Migraine headaches

DEFINITION: Chronic, severe, and throbbing neurovascular headaches

Causes and Symptoms

Migraine is the name given to a particularly severe, chronic, and painful headache that occurs often on one side but sometimes on both sides of the head, usually just behind or above one or both eyes. Until the early twenty-first century, migraines were medically described as headaches resulting from the of blood vessels that supply nervous tissue in the brain. Further research indicated that the primary source of migraines may be neurological rather than vascular. It appears that messages that control the size of blood vessels in the are interrupted as a result of chemical changes in the brain. The dilated vessels become swollen and press on adjacent nerves, neurons, and other brain tissue, which, in turn, become irritated and inflamed. The result is a throbbing headache that is often debilitating.

Many people throughout the world suffer from migraines, although the actual number may be even higher, as many cases remain undiagnosed or are mistaken for sinus or bouts of colds or influenza. According to the World Health Organization, migraines are more common in women than in men, potentially because of the influence of hormones. Many women experiencing migraines have more headaches near or during their menstrual cycle; these are referred to as menstrual migraines. The peak incidence of migraines occurs between the ages of thirty-five and forty-five, but they also occur in some children and older people. The incidence of migraine headaches has increased in all age groups, and according to the WHO, headache disorders, of which migraines is one type, affected more than three billion people worldwide as of 2021. Some medical research has linked certain genes to migraines, indicating that the source might be genetic.

Several distinct types of migraine headaches are recognized by the International Headache Society. They can be grouped broadly into three categories: those that are preceded by a warning aura, those that are not preceded by an aura, and atypical migraines.

Migraine symptoms often vary greatly from patient to patient and sometimes from one migraine episode to another. Warning aura symptoms typically occur within an hour of migraine onset and may include to bright lights and sound, especially flashing lights, strobe lights, and laser lights. Some people are disturbed by loud or unexpected noise. Other aura symptoms may include hallucinations, hot flashes, tingling of limbs that may extend to the hands and feet, or weakness on one side of the body, and cravings for certain kinds of foods.

Aura symptoms are followed by the onset of migraine headache. In most types of migraines, the pain is concentrated on one side of the head and then may radiate into the face, eyes, and sinuses. As the migraine becomes increasingly severe, nausea, vomiting, and are often manifested, along with increased urination and, sometimes, diarrhea. Some patients report vision problems, including blind spots, sensitivity to bright and flickering lights, double vision, or tunnel vision.

Three types of migraines occur mostly in children: migraine with brain stem aura, hemiplegic migraine, and retinal migraine. Sufferers of hemiplegic migraines sometimes experience temporary on the same side of the head as the migraine pain. Migraine with brain stem aura may last several days, and the pain is centered in the eye and the nerves that control vision. The patient may experience double vision, hearing loss, vertigo, and a bulging, enlarged eye. In both migraine with brain stem aura and retinal migraine, temporary or vision blurring may occur.

Two other atypical types of migraines are complicated, or complex, migraines, in which both symptoms and aura persist for a week or more, and abdominal migraines, in which migraine pain is transferred to the abdominal area. Abdominal migraine is a recurrent disorder that occurs mainly in children. Moderate to severe abdominal pain and may last for up to three days. The source of this type of migraine is unknown. Most children who experience abdominal migraines suffer migraine headaches later in life.

The causes of migraines are varied. Heredity, lifestyle, environmental factors, and changes in hormone levels have all been implicated and probably all contribute to some degree to the onset and severity of migraines. Some specific migraine triggers include lights, weather changes, certain foods, food additives, certain beverages, odors, lack of sleep, loud noises, and stress. In many patients, a single factor may trigger a migraine, while in other patients, several factors may work in tandem, each contributing to the onset of the migraine. It is recommended that migraine victims keep a headache log or diary. This will help to identify individual triggers and narrow down the causes. As much as possible, these triggers should be avoided or limited. A few patients report no obvious triggers that initiate their migraine headaches.

Bright or strong lights, especially when glaring or flickering, are incipient migraine triggers in some patients. In others, the flickering of a television or computer screen or strobe lighting may start a migraine. Changes in weather also initiate migraines, at least in some patients, especially the rapid temperature and humidity changes during the fall/winter and spring/summer transition periods.

Foods that trigger migraines in some patients include dairy products, eggs, red wines and other alcoholic drinks, and caffeinated and carbonated drinks. Preserved foods that contain high levels of nitrates, such as hot dogs or pepperoni, and pickled foods have also been implicated as migraine triggers. Some migraine sufferers also react to foods that contain a high content of specific amino acids, such as tyramine and tyrosine.

Probably the most compelling can be made between the amount of stress in a person’s life and the onset and frequency of migraines. Emotional factors that have been implicated as migraine triggers include frustration, anger, and depression. In addition, emotional stress may exacerbate response to other migraine triggers as well.

Unlike tension headaches, migraines are so frequent and so painful that most patients seek medical attention. Migraines are clinically diagnosed by health-care specialists who employ radiological and to ensure that other factors, such as tumors or , are not the cause of headaches.

Treatment and Therapy

The treatment of migraines falls roughly into two categories: or changes in lifestyle to prevent migraines and various strategies to alleviate the pain and duration of migraines. For many migraine sufferers, taking over-the-counter nonsteroidal (NSAIDs) as needed (such as Advil, Motrin, Aleve, or Excedrin Migraine), drinking plenty of water, and eating regularly spaced meals helps to prevent or minimize the occurrence of migraines.

To prevent the onset of migraines, powerful antidepressants may be prescribed, particularly drugs that shut down terminal nerve receptors, thereby stopping further pain sequences. Most effective are tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor), and protriptyline (Vivactil). They appear to reduce the effect of migraines by changing the level of and other brain chemicals. These medications are considered first-line treatment agents. In some cases, these medical treatments have met with mixed success and have limited effectiveness.

Therapeutic strategies for sufferers of severe migraines employ some of the armamentarium of medically prescribed drugs available, including beta-blockers, barbiturates, ergotamines, triptans, botulinum toxin type A (Botox) injections, serotonin inhibitors, and anticonvulsants. Of these drugs, some of the most powerful are ergotamines, which are derivatives of ergot alkaloids. They are injected into the muscle or vein or placed under the tongue. Ergot-derived drugs are potentially dangerous, however, and should be taken with caution. They should never be taken if the patient is pregnant or has a blood disease. Any medication that constricts blood vessels can be very dangerous if the victim already suffers from narrowing of the blood vessels, such as high or coronary artery disease.

The triptans, including sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig), almotriptan (Axert), naratriptan (Amerge), frovatriptan (Frova), and eletriptan (Relpax), can help to lessen the effects of migraines quickly. The first of the triptans to be used, Imitrex, acts to balance chemicals in the brain by binding to serotonin receptors and causing blood vessels to constrict. The others act similarly. Imitrex can be administered orally, by nasal spray, or by injection. Since triptans are not addictive or barbiturates, migraine pain can be relieved while the victim is still alert and in control. Side effects of triptans can include nausea, dizziness, and muscle weakness. On rare occasions, they can lead to or heart attack. The triptan drugs should not be used with ergotamines or with antidepressants, particularly or , such as Prozac. When used with antidepressants, triptans can produce serotonin syndrome, an excessive release of serotonin, which can result in weakness, tremors, and lack of coordination. A physician should be consulted before mixing any migraine drugs.

Self-care remedies aimed at preventing migraines include stress management, aerobic exercise, yoga, meditation, acupuncture, anger management, fasting, aimed at developing a positive attitude, emotional repair and stabilization, biofeedback, and the use of herbal and flower extracts. Magnesium supplements help some migraine victims.

A few migraine sufferers resort to folk remedies, such as vinegar compresses, warm salt packs, herbal or ice footbaths, or headache tonics. One popular headache tonic consists of fresh ginger root, coriander seeds, diced garlic, and honey. Folk remedies should never be substituted for medical attention.

During and immediately following a migraine, most patients attempt to lessen or alleviate pain with ice packs and aspirin, acetaminophen (Tylenol), or other nonprescription drugs. Many migraine sufferers seek out dark, quiet spaces until the migraine has subsided. Because migraine is such a common medical condition, new treatments constantly remained in development by pharmaceutical companies. Not long after the rise, beginning in the late 2010s, of the use of calcitonin gene-related peptide (CGRP) inhibitors to both treat and prevent migraines, in the early 2020s, the Food and Drug Administration approved Zavzpret, a fast-acting nasal spray for migraine sufferers without aura.

Perspective and Prospects

Although the pain is sometimes debilitating for short periods following attacks, migraines are not life-threatening. Furthermore, there are typically no serious aftereffects of migraine headaches, although the individual is often wan, fatigued, and sometimes confused following a migraine episode. Some medical studies have shown that some migraine sufferers are at increased risk of stroke.

The incidence and intensity of migraine headaches wane with age; most patients report that migraines either disappeared or become infrequent after the age of fifty. Many female patients also report that migraines stopped following menopause.

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