headache.

Ø Muscle relaxation exercises

Ø Get enough sleep, but don't oversleep.

Ø Rest and relax - If possible, rest in a dark, quiet room when you feel a headache coming on.

Ø Place an ice pack wrapped in a cloth on the back of your neck and apply gentle pressure to painful areas on your scalp.

Ø Keep a headache diary-  helps to identify trigger factors

ALTERNATIVE MEDICINE

Ø Acupuncture.

Ø Biofeedback.

Ø Massage therapy.

Ø Cognitive behavioral therapy.

Ø Herbs, vitamins and minerals. – riboflavin(vitamin B2); magnesium supplements

All these have been used with mixed result
PREVENTION
One or more of these suggestions may be helpful;

Ø Avoid triggers.

Ø Exercise regularly - Obesity is thought to be a factor in migraine headaches, and regular exercise can help to maintain a healthy weight

Ø  Reduce the effects of estrogen by avoiding or reducing the medications you take that contain estrogen.(birth control pills and hormone replacement therapy).

Migraine and children

Some points to note about migraine in children include

Ø Migraine is common in children. It affects about 1 in 10 school-age children.

Ø Symptoms can be similar to those experienced by adults. However, sometimes symptoms are not typical. For example, compared with adults, attacks are often shorter; pain may be on both sides of the head. Also, associated symptoms such as nausea and vomiting may not occur.

Ø Abdominal migraine mainly affects children.

Ø Common triggers in children include missing meals, dehydration and irregular routines.

Ø Many of the medicines used by adults are not licensed for children: Paracetamol or ibuprofen are suitable and are commonly used. Do not use aspirin.

Ø As regards anti-nausea medications, domperidone is licensed for children of all ages, and prochlorperazine is licensed for children older than 12 years.Triptans are not licensed for children and so should not be used.