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According to the World Health Organization (WHO) migraine is more common in women by two times more than men due to hormonal influences. As reported in the international journal Cephalalgia, globally, the percentages of the adult population with an active headache disorder is divided into 46% for headache in general, 11% for migraine, 42% for tension-type headache and 3% for chronic daily headache. Migraine is most prevalent in Europe and least prevalent in Africa.
Migraine or disambiguation is a common disabling primary headache disorder, characterized by sudden severe pain in the head, with feel like pulsing or throbbing in the head. The four stages of migraine are prodrome, aura, attack and post-drome. A patient with migraine may not got through all of these phases. Although each phase has its own symptoms, symptoms incommon between the four phases of migraine may include nausea, vomiting, and sensitivity to light, sound, or smell.
The presence of aura determines the two types of migraine. A combination of environmental and genetics factors along with other factors such as hormonal changes in women, may trigger migraine.
Diagnosis depends on the medical history of the patient, 6 the repetition of symptoms for more than five times, in addition to physical and neurological examination. Diagnosis tools include blood tests, magnetic resonance imaging (MRI) which uses a powerful magnetic field and radio waves to get detailed images of the brain and blood vessels, computerized tomography (CT) scan by which X-ray reveals detailed cross-sectional images of the brain, and spinal tap (lumbar puncture) that a sample of cerebrospinal fluid is take in the case of suspected bleeding or other underlying reasons.
The pathophysiology of migraines resides in the fact that trigeminovascular system and the trigeminal cervical complex (TCC) being the major sources for pain.
There is no clear understanding of the direct cause of migraine, and so treatment is not specific. The frequency, severity of the headaches, the degree of disability caused by the headaches, and other medical conditions could help determine the type of treatment used. In general, patients are treated with pain- relieving medications, and preventive medications so that signs and symptoms are controlled, and the incidence of the disease is decreased, respectively.
The side effect of drugs or drugs over dose could lead to complications, including abdominal problems, medication-overuse headaches, and serotonin syndrome. Taking on certain life-style changes and coping strategies could help prevent migraines or make them less severe.
Hormonal changes in women make them two times more vulnerable to have migraines than men. Migraine is most prevalent in Europe and least prevalent in Africa.
Migraine is sudden, strong, and severe pain in one or both sides of the head. Migraine is different from the normal headache by being more painful and having other accompanying symptoms. The patient usually starts feeling sudden pulsing or throbbing in the head. Migraine is classified as a common disabling primary headache disorder.
Two major subtypes are found for migraine:
It is a clinical syndrome that has specific features and associated symptoms, where a headache marks this type.
This type has a headache that is accompanied by or having transient focal neurological symptoms prior to it.
An unclear understanding of the direct causes of migraine until this day, however the following factors do contribute into causing migraine:
- Alterations in the brainstem and its interaction with the trigeminal nerve.
-Imbalances in brain chemicals, such as serotonin that is responsible for the regulation of pain the nervous system. Its level is decreased during migraine attacks which leads to the release of neuropeptides by the trigeminal nerve and by its role causes a painful migraine.
The possibility of getting migraine is increased by the following factors:
Although migraine occurs at any age, the third decade in the life of a person is considered the peak of migraine. Later on, less severe and less frequent migraine occurs.
The probability of having migraine is increased in families who have a history with the disease.
Menstruation, pregnancy, and menopause in women increase the probability of having migraine.
In childhood, boys tends to have migraine more than girls, to be reversed in puberty and later on. In general, women are three times more subjected to have migraine more than men.
Dysfunction of the brainstem pathways that normally alter sensory input is related to migraines. For individuals with a genetic predisposition, an inherited alteration of brain excitability, intracranial arterial dilatation, recurrent activation and sensitization of the trigeminovascular pathway, and consequential structural and functional changes are all related to migraine pathophysiology. The trigeminovascular system is responsible for innervating the cranial blood vessels and dura matter, and the central projections passing via the trigeminal ganglion (TG) to synapse on second order neurons in the dorsal horn, and forming the origin for the trigeminal cervical complex (TCC). Neurons in the trigeminocervical complex are major communicative neurons for nociceptive afferent input from the meninges and cervical structures, forming a neural substrate for pain. The trigeminovascular input from the meningeal vessels is considered the main source of pain in migraine. The course for these neurons begins throughout protruding from the trigeminothalamic tract, to pass into the brainstem, and form synapses; a synapse is the junction between two neurons that allows impulses to pass in between the two neurons, with neurons in the thalamus. The neurons in the pons and neurons in the superior salivatory nucleus have a reflex connection among them, which leads to a cranial parasympathetic outflow; the parasympathetic fibers follow the cranial nerves III, VII, IX and X ,that is mediated through the pterygopalatine, otic, and carotid ganglia. People who are not subjected to migraine have this trigeminal autonomic reflex, which is highly manifested in patients with trigeminal autonomic cephalalgias, such as cluster headache and paroxysmal hemicrania; it may be active in migraine.
Migraine can occur at any age but it often begins in childhood, adolescence or early adulthood. Migraine could progress into four phases, but it is not necessary for a person with migraine to go through all of these phases, which are: prodrome, aura, attack and post-drome.
Prodrome
Mild changes, one or two days before migraine, could be a warning sign of an upcoming migraine including:
Aura
Aura are symptoms of the nervous system, which appear before or during migraine. The majority of patients do not go through them. The usual form of aura are visual disturbances, such as flashes of light or wavy, zigzag vision. Other forms include sensory, motor or verbal disturbances.
These forms begin to build up later on in a progressive way, to reach the peak a few minutes later, and end after 20 to 60 minutes. Examples of migraine aura include:
Hemiplegic migraine is a case associated to limb weakness that could happen sometimes.
Attack
Four to 72 hours is the usual time for a migraine to end, when untreated. Frequencies and severity of the disease vary among different individuals. During a migraine patient may feel:
Post-drome
It is the last phase in migraine that occurs after an attack and could drastically vary from one person to another. Some people may experience exhaustion and tiredness, while others may feel euphoric. The coming 24 hours after post-drome, the patient may also face:
The medical history of the patient, the repetition of symptoms for more than five times, in addition to physical and neurological examination, are important in a migraine diagnosis.
The tools used for diagnosing migraine include:
This can be used when a doctor suspects blood vessel problems, infections in the spinal cord or brain, and toxins in the system.
This technique is based on using a powerful magnetic field and radio waves, in order to obtain detailed images of the brain and blood vessels. It is able to detect tumors, strokes, bleeding in the brain, infections, and other brain and nervous system (neurological) conditions.
A (CT) scan; where series of X-rays are able to reveal detailed cross-sectional images of the brain. This is helpful in diagnosing tumors, infections, brain damage, bleeding in the brain and other possible medical problems that could be causing headaches.
This tool uses a sample of cerebrospinal fluid, when bleeding in the brain or another underlying condition are suspected. In such a case, a spinal tap (lumbar puncture) may be recommended.
The chosen treatment depends on the frequency, severity of the headaches, the degree of disability caused by the headaches, and other medical conditions. Treatment in migraine aims either at treating migraines directly or at treating conditions that relieve or prevent migraines. The used medications are divide into two groups:
This type of medication is needed only after signs and symptoms appear, post a migraine attack, in order to terminate symptoms. This group of medications include:
These drugs work on relieving pain, in addition to other symptoms related to migraines, in an effective way. They include sumatriptan, rizatriptan, almotriptan, naratriptan, zolmitriptan, frovatriptan and eletriptan. These drugs cause blood vessels to become narrower and as a result the pain pathways in the brain are blocked.
To obtain the best result from ergots, they should be taken after symptoms occur and after a duration of 48 hours for pain. They are considered to be less effective than triptans and are with possible side effect that could make symptoms such as vomiting and nausea to become worse.
These medications are taken in combination with other medication such as chlorpromazine, metoclopramide and prochlorperazine.
They are a type of drugs that contain narcotics such as codeine that are used to treat migraine pain in a patient who can’t use triptans and ergots. They are potentially addictive drugs and so should only be used when other medications are not working.
It is combined with other medications so that the effectiveness of pain relief is increased.
Mild migraines are relieved via this type of medication. Moderate migraines are treated with drugs especially designed for migraines that use combinations of drugs such as acetaminophen, aspirin and caffeine. Aspirin or ibuprofen and acetaminophen are examples of pain relievers that shouldn’t be consumed for prolonged periods of time or repeated often since that could lead to ulcers, gastrointestinal bleeding and medication-overuse headaches.
The severity, frequency, and length of migraine are minimized by preventive medications. However, while having a migraine attack, the effectivity of symptom-relieving medications is increased by this type of medication. Having certain conditions favors the use of preventive medications such as having four or more attacks a month that leave a patient disabled, when the attacks last more than 12 hours, when pain-relieving medications are not being effective, and when migraine signs and symptoms include a prolonged aura or numbness and weakness. They could be prescribed on a daily basis or when an expected trigger is upcoming. In some case, this type of medication could not completely stop headaches and some medications could bear serious side effects. When good results are achieved and migraines are under control by preventive medications, it could be recommended to gradually decrease medication so that the possibility of the migraines to return is observed.
This group of medications include:
-Beta blockers
The beta blockers; usually used in treating high blood pressure and coronary artery disease, such as propranolol, metoprolol tartrate and timolol can effectively prevent migraine.
These cases require seeking alternative medication:
- Calcium channel blockers
They are used in treating high blood pressure, and have proved to prevent migraines and in relieving their symptoms. Such drugs include verapamil and lisinopril.
The frequency of migraines is decreased by this type of medication through controlling the level of serotonin and other brain chemicals. Only amitriptyline tricyclic antidepressants were proved to be effective in preventing migraines. A combination of selective serotonin reuptake inhibitors; not established to be effective in preventing migraines and may even provoke headaches or make them worse, with venlafaxine; norepinephrine reuptake inhibitor, could aid in migraine prevention.
Using valproate and topiramate, can decrease the incidence of migraines. High doses of these drugs could cause side effects.
In adults, using onabotulinumtoxinA can be useful in treating chronic migraines.
They help in preventing migraines and in reducing their symptoms such as nonsteroidal anti-inflammatory drugs, especially naproxen.
Some treatments have proven to reduce the incidence and the amount of pain in migraines such as acupuncture, biofeedback; a relaxation technique, massage therapy and cognitive behavioral therapy; a type of psychotherapy.
The majority of complications related to migraine occur as a result of the side effect of drugs or from drugs over dose. These complications includes:
Abdominal problems such as abdominal pain, bleeding, ulcers and other complications could be the outcome of prolonged use or large doses of some pain relievers, like nonsteroidal anti-inflammatory drugs (NSAIDs).
This case occurs when medication is taken for a period of time that lasts for more than 10 days a month for three months or in high doses, where the role of medication is reversed; it stops working and instead start to cause headaches.
This syndrome is manifested by changes in cognition, behavior and muscle control. When high levels of serotonin are present in the nervous system, serotonin syndrome happens. Some migraine medications such as triptans and selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs), especially when combined, could increase the incidence of having serotonin syndrome by raising serotonin to a high level.
When the duration of migraine lasts for 15 days or more days for more than three months, it becomes chronic migraine.
It is related to severe migraine attacks that last for period of time longer than three days.
The usual case for an aura phase is to disappear after the migraine attack. In some cases, aura will last for more than one week after a migraine attack and is similar to a stroke; bleeding in the brain, apart from bleeding in the brain, tissue damage or other problems.
An aura with a duration longer than an hour can indicate bleeding in the brain, where neuroimaging tests are used to identify this bleeding.
Avoiding triggering agents for migraines is recommended but is not always effective or achievable. The following life-style changes and coping strategies could help in reducing the severity and incidence of migraines, such as:
It is an electrical stimulator applied to the forehead using a headband-like device, which was approved by the Food and Drug Association (FDA) as a preventive therapy for migraine.
This method uses gradual exposure to migraine triggers in order to desensitize; becoming nonreactive to a sensitizing agent, an individual against these triggers.
This includes maintaining an everyday sleeping and eating habits, in addition to stress control.
Aerobic exercises such as walking, swimming and cycling, are commended for reducing tension and weight which can prevent migraines.
The increased sensitivity after a migraine attack leads to chronic daily migraine. However, the correct combination of drugs used to treat and prevent migraine attacks is capable of handling the bad outcomes of migraines. Women may encounter less severe symptoms and less frequent attacks after menopause, if their case is related to menstruation.
According to the World Health Organization (WHO) migraine is more common in women by two times more than men due to hormonal influences. As reported in the international journal Cephalalgia, globally, the percentages of the adult population with an active headache disorder is divided into 46% for headache in general, 11% for migraine, 42% for tension-type headache and 3% for chronic daily headache. Migraine is most prevalent in Europe and least prevalent in Africa.
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