Migraine

What is a migraine?

A migraine is a type of headache that typically involves throbbing pain, sensitivity to light and sounds, nausea and vomiting. Migraines can worsen with normal daily activities and can last anywhere from four hours to three days.

Migraines occur more commonly in women, with about one in five women being affected at some point. In contrast, about one in 20 men are affected. ^[1] The most common age bracket in which migraines occur is 20-50 years of age.

Signs and symptoms

Some of the signs and symptoms that are associated with migraines can include:

• Auras - these are the symptoms that occur before a migraine and include visual disturbances such as flashing lights and blind spots, sensitivity to smell, tingling in the face and hands, weakness in limbs and speech disturbance;
• Sound and light sensitivity;
• Pulsating headache;
• Nausea and vomiting;
• Long-lasting headache (up to 72 hours), and;
• Pain on one or both sides of the head.

Causes

The cause of migraines is complex. Migraines are thought to be caused by an alteration in the blood vessels to the brain. Migraines may also start like other headaches, with a wave of electrical activity spreading across the brain. This electrical activity is thought to give rise to auras. The electrical activity also stimulates the nerve that supplies sensation to the head and neck, known as the trigeminal nerve, causing localized pain. In addition, such activity heightens the sensitivity of nerve cells elsewhere in the brain, causing symptoms such as nausea and vomiting, light and sound sensitivity and pulsing sensation.

There are many different emotional, diet-related and environmental triggers that can start a migraine. Some causes include:

• Tension and stress;
• Tiredness, physical exhaustion, lack of sleep or oversleeping;
• Certain foods (e.g., cheese, chocolate, citrus fruits, tomatoes), food additives (e.g., monosodium glutamate (MSG) and sodium nitrite), certain drinks (e.g., caffeine and wine);
• Hormonal changes (e.g., before or during menstruation, during pregnancy or menopause);
• Head trauma (e.g., sporting injury);
• Bright or flickering lights, excessive noise, strong perfume;
• Dehydration, and;
• Medication (e.g., oral contraceptive pill, vasodilators).

Types

There are two main types of migraine. These relate to the presence or absence of an 'aura' prior to the migraine. An aura occurs 10-30 minutes prior to a migraine and can include seeing flashing lights or blind spots, numbness or tingling in the hands or face, or an altered sense of smell. A migraine with an aura is termed a classic migraine, while migraine without an aura are termed common migraine.

Methods for diagnosis

There is no specific test to diagnose a migraine. Your doctor will ask you questions about your medical history and symptoms that were experienced at the time. They may also ask you when and how often the symptoms occur, to help identify the cause of the migraines. It may also be useful to create a diary of the migraine occurrence. A diary could include the following information:

• The date of the migraine;
• Location of the pain;
• Length of migraine;
• Symptoms experienced;
• When the symptoms occurred, and;
• Suspected triggers.

If your doctor believes that there is something other than a migraine causing your headache, they might recommend blood tests and/or computerized tomography (CT) or magnetic resonance imaging (MRI) scans. It is important to note that the early signs of a stroke can sometimes be similar to those of a migraine, so imaging with CT or MRI can help exclude a stroke.

Types of treatment

There is no cure for migraines, but they can often be well managed. It is possible to adopt a lifestyle that helps to prevent them by identifying and possibly avoiding the various triggers. This could involve avoiding specific foods, reducing tension or stress, or avoiding bright lights or loud music where possible.

Treatment during a migraine

During a migraine, it is best to begin treatment as soon as possible. Treatment steps can include:

• Taking pain-relief medications such as aspirin or acetaminophen;
• Resting in a quiet, dark, cool room;
• Placing cold packs on the forehead or neck, and;
• Staying hydrated by drinking water.

Medications

Acute treatment

If pain-relief medications, including acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin, do not relieve symptoms, other medications may be prescribed by your doctor. These can include triptan medications that cause dilated blood vessels in the brain to constrict, helping to relieve the symptoms of a migraine. Examples of triptans include sumitriptan, zolmitriptan and naratriptan.

Anti-nausea medications can also be used to relieve the nausea associated with migraines. Some examples of anti-nausea medications include domperidone, metoclopramide and prochloperazine.

Preventative treatment

For some people who experience regular migraines (two or more each month), certain medications can be prescribed as a preventative measure. Preventative medication can also be used for people who cannot take or do not respond to medication used for acute treatment. These medications can help prevent the frequency or severity of migraines. Each medication works slightly differently to help prevent migraines, so your doctor will prescribe one that is right for you. Some medications can include:

• Beta-blockers including propranolol and metoprolol;
• Serotonin antagonists including pizotifen;
• Antiepileptic medications including topiramate, and;
• Ergot derivatives including methysergide.

Potential complications

Some complications associated with migraines can include:

• Abdominal problems from prolonged use of NSAIDs. This can lead to the formation of stomach ulcers and abdominal bleeding;
• Medication overuse - headaches can occur when too much headache medication, such as codeine, is used. These can occur when medication stops relieving pain and actually causes a headache (rebound headache);
• A condition called serotonin syndrome, which can also occur in people taking triptans. It occurs when your body has too much serotonin and is a rare but life-threatening condition. Certain medications should be avoided while taking triptans. Always check with your doctor or pharmacist when taking new tablets;
• Status migrainosus, a complication in which a migraine remains for three or more days;
• Chronic migraine, a complication in which migraine has been present for more than 15 days each month for more than three months, and;
• Persistent auras that last from one hour up to one week. This can also be a symptom of bleeding in the brain (stroke) and is important to be evaluated by your doctor.

Prognosis

Migraines are a common condition that affect one in five women and one in 20 men. There is no cure to stop them from ever happening again, but you can limit their occurrence by recognizing specific triggers and avoiding them.

If a migraine does start to occur, it is best to act quickly to reduce the severity of symptoms. This can include taking pain-relief medication and resting in a cool, dark room. For people that experience migraines often, preventative medication is possible to reduce the likelihood and severity of developing migraines.

Prevention

To help prevent migraines, some lifestyle changes can be made. This can include eating a healthy diet and exercising regularly. It is important to identify and avoid any trigger factors that cause your migraines such as tension and stress, fatigue, physical exhaustion and certain foods or drinks including cheese, chocolate and red wine. Some people benefit from relaxation or meditation techniques to help prevent migraines. There is sufficient evidence to suggest that acupuncture is effective for both acute treatment and preventative treatment of migraines, often with fewer side effects. If migraines occur frequently, specific medication can be prescribed by your doctor to help prevent their occurrence.

References

1. Murtagh John. MD. (2011) John Murtagh's General Practice (5th revised edition). North Ryde N.S.W.: McGraw-Hill Publishing.
2. Migraine. Accessed August 12 2014. link here
3. Migraine - The Migraine Trust UKs Leading Migraine Charity. Accessed August 12 2014. link here
4. Migraine Headaches in Adults. Accessed August 12 2014. link here
5. Murtagh John. Murtaghs Patient Education. Australian ed of 6th revised ed edition. North Ryde N.S.W.: McGraw-Hill Australia 2012.
6. Murtagh John MD. John Murtaghs General Practice. 5th Revised edition edition. North Ryde N.S.W.: McGraw-Hill Medical Publishing 2011.
7. Search - AMH. Accessed August 12 2014. link here
8. Stroke and Migraine | The Migraine Trust. Accessed August 12 2014. link here

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