Migraine Headache (Migraine)

What is Migraine Headache (Migraine)?

Migraines are severe headaches that are believed to be caused by a combination of genetics and particular conditions in the brain. These headaches can range from moderate to extreme in severity, often only affecting one side of the head. People who have migraines often feel sick and may have a strong reaction to light and noise. The term “migraine” is derived from ancient Greek and Latin words which were translated in French as “migraine”.

Migraines are one of the common conditions that can prevent people from working or going about their daily activities. These migraines are not just single events but can reoccur and last several hours or even days, interfering with a person’s quality of life. In fact, the most common type of migraine, accounting for 75% of all cases, is the type of migraine without aura).

Migraines can be categorized into four types:

1. Migraines without aura: These involve recurring headaches that last between 4 to 72 hours. The pain is usually on one side of the head, feels like a strong pulse, grows worse with physical activity, and is often accompanied by nausea, light sensitivity, and noise sensitivity.

2. Migraines with aura: Recurring episodes that start with a fully reversible set of symptoms that last a few minutes. These symptoms could include visual changes, sensory changes, speech and language issues, muscle weakness, brainstem disturbances, or retinal disturbances. After these initial symptoms, a headache and other migraine symptoms usually follow.

3. Chronic migraines: Defined as a headache that occurs on 15 or more days a month for more than three months, with migraine characteristics present on at least eight or more days in a month.

4. Probable migraines: Defined as a headache that exhibits migraine-like symptoms but lacks one of the features required to be classified into one of the above categories, and does not meet the criteria for another type of headache.

There are also episodic syndromes often associated with migraines:

– Recurrent gastrointestinal disturbances, which are recurring attacks of abdominal pain, discomfort, nausea, and vomiting;
– Benign paroxysmal vertigo, which features brief, recurring episodes of dizziness;
– Benign paroxysmal torticollis, which includes recurring episodes of the head tilting to one side.

Migraines can give rise to a few complications:

– Status migrainosus, refers to a severe migraine attack that continues for more than 72 hours;
– Persistent aura without infarction, refers to an aura that lasts more than a week without any evidence of a stroke or similar brain injuries evident in brain scans;
– Migrainous infarction, this occurs when one or more aura symptoms are accompanied by symptoms of stroke during a regular migraine attack;
– Migraine aura-triggered seizure, refers to seizures that are triggered during a migraine with aura.

What Causes Migraine Headache (Migraine)?

Migraines are headaches that scientists believe are caused by a mix of genetics, environmental influence, and certain brain activities. These activities affect how nerves send signals, and they impact the chemicals and blood vessels in your brain.

There seems to be a strong genetic link to migraines. People who have relatives with migraines are three times more likely to get migraines themselves. But, the exact way that migraines are inherited is not clear. It’s a complex issue, likely affected by multiple genes and determined by both genetic and environmental factors. Scientists are still working to pinpoint these genes as they could help give an insight into targeted preventative treatments against migraines.

There’s a specific type of migraine called Hemiplegic Migraine, which can run in families or can show up in people with no family history. It can be broken down into three types, each associated with different genes:

• Type 1 is caused by changes in the CACNA1A gene.
• Type 2 is caused by changes in the ATP1A2 gene.
• Type 3 is caused by changes in the SCN1A gene.

Changes in other genes like PRRT2 and SLC4A4 have also been associated with migraines.

Migraines have been linked with few other disorders as well:

• MELAS, a syndrome characterized by mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes.
• CADASIL, a blood vessel disorder caused by mutations in the NOTCH3 gene. People with CADASIL often experience migraines with auras (warning signs that a migraine is coming), with about half of carriers reporting this.
• RVCL, a blood vessel disorder primarily caused by mutations in the TREX1 gene.
• HIHRATL, a condition that affects retinal and cerebral vessels.
• HERNS, a blood vessel disorder in the brain and retina linked to a location on chromosome 3.

Triggers or things that can cause migraines to happen vary:

• Stress triggers migraines in 80% of cases.
• Hormonal changes during menstruation, ovulation, and pregnancy are a trigger for 65% of cases.
• Skipping meals can be a trigger for 57% of people.
• Weather changes affect 53% of people.
• Too much or too little sleep is a possible trigger for 50% of patients.
• Certain smells like perfumes, colognes, and petroleum distillates can affect 40% of people.
• Neck pain and exposure to lights can trigger migraines in 38% of cases each.
• Drinking alcohol, especially wine, can trigger migraines in 38% of people.
• Smoking and sleeping late have not been proven but could potentially trigger migraines.
• Extreme heat can be a trigger for 30% of people.
• Some foods, like aspartame (an artificial sweetener), tyramine (found in certain foods), and chocolate, can trigger migraines in 27% of cases.
• Exercise can be a trigger for 22% of people.
• Sexual activity can trigger migraines in about 5% of cases.

Risk Factors and Frequency for Migraine Headache (Migraine)

Migraines are quite common, affecting around 12% of people. Women tend to experience migraines more often than men, with 17% of women and 6% of men getting them each year. Girls are more likely to have migraines than boys. The occurrence of migraines usually goes up during puberty, is most frequent between the ages of 35 and 39, and decreases later in life, especially after menopause.

In terms of prevalence, North America has the most cases of migraines, followed by South America, Central America, Europe, Asia, and then Africa. Across the world, migraines are the second leading cause of disability.

• Migraines are often hereditary. If one parent has a history of migraines, there’s a 40% chance their child will also have them. This risk increases to 75% if both parents have a history of migraines.
• Migraines are one of the top reasons people go to the emergency room, accounting for about 3% of all emergency room visits annually.
• In terms of years lived with a disability, migraines rank second just after back pain.

Signs and Symptoms of Migraine Headache (Migraine)

Migraine is a condition that commonly progresses in 4 stages, each with unique symptoms. Knowing these phases can help in managing the condition better.

The phases are:

• Prodrome: This phase, also known as pre-migraine phase, is triggered by hypothalamic activation (dopamine). Around 77% of patients usually experience signs like frequent yawning, mood changes, neck stiffness, sensitivity to light and sound, difficulty focusing, feeling cold, cravings, sweating, high energy, thirst, and swelling. These symptoms can appear about 24 to 48 hours before the headache starts and appear more frequently in women than men.
• Aura: Aura phase involves changes in cortical function, blood circulation, and neurovascular integration and occurs in approximately 25% of migraines. Auras can be experienced before a headache or during a headache and are often visual like bright lines or shapes, tinnitus, noises, or rhythmic movements. Other auras signify a lack or loss of function like reduced or lost vision, hearing, sensation or movement. Importantly, auras should be reversible by definition. Sometimes, there might be unusual tingling sensations on one side of the face or a limb too.
• Headache: This phase involves intense headaches which are usually one-sided and can be throbbing or pulsating, steadily increasing in intensity for the first few hours. Associated symptoms can include nausea, vomiting, sensitivity to light and sound (photophobia, phonophobia), runny nose, tearing, pain response to otherwise non-painful stimuli (allodynia), and sensitivity to smells (osmophobia). This phase can last from a few hours to a few days and the patient might seek relief in a dark room. Usually, sleep helps ease the pain.
• Postdrome: This phase occurs after the headache ends. This may involve symptoms like exhaustion, dizziness, difficulty concentrating, and euphoria along with lingering pain, particularly with movement, at the original headache site.

Testing for Migraine Headache (Migraine)

To diagnose a migraine, your doctor will consider numerous factors. Firstly, he or she will go through your personal history, conduct a physical exam, and see if you match the criteria specifically established for migraines. Your age, sex, race, and profession are also noted down and considered during the diagnosis.

Your doctor will likely ask you certain straightforward questions about your headache, such as: when did it start? Where does it hurt and how intense is the pain? What does the pain feel like? How long does the pain last and when does it typically occur? Has the pain changed since it first started? How often do you get these headaches and what usually triggers them? Do you experience any other symptoms at the same time? Is the headache related to sleep? What makes it better or worse? What medication do you use to alleviate the pain and how often do you take it? It’s important to answer these questions as accurately as possible to help your doctor make the correct diagnosis.

You will also be asked if you’re experiencing any sensory disturbances, such as temporary numbness or a tingling feeling on one side of your face or arm, or any disruptions in speech or thinking. Some of these symptoms might indicate rarer types of migraines involving symptoms like muscle weakness, difficulty speaking, hearing loss, double vision, lack of coordination, dizziness, ringing in the ears, or a decreased level of consciousness.

To diagnose migraines, your doctor uses guidelines known as the International Classification of Headache Disorders (ICHD-3). For instance, a migraine without aura – the most common type, which doesn’t involve sensory disturbances preceding the headache – is generally characterized by headaches lasting between 4 to 72 hours, which have a throbbing quality, cause moderate to severe pain (usually on one side of the head), and are either made worse by, or cause avoidance of, physical activity. During these headaches, the person often also experiences nausea, vomiting, and sensitivity to light and sound.

Migraine with aura, on the other hand, which involves various sensory disturbances preceding the headache, is characterized by one or more fully reversible aura symptoms, which include visual symptoms, sensory disturbances, speech or language difficulties, motor (muscle) weakness, issues with brainstem function, and symptoms in the retina of the eye.

If you suffer from headaches 8 or more days per month for more than 3 months that meet the above-mentioned criteria, then you may be diagnosed with chronic migraines.

In some cases, your doctor may recommend neuroimaging tests like a CT scan, MRI, MRA or MRV to help diagnose your condition. These tests are generally recommended if you have a severe and sudden headache, especially if it’s the worst headache of your life or the first of its kind; if you have a sudden change in your usual headache pattern; if your headache persists for over 72 hours; if new symptoms appear that indicate a serious condition like meningitis or a stroke; or if your headache does not respond to treatment.

Your doctor may also perform these tests based on a useful acronym: “SNOOP”. It covers Systemic symptoms or risk factors, Neurological symptoms or signs, Onset that is sudden or severe, Older age (over 50), and Pattern changes or Postural triggers. Any of these factors can indicate a need to perform neuroimaging tests to identify the underlying cause of your headaches.

It’s worth noting that in most cases, a spinal fluid analysis and EEG (a test that measures the electrical activity of your brain) are not performed unless there are concerns about seizures or infection.

Treatment Options for Migraine Headache (Migraine)

Treating migraine headaches involves a variety of methods to alleviate symptoms, prevent attacks, and improve patients’ general quality of life. This approach often combines immediate treatments during attacks, preventive strategies to reduce the intensity and frequency of migraines, and personalized lifestyle changes that address individual triggers and patients’ needs.

Immediate Relief Treatments

The goal of immediate relief treatments is to stop the progression of a migraine headache. The treatment typically involves taking a single dose of a potent medication as quickly as possible. Oral medications might not be effective for patients experiencing issues with their digestive system caused by the migraine. Therefore, for some patients, medication is directly administered into the body using a method other than swallowing, especially for those suffering from nausea or vomiting. Various types of medications can be used, such as:

– Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, diclofenac, aspirin, or acetaminophen.
– Triptans, which can alleviate pain and sensitivity.
– Anti-nausea medications such as metoclopramide, chlorpromazine, or prochlorperazine can be used along with NSAIDs or triptans to reduce nausea and vomiting.
– Calcitonin gene-related peptide antagonists which can be considered for patients who do not respond to other treatments.
– FDA-approved tablets like lasmiditan for patients who cannot use triptans due to risks associated with heart disease.
– Ergots such as ergotamine and dihydroergotamine are also recommended for severe migraines.
– Dexamethasone, although it does not provide immediate relief, can reduce the recurrence of early headaches.

Preventive Treatments

The goal of preventive treatment is to reduce the frequency of migraines, improve responsiveness to treatments, reduce the severity and duration of attacks, and alleviate disability. Patients may use strategies like:

– Documenting their migraine triggers to effectively reduce their future impact.
– Using drugs like beta blockers, antidepressants, anticonvulsants, calcium channel blockers, CGRP antagonists, and botulin toxin to reduce the frequency of migraines.

Alternative Treatments

Lastly, incorporating lifestyle changes such as regular exercise, yoga, relaxation training, cognitive-behavioral therapy, biofeedback, reducing triggers, detoxification, using the herb butterbur and the hormone melatonin can also be included to improve quality of life in patients suffering from migraine headaches.

What else can Migraine Headache (Migraine) be?

Properly figuring out if someone has a migraine involves making sure it’s not a different kind of headache or a different brain-related issue. Doctors have to think about a lot of different things and look for signs that might mean it’s a different disorder. Doing this carefully helps make sure patients get the treatment that is best suited to their specific issue.

When a doctor thinks a patient might have a migraine, they also have to think about whether it could be the following conditions:

• Tension-type headache
• Cluster headache
• Brain aneurysms
• Chronic paroxysmal hemicrania, a rare type of headache
• Dissection syndromes, when a tear happens in the wall of a blood vessel leading to the brain
• Encephalitis, a brain inflammation
• Subarachnoid or intracranial hemorrhage, bleeding into or around the brain
• Meningitis, which is an infection of the membranes surrounding the brain and spinal cord
• Temporal/giant cell arteritis, an inflammation of the arteries

Tension-type headaches are often felt on both sides of the head, can last anywhere from half an hour to 7 days and can feel like a pressure or tightness. Despite the pain, people can often still go about their day-to-day activities and don’t typically have any other symptoms.

Cluster headaches usually show up as a sudden, severe pain around the eye or the temple on one side of the head. They quickly become extremely painful and don’t stop, lasting anywhere from 15 minutes to 3 hours. Other signs might include teary or red eyes, a stuffed or runny nose, pale skin, sweating, a droopy eyelid and small pupil on one side (a condition known as Horner’s syndrome), nervousness, and specific neurological symptoms. Drinking alcohol can often trigger these headaches.

What to expect with Migraine Headache (Migraine)

The way migraines affect people can vary a lot. However, with the right treatment, many people can experience significant relief and better quality of life. Although migraines are a long-term condition with no definite cure, significant improvements in treatment, including preventive medicine and lifestyle changes, can drastically lessen the frequency and intensity of migraine attacks.

It’s important to diagnose migraines early and start treatment right away. This allows healthcare providers to create a personalized treatment plan to prevent migraines from becoming chronic (long-lasting). Between 26% to 70% of patients with chronic migraines can revert to having them only occasionally. Extended periods of freedom from migraines are not uncommon, but some people may go back and forth between experiencing migraines every now and then and having them frequently.

Migraines usually become less severe and less frequent as people get older. The number of attacks tends to increase during puberty and continues climbing until around the ages of 35 to 39. After this point, the number of attacks usually decreases, especially after menopause. However, while some people may experience fewer migraines as they age, others may continue to have them regularly. In general, continuous medical care and education is important for managing migraines effectively and improving long-term health outcomes.

Possible Complications When Diagnosed with Migraine Headache (Migraine)

Migraine headaches can cause various problems that significantly change the lifestyle of the person suffering from them. It is crucial for doctors and other healthcare professionals to recognize these potential issues in order to provide effective treatment and minimize long-term health effects.

Here are some of the complications related to migraine headaches:

• Status migrainosus: A severe migraine attack that lasts more than 72 hours
• Migrainous infarction: A rare type of stroke related to migraines
• Migraine aura-triggered seizure: A type of seizure linked to the aura phase of migraines
• Persistent aura without infarction: An ongoing ‘aura’ phase without leading to a stroke
• Work disability and loss of productivity: Often, due to the debilitating nature of migraines

Preventing Migraine Headache (Migraine)

It’s crucial to diagnose and treat migraines quickly, as they can severely affect a person’s quality of life. Teaching patients about their condition is an important part of helping them manage their migraines. Patients need to understand the different stages of migraines and the benefits of using treatments to either stop a migraine that’s already started (abortive therapies) or prevent future migraines from happening (preventive therapies).

Patients should also be encouraged to make certain lifestyle changes. Regular exercise, drinking enough water, and learning relaxation techniques can all help reduce how often and how severe migraines are. Keeping a diary of when headaches happen can help spot patterns and triggers that make migraines more likely.

Finally, it’s important for patients to know they should reach out to a medical professional if their symptoms get worse or if they start experiencing new symptoms that affect their nervous system (neurological symptoms). In these cases, a type of medical scan (neuroimaging) might be needed.