Migraine
(Important-Before labeling the headache as Migraine, one should rule out any ENT causes, eye pathology, Dental causes or any Neurological problems presenting as headache.)
Migraine headache is a severe pain felt on one, and sometimes, both sides of the head. Migraine headache is a form of vascular headache.
The pain is mostly in the front around the temples or behind one eye or ear. Besides pain, you may have nausea and vomiting, and be very sensitive to light and sound.
During a migraine attack, the temporal artery enlarges. Enlargement of the temporal artery stretches the nerves that coil around the artery and causes the nerves to release chemicals. The chemicals cause inflammation, pain, and further enlargement of the artery. The increasing enlargement of the artery magnifies the pain.
What triggers migraine?
and lack of food or sleep
and bright light or loud noise
and hormone changes during the menstrual cycle
and stress and anxiety
and weather changes
and chocolate, alcohol, or nicotine
and some foods and food additives, such as MSG or nitrates
Types of Migraine?
Classic migraine
With a classic migraine, a person has these visual symptoms also called an “aura”, 10 to 30 minutes before an attack, sees flashing lights or zigzag lines and may have blind spots or loses vision for a short time
The aura can include seeing or hearing strange things. It can even disturb the senses of smell, taste, or touch. Women have this form of migraine less often than men.
Common migraine.
With a common migraine, a person does not have an aura, but does have the other migraine symptoms, such as nausea and vomiting.
How is a migraine headache diagnosed?
Migraine headaches are usually diagnosed when the symptoms described above are present.. A family history is usually present, suggesting a genetic predisposition in migraine sufferers.
Patients with the first headache ever, worst headache ever, or where there is a significant change in headache or the presence of nervous system symptoms, like visual or hearing or sensory loss, may require additional tests. The tests may include blood testing, brain scanning as MRI or CT scan
Migraine headache and Tension headache
Tension headaches cause a more steady pain over the entire head rather than throbbing pain in one spot. Most of the time, migraine attacks happen once in awhile, but tension headaches can occur as often as every day. While fatigue and stress can bring on both tension and migraine headaches, migraines can be triggered by certain foods, changes in the body’s hormone levels, and even changes in the weather.
Women get it more than men
Yes, migraine headaches are more common in women. In fact, about three out of four people who have migraines are women. Women also tend to report higher levels of pain, longer headache time, and more symptoms, such as nausea and vomiting.
Female hormones and migraine
Hormones may also trigger migraine. Some women who suffer from migraine headaches experience more headaches around the time of their menstrual periods. Other women experience migraine headaches only during the menstrual period. The term “menstrual migraine” is used mainly to describe migraines that occur in women who have almost all of their headaches from two days before to one day after their menstrual periods. Declining levels of estrogen at the onset of menses is likely to be the cause of menstrual migraines. Decreasing levels of estrogen also may be the cause of migraine headaches that develop among users of birth control pills during the week that estrogens are not taken.
Stress can cause migraine
Yes, stress is the most common trigger of headache.
Some things you can do to help prevent or reduce stress include doing relaxation exercises, Yoga and getting enough sleep
How is migraine headaches prevented ?
There are two ways to prevent migraine headaches: 1) by avoiding factors “triggers” that cause the headaches, and 2) by preventing headaches with medications (prophylactic medications).
What are migraine triggers?
Examples of triggers include stress, sleep disturbances, fasting, hormones, bright or flickering lights, odors, cigarette smoke, alcohol, aged cheeses, chocolate, monosodium glutamate, nitrites, aspartame, and caffeine.
For some women, the decline in the blood level of estrogen during the onset of menstruation is a trigger for migraine headaches.
Sleep and migraine
Disturbances such as sleep deprivation, too much sleep, poor quality of sleep, and frequent awakening at night are associated with both migraine and tension headaches, whereas improved sleep habits have been shown to reduce the frequency of migraine headaches. Sleep also has been reported to shorten the duration of migraine headaches.
Fasting and migraine
Fasting possibly may precipitate migraine headaches by causing the release of stress-related hormones and lowering blood sugar. Therefore, migraine sufferers should avoid prolonged fasting.
Bright lights and migraine
Bright lights and other high intensity visual stimuli can cause headaches in healthy subjects as well as patients with migraine headaches, but migraine patients seem to have a lower than normal threshold for light-induced pain. Sunlight, television, and flashing lights all have been reported to precipitate migraine headaches.
Caffeine and migraine
Caffeine is contained in many food products (cola, tea, chocolates, and coffee) and OTC analgesics. Caffeine in low doses can increase alertness and energy, but caffeine in high doses can cause insomnia, irritability, anxiety, and headaches. The over-use of caffeine-containing analgesics causes rebound headaches. Furthermore, individuals who consume high levels of caffeine regularly are more prone to develop withdrawal headaches when caffeine is stopped abruptly.
Chocolate, wine, tyramine, MSG, nitrites, aspartame and migraine
Chocolate has been reported to cause migraine headaches, but scientific studies have not consistently demonstrated an association between chocolate consumption and headaches. Red wine has been shown to cause migraine headaches in some migraine sufferers, but it is not clear whether white wine also will cause migraine headaches. Tyramine (a chemical found in cheese, wine, beer, dry sausage, and sauerkraut) can precipitate migraine headaches, but there is no evidence that consuming a low-tyramine diet can reduce migraine frequency. Monosodium glutamate (MSG) has been reported to cause headaches, facial flushing, sweating, and palpitations when consumed in high doses on an empty stomach. Nitrates and nitrites (chemicals found in hotdogs, ham, frankfurters, bacon and sausages) have been reported to cause migraine headaches. Aspartame, a sugar-substitute sweetener found in diet drinks and snacks, has been reported to trigger headaches when used in high doses for prolonged periods.
Treatment of Migraine
Life style changes for migraine
Preventing migraine takes motivation for the patient to make some life changes. Patients are educated as to triggering factors that can be avoided. These include smoking cessation, avoiding certain foods especially those high in tyramine or those containing sulphites or nitrates .
Generally, leading a healthy life style with good nutrition, adequate water intake, sufficient sleep and exercise may be useful..
What should migraine sufferers do?
Individuals with mild and infrequent migraine headaches that do not cause disability may require only OTC analgesics. Individuals who experience several moderate or severe migraine headaches per month or whose headaches do not respond readily to medications should avoid triggers and consider modifications of their life-style. Life-style modifications for migraine sufferers include: Go to sleep and waking up at the same time each day.
Exercise regularly (daily if possible). Make a commitment to exercise even when traveling or during busy periods at work. Exercise can improve the quality of sleep and reduce the frequency and severity of migraine headaches. Build up your exercise level gradually. Over-exertion, especially for someone who is out of shape, can lead to migraine headaches.
Do not skip meals, and avoiding prolonged fasting. Limit stress through regular exercise and relaxation techniques. Limit caffeine consumption to less than two caffeine-containing beverages a day. Avoid bright or flashing lights and wearing sunglasses if sunlight is a trigger.
Identify and avoid foods that trigger headaches by keeping a headache and food diary. Review the diary with your doctor. It is impractical to adopt a diet that avoids all known migraine triggers; however, it is reasonable to avoid foods that consistently trigger migraine headaches.
Medications
There are two ways to approach the treatment of migraine headache with drugs:
1-prevent the attacks
2-relieve the symptoms during the attacks.
Medication therapies for migraine-
Pain relievers (analgesics).Paracetamol, NSAIDs-ibuprofen, naproxen etc
Many OTC analgesics are available. OTC analgesics have been shown to be safe and effective for short-term relief of headache
NSAIDs relieve pain by reducing the inflammation that causes the pain (They are called non-steroidal anti-inflammatory drugs.
Aspirin, acetaminophen, and caffeine also are available combined in OTC analgesics for the treatment of headaches.
Finding an effective analgesic or analgesic combination often is a process of trial and error because individuals respond differently to different analgesics.
Precautions with OTC analgesics-
Children and teenagers should not use aspirin for the treatment of headaches, other pain, or fever, because of the risk of developing Reye’s syndrome, a life-threatening neurological disease that can lead to coma and even death.
Patients with balance disorders or hearing difficulties should avoid using aspirin because aspirin may aggravate these conditions.
Patients with active ulcers of the stomach and duodenum should not take aspirin and non-aspirin NSAIDs because they can increase the risk of bleeding from the ulcer and impair healing of the ulcer.
Patients with advanced liver disease should not take aspirin and non-aspirin NSAIDs because they may impair kidney function. Deterioration of kidney function in these patients can lead to rapid and life-threatening deterioration of their liver disease.
Patients should not overuse OTC or prescription analgesics. Overuse of analgesics can lead to the development of tolerance (increasing ineffectiveness of the analgesic) and rebound headaches (return of the headache as soon as the effect of the analgesic wears off, usually in the early morning hours). Thus, overuse of analgesics can lead to a vicious cycle of more and more analgesics for headaches that respond less and less to treatment and occur more frequently.
What is the treatment for moderate to severe migraine headaches?
Sumatriptans
The triptans attach to serotonin receptors on the blood vessels and nerves and thereby reduce inflammation and constrict the blood vessels. This stops the headache. The triptan with the longest history of use is sumatriptan .Sumatriptan is available as an injection, oral tablet, and nasal spray.
Side effects of Sumatriptans
The most common side effects of triptans are facial flushing, tingling of the skin, and a sense of tightness around the chest and throat. Other less common side effects include drowsiness, fatigue, and dizziness. These side effects are short-lived and are not considered serious. Men complaints of temporary impotency while taking the drugs.
Triptans should not be given to patients who have had heart attacks and strokes, or to patients who have symptoms of atherosclerosis such as angina, transient ischemic attack (TIAs) and intermittent claudication.
Triptans should not be used in pregnant women and are not generally used in young children.
Ergots
Ergots, like triptans, are medications that abort migraine headaches. Examples of ergots include ergotamine preparations like Cafergot and dihydroergotamine preparations Migranil. Ergots, like triptans, cause constriction of blood vessels, but ergots tend to cause more constriction of vessels in the heart and other parts of the body than the triptans, and their effects on the heart are more prolonged than the triptans. Therefore, they are not as safe as the triptans. The ergots also are more prone to cause nausea and vomiting than the triptans. The ergots can cause prolonged contraction of the uterus and miscarriages in pregnant women.
What other medications are used for treating migraine headaches?
Narcotics are used to treat migraine headaches; however, these medications are potentially addicting and are not used as initial treatment.
In patients with severe nausea, a combination of a triptan and an anti-nausea medication, for example, prochlorperazine or metoclopramide may be used. When nausea is severe enough that oral medications are impractical, intravenous medications such as prochlorperazine and valproate are useful.
What are prophylactic medications for migraine headaches?
Prophylactic medications are medications taken daily to reduce the frequency and duration of migraine headaches. They are not taken once a headache has begun. There are several classes of prophylactic medications: beta blockers, calcium-channel blockers, tricyclic antidepressants, antiserotonin agents and anticonvulsants. Medications with the longest history of use are propranolol (Inderal), a beta blocker, and amitriptyline, an antidepressant. When choosing a prophylactic medication for a patient the doctor must take into account the drug side effects, drug-drug interactions, and co-existing conditions such as diabetes, heart disease, and high blood pressure.
Beta blockers
Beta-blockers are a class of drugs that block the effects of beta-adrenergic substances such as adrenaline (epinephrine). By blocking the effects of adrenaline, beta-blockers relieve stress on the heart by slowing the rate at which the heart beats. Beta-blockers have been used to treat high blood pressure, angina, certain types or tremors, stage fright, and abnormally fast heart beats. Beta-blockers have been used for many years to prevent migraine headaches.
It is not known how beta-blockers prevent migraine headaches. It may be by decreasing prostaglandin production, though it also may be through their effect on serotonin or a direct effect on arteries. The beta-blockers used in preventing migraine headaches include propranolol (Inderal), atenolol (Tenormin) etc
Beta-blockers generally are well-tolerated. They can aggravate breathing difficulties in patients with asthma, chronic bronchitis, or emphysema. In patients who already have slow heart rates (bradycardias) and heart block (defects in electrical conduction within the heart), beta-blockers can cause dangerously slow heartbeats. Beta-blockers can aggravate symptoms of heart failure. Other side effects include drowsiness, diarrhea, constipation, fatigue, decrease in endurance, insomnia, nausea, depression, dreaming, memory loss, impotence..
Tricyclic antidepressants
Tricyclic antidepressants (TCAs) prevent migraine headaches by altering the neurotransmitters, norepinephrine and serotonin, that the nerves of the brain use to communicate with one another. The tricyclic antidepressants that have been used in preventing migraine headaches like amitriptyline.
The most commonly encountered side effects associated with TCAs are fast heart rate, blurred vision, difficulty urinating, dry mouth, constipation, weight gain or loss, and low blood pressure when standing.
