Migraine

Migraine is a common neurological condition characterized by recurrent, moderate to severe headaches, often accompanied by throbbing pain on one side of the head. Unlike typical headaches, migraines often come with other symptoms such as nausea, vomiting, and extreme sensitivity to light (photophobia) and sound (phonophobia). Migraine attacks can be debilitating, lasting from a few hours to several days, and significantly impact a person’s daily life. While the exact cause is not fully understood, it’s believed to involve complex interactions between the brain, nerves, and blood vessels.

Causes:

The precise cause of migraines is complex and likely involves genetic predisposition combined with environmental and lifestyle triggers. It’s thought to be due to abnormal brain activity affecting nerve signals, chemicals, and blood vessels in the brain.

• Genetics: Migraines, especially those with aura, often run in families, suggesting a strong genetic component.
• Brain Chemistry: Changes in brain chemicals, particularly serotonin, which helps regulate pain, can play a role. A drop in serotonin levels may trigger migraine symptoms.
• Brain Regions Involved: Areas like the trigeminal nerve and the brainstem are thought to be involved in the pain pathways.
• Triggers (often individual-specific):
  • Hormonal Changes in Women: Fluctuations in estrogen (before or during menstrual periods, during pregnancy, or around menopause) are common triggers.
  • Stress: High stress or even the “let-down” period after stress can trigger migraines.
  • Certain Foods and Drinks: Aged cheeses, processed meats, chocolate, caffeine withdrawal, alcohol (especially red wine), and artificial sweeteners.
  • Skipping Meals: Can lead to low blood sugar, a migraine trigger.
  • Sensory Stimuli: Bright or flickering lights, loud noises, strong smells (perfume, smoke, certain foods).
  • Changes in Sleep Pattern: Both too little and too much sleep can trigger migraines.
  • Physical Exertion: Intense exercise or prolonged physical activity can sometimes trigger an attack.
  • Weather Changes: Barometric pressure changes, strong winds, or storms.
  • Medication Overuse: Overuse of pain relievers can lead to medication overuse headaches, which can mimic or worsen migraines.

Symptoms:

Migraine symptoms can occur in several stages, though not everyone experiences all stages or all symptoms. The main stages are prodrome, aura, attack, and postdrome.

• Prodrome (Warning Stage – 1 to 2 days before):
  • Constipation.
  • Mood changes (from depression to euphoria).
  • Food cravings.
  • Neck stiffness.
  • Increased urination.
  • Frequent yawning.
• Aura (Occurs in 20-30% of people, just before or during the headache):
  • Visual Aura: Flashing lights, zig-zag lines, blind spots, shimmering lights (most common).
  • Sensory Aura: Numbness or tingling in an arm or leg, or on one side of the face.
  • Verbal/Language Aura: Difficulty speaking or finding words.
  • Motor Aura: Weakness on one side of the body (rare, indicates hemiplegic migraine).
• Attack (Headache Phase – 4 to 72 hours without treatment):
  • Moderate to Severe Pain: Often throbbing or pulsing.
  • Unilateral Pain: Usually on one side of the head, but can be bilateral.
  • Nausea and Vomiting.
  • Photophobia: Increased sensitivity to light.
  • Phonophobia: Increased sensitivity to sound.
  • Osmophobia: Increased sensitivity to smells.
  • Worsened by physical activity.
• Postdrome (After the Attack – lasts 24-48 hours):
  • Fatigue, drained feeling.
  • Confusion.
  • Mood changes.
  • Muscle weakness.
  • Head pain may recur with sudden head movement.

Diagnosis:

Diagnosis of migraine is based on a detailed medical history, physical and neurological examination, and the characteristic pattern of symptoms. There are no specific lab tests or imaging studies that definitively diagnose migraine.

• Medical History:
  • The doctor will ask detailed questions about your headaches, including frequency, severity, location, type of pain, accompanying symptoms (nausea, sensitivity), and any triggers.
  • Family history of migraines.
  • Impact on daily life.
• Physical and Neurological Exam: To rule out other conditions that could cause similar symptoms (e.g., tumors, strokes, or other neurological disorders). This involves checking reflexes, sensation, vision, and coordination.
• Imaging Tests (not for routine diagnosis of migraine, but to rule out other conditions):
  • CT Scan (Computed Tomography) or MRI (Magnetic Resonance Imaging): May be performed if symptoms are unusual, severe, or suggest other neurological problems, such as a tumor, stroke, or bleeding in the brain.
• Keeping a Headache Diary: Can be very helpful for both diagnosis and identifying triggers. Patients record details of each headache episode.

Treatment:

Migraine treatment involves two main approaches: acute (abortive) treatments to relieve symptoms during an attack and preventive treatments to reduce the frequency and severity of attacks.

• Acute (Abortive) Treatments (taken at the first sign of a migraine):
  • Over-the-Counter Pain Relievers: (e.g., ibuprofen, naproxen, acetaminophen, aspirin). Effective for mild to moderate migraines.
  • Triptans: (e.g., sumatriptan – Imitrex, zolmitriptan – Zomig). Specific migraine drugs that constrict blood vessels and block pain pathways in the brain. Highly effective for many.
  • CGRP Receptor Antagonists (Gepants): (e.g., ubrogepant – Ubrelvy, rimegepant – Nurtec ODT). Newer oral medications that block the CGRP protein, involved in migraine pain.
  • Ditans: (e.g., lasmiditan – Reyvow). Targets serotonin receptors different from triptans; does not cause vasoconstriction.
  • Ergots: (e.g., ergotamine with caffeine – Cafergot). Older class of drugs, less commonly used due to side effects.
  • Anti-Nausea Medications: (e.g., prochlorperazine, metoclopramide) To relieve nausea and vomiting.
• Preventive (Prophylactic) Treatments (taken regularly to reduce frequency/severity):
  • Beta-Blockers: (e.g., propranolol, metoprolol). Commonly used for high blood pressure or heart conditions, but also effective for migraine prevention.
  • Antidepressants: (e.g., amitriptyline, venlafaxine). Tricyclic antidepressants and SNRIs can help prevent migraines.
  • Anticonvulsants: (e.g., topiramate – Topamax, valproic acid). Used for epilepsy but also effective for migraine prevention.
  • CGRP Inhibitors (Monoclonal Antibodies): (e.g., erenumab – Aimovig, fremanezumab – Ajovy, galcanezumab – Emgality, eptinezumab – Vyepti). Newer injectable medications that target CGRP or its receptor to prevent migraines.
  • Botulinum Toxin (Botox) Injections: For chronic migraine (15 or more headache days per month), injections into specific head and neck muscles can help prevent attacks.
  • Blood Pressure Medications (e.g., candesartan): Can be used for prevention.
• Lifestyle Management:
  • Identify and Avoid Triggers: Keeping a headache diary is crucial.
  • Stress Management: Relaxation techniques, yoga, meditation.
  • Regular Sleep Schedule: Consistent bedtime and wake-up times.
  • Regular Meals: Avoid skipping meals.
  • Regular Exercise: Moderate, consistent physical activity.
  • Biofeedback: Learning to control certain body responses to reduce tension.

Effective migraine management often involves a combination of these approaches, tailored to the individual’s specific needs, in consultation with a healthcare professional.