Migraine: Symptoms, Causes, Diagnosis And Treatments

Migraine

DEFINITION

A migraine headache is an excruciating type of throbbing headache often associated with nausea and sensitivity to light or sound.

Several migraines have been identified, including migraine with aura, migraine without aura, and chronic migraine.

DESCRIPTION AND SYMPTOMS

Migraine headaches are a neurological disorder for which the cause is not completely understood but seems to possess both a genetic and an environmental component.

People who experience migraines describe them as intensely painful, throbbing headaches that can be incapacitating and can last from 2 to 72 hours.

Often pain occurs only on one side of the head. The frequency of migraine headaches varies in individuals that have them, with about one per month being average.

Several types of migraine headaches are recognized based on variations in symptoms. There are four phases of migraines, and each type of migraine may not include every phase.

• Premonition phase (prodromal phase): Some people experience nonspecific symptoms hours to a day before pain begins. These symptoms can include altered mood, increased sensitivity to smells, food cravings, changes in bowel habits, unexplained stiffness in neck muscles, uncontrollable yawning, increased thirst, fluid retention, and increased urination.
• Aura: About 20% of individuals experience a neurological event called an aura shortly before migraine pain begins. During an aura, individuals most often see flashes of light, zigzags, or spots; lose their vision; feel a tingling in the hands, face, or on one side of the body; hear noises or music, or have uncontrollable jerking or other movements. Occasionally speech is affected. Normally auras last less than 20 minutes and rarely as long as one hour.
• Headache pain: Pain begins gradually, then builds to a throbbing crescendo, typically on one side of the head. Pain may be worsened by exposure to light, sound, or odors; physical activity; sneezing; coughing; and turning the head. The pain phase is usually accompanied by nausea and vomiting. Other symptoms during the pain phase include blurred vision, dizziness, and nasal congestion.
• Resolution phase (prodromal phase): Pain gradually eases and finally disappears. The individual often feels exhausted, weak, and confused after the pain is gone. This phase can last up to a day.

Migraine with aura, formerly called classic migraine, includes all four distinct phases, whereas migraine without an aura does not include the aura phase.

People who encounter any of the symptoms mentioned below should seek medical care immediately or go to the emergency room:

• sudden, hard headache like a thunder-clap
• headache with fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness, or trouble speaking
• headache after a head injury, especially if the headache worsens
• a chronic headache that is worse after coughing, exertion, straining, or sudden movement
• new headache pain after age 50

DEMOGRAPHICS

Corresponding to the World Health Organization (WHO), about 15%–20% of adults worldwide have migraines.

Chronic migraine (15 or more headache days per month) affects about 1.7%–4% of adults worldwide.

Also, the Global Burden of Disease Study in 2013 claims, migraine was the sixth highest cause worldwide of years lost due to disability.

In the United States, more than 15% of Americans get migraines, including 17% of women and 6% of men.

Children can develop migraine headaches, but they more commonly begin around adolescence.

Ahead of puberty, migraines are more prevalent in boys, whereas they are more common in girls after puberty.

In adulthood, women experience about 75% of all migraines. The frequency of migraines peaks at about age 40 for women, with a secondary peak occurring around menopause. Caucasians experience more migraines than African Americans or Asians.

Migraine headaches are less common and generally less severe among the elderly than among younger people. After age 70, only about 5% of women and 2% of men experience migraines.

The characteristics of migraines in older people also tend to be somewhat different from those in younger men and women.

They tend to be more aura-like in nature and less commonly include a severe headache.

This form of migraine is known as late-life migrainous accompaniments or transient migraine accompaniments (TMA) and can easily be confused with a transient ischemic attack (TIA, or mini-stroke).

Symptoms of TMA include weakness in the arms and legs and sensory changes that occur with migraine accompanied by vision problems, such as temporary blindness, homonymous hemianopsia (a loss of vision on one side of one’s visual field), and blurring of vision;

numbness, tingling, and a pins-and-needles sensation; dysfunctions of the brain, including ataxia, hearing loss, tinnitus, vertigo, and syncope; and a variety of speech disorders, including slurred speech and aphasia (inability to speak).

CAUSES

Migraines appear to be caused by a combination of genetic and environmental factors.

About 70% of individuals who have migraine headaches have a first-degree relative (parent or sibling) who also has migraines.

Twin studies also support the idea of a genetic component. Research suggests that multiple genes are involved.

Albeit the precise cause is still being researched, migraine-triggering factors have been documented.

For example, people have commonly reported migraines on the weekend following a stressful week at work, before or in time of the onset of menstruation, or waking up with a migraine in the morning.

Other triggers are as follows:

• stress
• anxiety
• too much or not enough sleep
• overexertion
• bright or flashing noises
• strong smells
• loud noises
• changes in weather
• hormonal changes in women
• use of contraceptives
• use of hormone replacement therapies
• environmental chemicals
• skipped meals
• some foods, including cured meats, fermented or pickled foods, red wine, chocolate, onion, freshly baked yeast products, eggs, alcohol, nuts, aged cheese, and monosodium glutamate (MSG)
• tobacco
• caffeine or caffeine withdrawal
• medications
• medication overuse
• liver problems
• dental infections

Risk factors

Individuals are more likely to experience migraines if they

• are an adolescent or young adult
• are a woman, especially during hormonal changes
• have a family history of migraines
• have certain medical conditions (depression, anxiety, bipolar disorder, sleep disorders, and epilepsy)

DIAGNOSIS

Diagnosis interpretation is usually established based on the patient’s medical history, physical exam, and interview.

For a diagnosis of migraine, the International Headache Society requires that the individual have five attacks that meet the following criteria and are not attributable to any other disorder:

• The headache must have lasted 4–72 hours.
• Two of the following must have occurred: unilateral pain; throbbing, pulsating pain; moderate to severe pain; pain worsened by physical activity.
• One of the following symptoms must have occurred: nausea or vomiting; sensitivity to light or sound.

In 2014, Dawn Buse and colleagues developed a 12-item interview screening tool, called ID-CM, to diagnose chronic migraine, defined as 15 or more migraine days per month. This tool has a positive predictive value of 90%.

The following tests may be specified to rule out other potential causes of headaches:

• Computer tomography (CT) scan: A CT scan uses computer-directed x-rays, which provide a visual image of the brain to determine probable issues that may also induce headaches, such as infections, tumors, and other medical conditions.
• (MRI) Magnetic resonance imaging: This imaging technique uses radio waves and a powerful magnet to produce detailed views of the brain and its blood vessels. It may also help diagnose tumors, strokes, aneurysms, and other brain abnormalities.
• Lumbar puncture (spinal tap): This procedure goes like this. A thin needle is injected amid two vertebrae inside the lower back to extract a sample of cerebrospinal fluid for laboratory analysis. It may eliminate other diseases such as meningitis that also cause intense headaches.

Diagnosis of TMA includes several observations and tests to exclude other possible conditions.

These observations include a series of characteristic visual displays during the episode, a buildup of scintillations (flashes of light), progression of one stage of TMA often in rapid succession, an occurrence of more than one episode of the condition,

a period of about 15–20 minutes for the episode, an otherwise benign course of events, and a negative angiography (x-ray of the blood vessels) for the patient.

TREATMENT

Acute treatment

Acute treatment is used to interrupt a migraine that has already begun. It is most effective when treatment is started at the first sign of a migraine.

Nonprescription pain-relief drugs used to treat mild to moderate migraine include aspirin, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin, Advil) or naproxen (Naprosyn or Aleve), and acetaminophen (Tylenol, also called paracetamol in Europe).

Some of these nonprescription drugs are available in combination with caffeine, such as Excedrin Migraine, enhancing their effect.

Prescription drugs for acute migraine relief include:

• Triptans: sumatriptan (Imitrex, Tosymra), zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), almotriptan (Axert), eletriptan (Relpax), and frovatriptan (Frova), available as pills, shots, or nasal sprays. Individuals with cardiovascular disease should not take triptans.
• Dihydroergotamine (D.H.E. 45, Migranal): available as a nasal spray or injection. Side effects include worsening of migraine-related vomiting and nausea. People with coronary artery disease, high blood pressure, kidney disease, or liver disease should not take dihydroergotamine. Ergotamine (Ergomar), a related drug, and ergotamine with caffeine (Cafergot, Ercaf) are older migraine-specific drugs and have more side effects than dihydroergotamine. They should not be taken by people who take some HIV drugs or antifungal drugs.
• Lasmiditan (Reyvow): A new, first-in-class tablet FDAapproved in 2019. It works as a serotonin receptor agonist and specifically blocks nerves in the brain that transmit headache pain. Lasmiditan significantly improved pain, nausea, and sensitivity to light and sound in clinical trials. Side effects include tiredness and dizziness, so people should not drive or operate machinery for eight hours after taking it. Lasmiditan should not be taken along with alcohol or other central nervous system depressors.
• Calcitonin gene-related peptide (CGRP) antagonists (commonly called gepants): A new class of FDA-approved drugs specifically for migraine treatment, including ubrogepant (Ubrelvy, FDA-approved in December 2019) and rimegepant sulfate (Nurtec ODT, FDA-approved in February 2020). These small molecule drugs block the CGRP receptor. CGRP is known to cause migraines because it dilates blood vessels, which causes inflammation and migraine pain.
• Opioids: If no other treatment is effective, narcotic opioids, especially those containing codeine, may be prescribed. Due to the highly addictive nature of these drugs, they are only used as a last resort.
• Anti-nausea medications: chlorpromazine (Ormazine, Thorazine), metoclopramide (Reglan), prochlorperazine (Compro), indomethacin (Indocin, Tivorbex) rectal suppository. These drugs do not treat the migraine itself; they relieve nausea and vomiting side effects of some migraines.

Drug therapy for migraine is approached in a stepwise fashion, starting with general painkillers, and if they do not work, moving on to migraine-specific prescription drugs and occasionally opioid painkillers.

Individuals should review their health history with a physician before taking these drugs.

Individuals can help decrease the intensity of their headache in the following ways:

• Resting with their eyes closed in a quiet, dark room
• Placing a cool cloth or ice pack on their forehead
• Drinking plenty of fluids, especially water

TMA TREATMENT. With TMA, usually, no treatment is necessary because the episodes are so brief that few medications act rapidly enough to have any effect.

TMA presents no long-term medical issues, but it must be distinguished from a transient ischemic attack (TIA), which is serious.

Some practitioners suggest using isoproterenol, an inhaled beta-agonist, or vasodilators for patients who need the reassurance of some form of medications.

Either of these medications may shorten the length of an episode but provide no other benefit.

Triptans should not be used in older patients because they act too slowly and may exacerbate a patient’s preexisting vascular problems.

Preventative treatment

Preventative treatment begins with avoiding migraine triggers. Besides, drug therapy can effectively prevent or reduce migraines in many people.

Drugs may need to be taken daily or only when the individual is exposed to a trigger or in the prodromal phase. A variety of drugs are used prophylactically.

It is not consistently clear how or why these drugs work, but they control migraines in many people.

Preventative drugs include:

• Beta blockers such as propranolol (e.g., Inderal La, Innopran XL), metoprolol tartrate (Lopressor), and timolol (Betimol). Atenolol (Tenormin) and nadolol (Corgard) may also be used, but they are typically reserved for second-line therapy. These drugs were developed to treat high blood pressure. They reduce migraines in 60%–80% of patients but may not be suitable for some people over age 60 because they affect blood pressure.
• Calcium channel blockers, such as verapamil (e.g., Calan, Verelan), often the calcium channel blocker of choice to treat migraine. These drugs were also developed to treat high blood pressure.
• Tricyclic antidepressants, which are drugs that change serotonin, a neurotransmitter, in the brain. Amitriptyline (Vanatrip, Elavil, and Endep) is the tricyclic antidepressant that has proved most effective in preventing migraine, but it may have side effects unacceptable to some individuals. Venlafaxine (Effexor) may also be effective and is typically used as second-line therapy.
• Anti-seizure drugs, such as valproate (Depakote), gabapentin (Neurontin), and topiramate (Topamax), have advantages and disadvantages depending on the individual’s health status and tolerance of side effects.
• Botulinum toxin A (Botox) is approved by the U.S. Food and Drug Administration (FDA) to prevent chronic migraines. It is administered as an injection once every 12 weeks.
• CGRP inhibitors are a new class of drugs specifically for migraine prophylaxis. Erenumab (Aimovig) was the first in the class (FDA-approved in May 2018), followed by fremanezumab (Ajovy, FDA-approved in September 2018) galcanezumab-gnlm (Emgality, FDA-approved in September 2018), and eptinezumab-jjmr (Vyepti, FDA-approved in February 2020). CGRP inhibitors are monthly self-injectable biologic drugs (called monoclonal antibodies) that block the activation of a certain protein (CGRP).

NEUROSTIMULATORS

Neurostimulators offer a non-pharmacological option for the treatment and prevention of migraines. There are three types of FDA-approved devices:

• External Trigeminal Nerve Stimulation Device (e-TNS): a diamond-shaped device that attaches to the center of the forehead and generates an electrical current to stimulate nerves in the forehead trigeminal nerve. The Cefaly device was the first neurostimulator approved by the FDA in 2014 to prevent headaches; it was approved to treat acute migraines in 2017. It is available in three versions: Cefaly Acute is used for migraines in progress, Cefaly Prevent is used to prevent migraines, and Cefaly Dual can be used to prevent and treat migraines.
• Spring Transcranial Magnetic Stimulator (sTMS): a rectangular device that cradles the back of the neck and delivers magnetic split-second pulses. The magnetic energy disrupts the decreased nerve activity that causes a visual aura. The sTMS device manufactured by eNeura was approved in 2013 and is prescribed to treat migraines with or without aura.
• gammaCore Non-Invasive Vagus Nerve Stimulator: a rectangular device placed on the side of the neck (near the vagus nerve) that stimulates the vagus nerve to block migraine pain. The gammaCore Sapphire device was FDA-approved to treat migraines in 2018.

ALTERNATIVE TREATMENTS

Before beginning an alternative or complementary therapy, individuals should discuss its use with a healthcare provider.

Some therapies interact negatively with pharmaceutical drugs that the individual may be taking to treat other conditions.

Also, standardized dosages of many alternative therapies have not been established, and in some cases, evidence of safety and effectiveness has been suggested but not proven in rigorous trials.

The herb Petasites hybridus, commonly known as butterbur, has been shown in well-designed trials to prevent migraines and is recommended as a treatment by the American Headache Society.

It is sold in extract form under the name Petadolex. Use of butterbur requires monitoring of liver enzymes.

Evidence is encouraging but mixed that Tanacetum parthenium, commonly known as feverfew or bachelor’s buttons, can prevent migraines.

Moderately strong evidence suggests that vitamin B2, coenzyme Q10, and, in some people, low doses of magnesium may help in reducing the frequency of migraines. Individuals should work with their healthcare providers to determine an appropriate dosage. High doses of these supplements can have negative health effects.

Lifestyle changes that might prevent migraines or relieve migraine pain include the following:

• Reducing stress through relaxation techniques, such as biofeedback, massage therapy, and acupuncture
• Exercising regularly (regular aerobic exercise, such as walking, swimming, or cycling, can reduce tension)
• Following a consistent sleeping and eating routine (not sleeping too much, waking and going to bed at the same time each day, eating at the same times each day)
• Drinking enough fluids, especially water, to stay hydrated
• Keeping a headache diary to learn about potential triggers and which treatment is most effective

PROGNOSIS

Up to 2020, there is no cure for migraines. Drug therapies, alternative therapies, and lifestyle changes can prevent or reduce the frequency of migraines.

Newer drug classes, such as CGRP inhibitors, designed specifically for migraine treatment and prevention are promising as they tend to work well and have fewer side effects than older migraine medications.

After onset, drug therapy can provide some relief to most people, which reduces the disabling effects of these headaches.

Migraines generally decrease as the individual ages. In some people, migraines resolve on their own and disappear completely. In general, after menopause, women experience fewer and less severe migraines.

SPECIAL CONCERNS FOR SENIORS

Migraines have not been well studied in the elderly, but it is known that the frequency and intensity of migraine headaches tend to decrease with age.

Treatment in this age group presents special problems. The presence of other diseases may prevent the use of some drugs.

Another concern is that older individuals are more likely than younger ones to experience adverse side effects of drug therapy.

Older migraine patients accordingly require cautious treatment that considers possible pharmacological interactions associated with their greater use of drugs for other medical conditions.

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