Treatment of Migraine

Migraine episodes usually start at 20 to 30 years of age, but headache episodes may develop in childhood or adolescence. A migraine episode may have four phases: Prodrome, aura, headache and postdrome. One does not have to go through all phases in each migraine episode.

Prodrome

Patients may recognize minor alarming changes one or two days before headaches begin:

• Constipation
• Mood swings, pessimism, restlessness
• Food craving
• Neck stiffness
• Sensation of dehydration and frequent urination
• Frequent yawning

Aura

Most patients experience aura-free episodes. Neurologic deficit is likely before or after headache in patients with aura. Migraine episodes with aura may lead to problems, including but not limited to weak tactile sensation, speech disorder, visual impairment, numbness or tingling.

Episode

An untreated migraine episode may last 4 to 72 hours, although interpersonal changes apply. Episodes may occur rarely or several times per month or week. Patients may experience throbbing (a sense of heartbeat at pain site), nausea and vomiting, photosensitivity, phonosensitivity and even sensitivity provoked by tactile sensation, blurred vision, dizziness and fainting in some cases during a migraine episode.

Postdrome (after the episode)

The patient may feel fatigued, exhausted and slightly relieved in postdrome phase (after the episode). Weakness, dizziness, restlessness and photo- and phono-sensitivity may be experienced within 24 hours after the episode.

When Should You See a Neurologist?

Since patients prefer to control headache with pain killers on their own discretion rather than seeing a neurologist, awareness on migraine is poor and therefore, the condition may be left untreated.

It would be best to record regular migraine episodes and symptoms, if you have them. If you think episodes and severity of your headache have changed, you should see a neurologist as soon as possible.

You should urgently see a physician, if any of the following symptoms has developed;

• Sudden and severe headaches like thunder.
• Fever, neck stiffness, confusion, double vision, numbness or impaired speech
• Worsened headache, especially following a head trauma
• Onset of headache following cough, exercise, sprain or sudden movements
• Recently-onset headache after 50 years of age,

Causes of Migraine

Genetic or environmental factors are known to play a role in migraine, although the exact cause is not yet known. Imbalance of chemicals in brain, including serotonin, is thought to cause the episodes.

Certain chemicals that trigger pain in membranes of brain (meninx) are secreted in migraine episodes, resulting in development of migraine-type headache. Calcitonin Gene Related Peptide (CGRP) is one of the crucial chemical mediators that play a role in migraine headache.

Triggers of Migraine

There are several elements which may trigger migraine episodes:

• Hormonal fluctuations in women facilitate onset of migraine episodes. Fluctuating estrogen may trigger headache in many women. Women with medical history of migraine may suffer from headache when estrogen level decreases before or after menstrual cycle. Pregnancy or pre-menopausal period may not only lead to onset of migraine, but it may also change the course of existing migraine episodes.
• Hormonal medications such as oral contraceptives and hormone replacement medication may worsen the course of migraine.
• Certain foods, such as aged cheese, salty or processed food, may trigger migraine. Aspartame, an artificial sweetener, and monosodium glutamate, a food preservative, which are found in many foods, are known to trigger migraine.
• Change in dietary habits, e.g. skipping meals or overeating, may facilitate development of migraine episodes.
• Migraine can also be triggered by beverages, including alcohol – especially wine – and highly caffeinated beverages.
• Stress plays an important role in migraine episodes. Stress at home or work may be the underlying cause of migraine episodes at frequent intervals.
• High sounds, bright lights or sunlight exposure may start a migraine episode. Certain smells, including perfumes, paint thinners and cigarette smoke, may trigger migraine.
• Changes in sleep pattern are among known triggers of migraine. Sleep deprivation, long hours of sleep, poor sleep quality, jet lag and other similar conditions may pave the way for or increase frequency of migraine episodes.
• Sexual activity or strenuous physical effort may lead to migraine episodes.
• Changes in air pressure or barometric parameters may trigger migraine.
• Medications, such as vasodilator agents (that dilate blood vessels, such as nitroglycerine) or oral contraceptives, may worsen migraine episodes.

Risk Factors

Factors that may increase the risk of migraine are listed below:

• A family member with migraine increases the risk of migraine.
• Migraine may develop at any age range. Hormonal changes in adolescence play a major role in development of migraine. However, migraine episodes usually emerge at age range of 20 to 30 years. Severity and frequency of migraine episodes may gradually decrease thereafter.
• Migraine is more common in women compared to men. Migraine is more prevalent in men during childhood, but incidence substantially increases in women compared to men in and after adolescence.
• A person with migraine may suffer from headache immediately before or after onset of menstrual period.

Character and incidence of migraine may change during pregnancy or menopause. Migraine generally disappears after menopause. Some women may complain that migraine episodes develop or worsen in pregnancy. On the other hand, many patients with migraine do not suffer from migraine episodes in pregnancy. However, migraine generally recurs after the delivery.

Potential Adverse Effects of Migraine

Sometimes, attempting to control migraine headache may lead to various problems;

• Gastrointestinal disorders: Some pain killers taken at high doses or for long term may cause gastrointestinal diseases, especially including abdominal pain, bleeding, gastritis and ulcer.
• Headache secondary medication overuse:  Using prescribed or over-the-counter medications in high doses for more than 10 days a month within last three months may lead to severe medication overuse headache which persists indefinitely.
• Medication overuse headache occurs when the medicines lose their pain alleviating features and become the origin of headaches. This vicious cycle may lead to use of even more painkillers. However, this does not alleviate the pain, but makes the headache more chronic than they are.
• Serotonin syndrome: Serotonin syndrome is a rare condition characterized by potentially life-threatening exposure of body to serotonin. Serotonin syndromes require strict care and medication use under supervision of a doctor.
• Chronic migraine: Migraine episodes may become chronic. All people suffering from headache for 15 days or more in a month within last 3 months are recommended to visit a neurologist regarding chronic migraine.
• Status Migrainosus: Migraine episodes may persist 4 to 72 hours, if left untreated or undertreated. Status migrainosus implies severe migraine episodes that last longer than 3 days.
• Persistent aura without infarction (vascular occlusion): Temporary neurologic disorders, called aura, generally disappear after headaches start. However, aura may sometimes persist longer than a week, after headache disappears. MRI should be scanned to evaluate brain in case of persistent aura in order to rule out any tissue damage or any other problem in brain.
• Migrainosus infarction (occlusion of blood vessels in brain): It is recommended to visit a neurologist regarding a potential cerebrovascular occlusion, if aura persists longer than one hour. Your physician may order an imaging study for your brain in order to rule out brain a possible infarction or bleeding.

Diagnosis

Migraine is a clinical diagnosis. The condition can be diagnosed while patient is comprehensively evaluated and examined by a neurologist without any need of further examination. In case of atypical headache that does not comply with characteristics of migraine, a neurologist may consider certain examinations and tests to rule out other reasons.

Laboratory tests and radiology studies help exclusion of conditions that may also lead to headache.