What is migraine?
Migraine is the most common disabling headache syndrome, usually felt as a throbbing pain on one side of the head. It affects about 15% of the population and the majority of sufferers are aged 30-50, affecting them during their most productive years. Twice as many women than men are affected. A migraine is not ‘just a headache’, it typically also causes other symptoms such as nausea, vomiting, sensitivity to light and sound. Temporary neurological dysfunction can also occur, ranging from visual loss, numbness, difficulty speaking and thinking, profound dizziness and in rare cases, even paralysis. Migraine is known to occur as a result of sudden activation of brain areas that cause a cascade of brain dysfunction but exactly why this occurs still remains a mystery.
Where is migraine pain located?
The headache location can vary between and within individuals, although many patients will have stereotypical attacks. Besides headache, pain may be centred over the neck, eye, face or sinuses. Consequently, many patients are misdiagnosed, and correct treatment is often delayed until a specialist neurologist becomes involved in their care.
What are the types of Migraine?
There are many subtypes of migraine but the main 2 are:
- Migraines with aura
- Migraines without aura
An aura is a neurological warning sign, which may occur 10 to 15 minutes before an attack. These include flashes of light, loss of vision, dizziness, tingling sensations, or speech problems. These warning symptoms can be helpful in guiding patients when to take their acute treatments, as earlier treatment is more successful in aborting attacks.
What is the difference between episodic and chronic migraine?
Migraines can occur episodically or in a clinically distinct chronic pattern. Typical migraine symptoms include intense, throbbing headache associated with nausea or vomiting. Light and sound can aggravate the pain causing one to withdraw into a dark and quiet room. These symptoms are common to both the episodic and chronic type, however with chronic migraines, attacks occur more frequently i.e. greater than 15 headaches a month with at least 8 headaches having typical migraine symptoms. The condition is more disabling and significantly affects quality of life. Diagnosis may be difficult as symptoms often resemble tension-type headache, sinus headache or headache associated with neck pain. A neurologist should be consulted for a more accurate diagnosis.
What are the causes of Migraine?
Much has been learned about the biology of migraine. It is known that at the onset of an episode a network of neurons within the brain suddenly activates. This activation results in the many and varied symptoms including pain, nausea, sensitivity to one’s surroundings and neurological dysfunction. Migraines occur more often in women than men and may run in families. Migraine attacks may be associated with alcohol use, smoking, lack of sleep, prolonged muscle tension and stress, changes in hormone levels during a woman's menstrual periods or with the use of oral contraceptives and certain foods, especially chocolate, cheese, nuts, alcohol, and foods containing preservatives and artificial sweeteners. Overuse of short-acting headache medications can increase the likelihood of a migraine attack.
Many questions remain unanswered about the biology of migraine. Fortunately, large numbers of researchers continue to pursue a better understanding of the condition and more effective treatments. The global market for migraine treatment is estimated to be $8 billion by the year 2026 hence pharmaceutical companies are keenly competing to find medications with better outcomes for patients.
How does Migraine impact your health?
The pain from migraines can be quite intense causing distress and preventing participation in work and regular activities. The sensitivity to light and sound may cause you to withdraw into a dark and quiet room. Even simple physical activity aggravates the pain so rest in bed is often required.
What are the symptoms associated with Migraine?
The symptoms and severity of migraines can vary between individuals and episodes. Besides severe headache pain, migraines may be accompanied by secondary symptoms such as nausea, vomiting and sensitivity to light, sound or smell. It is usually aggravated by physical activity. Migraines may sometimes be associated with poor balance. These symptoms help to distinguish a migraine from other headaches such as tension headache.
What are the stages of Migraine Headaches?
Four stages have been identified to describe migraine attacks. These stages do not occur in all people and can vary with different episodes in the same person.
Prodromal Stage: This is the first stage which indicates that a migraine attack is impending. It can occur hours or days before the attack. What you experience is usually emotional or cognitive, but certain physical symptoms may also be present. Symptoms include depression, excessive urination, food cravings, increased yawning, neck stiffness, fatigue, difficulty concentrating and irritability. If recognised, patients know to have their acute treatment on hand for when they progress to the next stage.
Aura: This stage occurs just before an attack in 25% of migraine sufferers and may continue into the headache stage. It mainly consists of sensory symptoms such as changes in vision, smell or touch. Visual auras are the most common and include flashes of light, blurriness, blind spots or bright spots. Paraesthesia’s such as numbness and tingling of the face or limbs on the affected side can also occur. The symptoms are usually one sided.
Headache stage: The headache is moderate to severe in intensity and is usually accompanied by other symptoms such as light sensitivity and nausea and vomiting, and can last a few hours to a few days.
Resolution: In the final stage, the headache is relieved, but you feel fatigued. Patients call this their migraine ‘hangover’, a period where they are still not back to their usual level of functioning which contributes to their overall disability.
What are methods used to diagnose Migraines?
There is no test as such for migraine. It is important that patients undergo neurological examination and MRI scan of the head for potential secondary causes, as migraine is considered a ‘primary’ headache syndrome. Your doctor can diagnose a migraine by asking questions about your symptoms, family history, medical history, diet, and lifestyle. Diagnosis depends on your description about the headache, its location, length, duration, causative factors and associated symptoms.
The Headache Diary
A diagnostic headache diary is a crucial part of the diagnostic process. It may reveal that patients have more than one headache type (e.g. migraine-tension overlap) or show that years of ‘tension headache’ or ‘sinusitis’ are actually episodic or chronic migraines. Once the correct diagnosis is made, the diary is used to track progress and response to various drug and non-drug treatments, including injection therapies.
What are the consequences if Migraine goes untreated?
If migraines are left untreated, they can transform into a severe form called chronic migraine that is more disabling and difficult to manage.
What are the treatment choices or options available for migraines?
Treatment of migraine headache includes:
- Abortive/Acute medications: These are taken during migraine attacks and are designed to stop it once it starts. They can be taken by mouth, nasal spray, or administered by self-injection. These may include over-the-counter medications such as aspirin and anti-inflammatories or prescription medications called ‘triptans’.
- Preventive medications: These include oral medications which must be taken daily. Gradually over 2-3 months, the severity or frequency of the migraine attacks is reduced by 50% or more. Alternatively, injections of Botulinum toxin every 3-4 months can have similar effects in certain types of migraine.
Lifestyle changes including stopping smoking, avoiding dietary triggers, reducing stress, exercising and sleeping better have all been proven to improve migraines.
Numerous behavioural and complementary treatments have been trialled in migraine, with only a few such as relaxation training, cognitive-behavioural therapy and biofeedback showing good evidence of benefit. While other complementary therapies may anecdotally help individuals, some of these are not harmless and should be undertaken with caution.
'What is Migraine' - Dr Rodrigues explains in this video.
Source: Virtual Medical Centre
'How is migraine treated?' - Dr Rodrigues explains in this video.
Source: Virtual Medical Centre
'How can Botulinum toxin be used to treat migraine?' - Dr Rodrigues explains in this video.
Source: Virtual Medical Centre