MIGRAINE
Definition
Migraine is a neurological syndrome characterized by altered bodily perceptions, headaches, and nausea. Physiologically, the migraine headache is a neurological condition more common to women than to men. Etymologically, the French word migraine derives from the Old English megrim (severe headache) and the Greek hemicrania (half skull). The latter term was in turn simply a translation of an ancient Egyptian name for migraine (literally "half head")
The typical migraine headache is unilateral and pulsating, lasting from 4 to 72 hours symptoms include nausea, vomiting, photophobia (increased sensitivity to bright light), and hyperacusis (increased sensitivity to noise); approximately one third of people who suffer migraine headache perceive an — unusual visual, olfactory, or other sensory experiences that are a sign that the migraine will soon occur.
Initial treatment is with analgesics for the head-ache, an anti-emetic for the nausea, and the avoidance of triggering conditions. The cause of migraine headache is unknown; the accepted theory is a disorder of the control system, as PET scan has demonstrated the aura coincides with diffusion of cortical depression consequent to increased blood flow (up to 300% greater than baseline). There are migraine headache variants, some originate in the brainstem (featuring intercellular transport dysfunction of calcium and potassium ions) and some are genetically disposed. Studies of twins indicate a 60 to 65 percent genetic influence upon their developing propensity to migraine headache. Moreover, fluctuating hormone levels indicate a migraine relation: 75 percent of adult patients are women, although migraine affects approximately equal numbers of prepubescent boys and girls; propensity to migraine headache is known to disappear during pregnancy.
Classification
The International Headache Society (IHS) classifies migraine headache
The IHS defines the intensity of pain with a verbal, four-point scale:
| Number | Name | Annotations |
| 0 | no pain | |
| 1 | mild pain | does not interfere with usual activities |
| 2 | moderate pain | inhibits, but does not wholly prevent usual activities |
| 3 | severe pain | prevents all activities |
Migraine without aura
The common form of migraine headache; the patient primarily suffers migraine without aura, and might also suffer migraine with aura. The International Classification of Headache Disorders definition is:
Description: Recurrent headache disorder manifesting in attacks lasting 4–72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and photophobia. Diagnostic criteria:
A. At least five attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours [when untreated]
C. Headache has at least two of the following characteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe pain intensity
4. Aggravation by or causing avoidance of routine physical activity
D. During the headache at least one of the following:
1. Nausea and/or vomiting
2. Photophobia and photophobia
E. Not attributed to another disorder
Migraine with Aura
The second-most common form of migraine headache: the patient primarily suffers migraine with aura, and might also suffer migraine without aura. The International Classification of Headache Disorders definition is:
Description: Recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5–20 minutes and last for less than 60 minutes. Headache with the features of "migraine without aura" usually follows the aura symptoms. Less commonly, headache lacks migrainous feature or is completely absent [i.e., the aura may occur without any subsequent headache].
Diagnostic criteria:
A. At least two attacks fulfilling criterion B
B. Migraine aura fulfilling criteria
C. Not attributed to another disorder. ... [Criteria for "Typical aura":]
Aura consisting of at least one of the following, but no motor weakness:
1. Fully reversible visual symptoms including positive features (e.g. flickering lights, spots or lines) and/or negative features (i.e., loss of vision)
2. Fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness)
3. Fully reversible dysphasic speech disturbance
[Aura also has] at least two of the following:
1. Homonymous visual symptoms [i.e., affecting just one side of the field of vision] and/or unilateral sensory symptoms [i.e., affecting just one side of the body]
2. At least one aura symptom develops gradually over [at least] 5 minutes and/or different aura symptoms occur [one after the other] over [at least] 5 minutes
3. Each symptom lasts [from] 5 [to] 60 minutes ...
Other potential aura criteria:
· Fully reversible motor weakness...
· Each aura symptom lasts [from] 5 minutes [to] 24 hours...
· [In the case of a "Basilar-type" migraine], Dysarthria [difficulty speaking], vertigo [dizziness], tinnitus [ringing in the ears], [and other symptoms].
Basilar type Migraine
Basilar type migraine (BTM) previously basilar artery migraine [BAM] and basilar migraine [BM]) is an uncommon, complicated migraine with symptoms caused by brainstem dysfunction. Serious episodes of BTM can lead to stroke, coma, and death. Using trip tans and other vasoconstrictors as abortive treatments for BTM is contraindicated. Abortive treatments for BTM address vasodilatation and restoration of normal blood flow to the vertebrobasilar territory to restore normal brainstem function.
Familial hemiplegics migraine
Familial hemiplegics migraine (FHM) is migraine with a possible polygenetic cause. An FHM episode might last 4–72 hours [ and appear caused by ion channel mutations; FHM is in three types. The patient experiences typical migraine headache either preceded or accompanied with unilateral, reversible limb weakness and sensory and speech difficulties. There also exists the "sporadic hemiplegics migraine" (SHM) a non-familial form. Affecting a differential diagnosis, between basilar migraine and hemiplegics migraine, is difficult; often, the decisive symptom is either motor weakness or unilateral paralysis that occurs in FHM and SHM; basilar migraine can present tingling and numbness, true motor weakness and paralysis occur only in hemiplegics migraine.
Abdominal migraine
Abdominal migraine is a recurrent disorder of unknown origin, principally affecting children; episodes feature nausea, vomiting, and moderate-to-severe central, abdominal pain (ca. 1–72 hrs); the child is well between episodes. Formal diagnosis requires at least five (5) episodes (unattributable to another cause) and fulfillment of these criteria:
1. Episodes last 4–72 hours, untreated
2. Pain must feature ALL these characteristics:
o Location in the mid-abdomen, around the umbilicus; or poorly localized
o Dull pain; 'just sore' quality
o Moderate-to-severe intensity
3. An episode must feature at least two of these symptoms:
o Loss of appetite
o Nausea
o Vomiting
o Pallor
o Moody
Most children suffering abdominal migraine will develop propensity to migraine headache in adult life; the two propensities might co-exist during the child's adolescence.
Treating an abdominal migraine can often be difficult; medications used to treat other forms of migraines are usually employed. These include Elavil (75-150 mg), Wellbutrin SR (400 mg), and Topamax (200-400 mg). In some cases, the abdominal migraine is a symptom linked to cyclic vomiting syndrome there may be a history of migraines in the family of the sufferer.
Acephalgic Migraine
Acephalgic migraine is a neurological syndrome. It is a variant of migraine in which the patient may experience aura symptoms such as scintillating scotoma, nausea, photophobia, hemi paresis and other migraine symptoms but does not experience headache. Encephalic migraine is also referred to as amigrainous migraine, ocular migraine, or optical migraine.
Sufferers of encephalic migraine are more likely than the general population to develop classical migraine with headache.
The prevention and treatment of encephalic migraine is broadly the same as for classical migraine. However, because of the absence of "headache", diagnosis of encephalic migraine is apt to be significantly delayed and the risk of misdiagnosis significantly increased.
Visual snow might be a form of encephalic migraine.
If symptoms are primarily visual, it may be necessary to consult an ophthalmologist or optometrist to rule out potential eye disease before considering this diagnosis.
Menstrual migraine
Menstrual migraine is distinct from other migraines. Approximately 21 million women in the
· MRM is a headache of moderate-to-severe pain intensity that happens around the time of a woman’s period and at other times of the month as well.
· PMM is similar in every respect but only occurs around the time of a woman’s period. The exact causes of menstrual migraine are uncertain but evidence suggests there may be a link between menstruation and migraine tdue to the drop in estrogen levels that normally occurs right before the period starts. Menstrual migraine has been reported to be more likely to occur during a five-day window, from two days before to two days after menstruation. Signs and symptoms
Signs and Symptoms
The signs and symptoms of migraine vary among patients. Therefore, what a patient experiences before, during and after an attack cannot be defined exactly. The four phases of a migraine attack listed below are common but not necessarily experienced by all migraine sufferers. Additionally, the phases experienced and the symptoms experienced during them can vary from one migraine attack to another in the same migraineur:
1. The prodrome, which occurs hours or days before the headache.
2. The aura, which immediately precedes the headache
3. The pain phase, also known as headache phase.
Diagnosis
Migraines are under diagnosed and misdiagnosed The diagnosis of migraine without aura, according to the International Headache Society, can be made according to the following criteria, the "5, 4, 3, 2, 1 criteria":
· 5 or more attacks
· 4 hours to 3 days in duration
· 2 or more of - unilateral location, pulsating quality, moderate to severe pain, aggravation by or avoidance of routine physical activity
· 1 or more accompanying symptoms - nausea and/or vomiting, photophobia, phonophobia
For migraine with aura, only two attacks are required to justify the diagnosis.
The mnemonic pounding (Pulsating, duration of 4–72 hours, Unilateral, Nausea, and Disabling) can help diagnose migraine. If 4 of the 5 criteria are met, then the positive likelihood ratio for diagnosing migraine is 24. The presence of either disability, nausea or sensitivity, can diagnose migraine with:[34]
· sensitivity of 81%
· specificity of 75%
Migraine should be differentiated from other causes of headaches such as cluster headaches. These are extremely painful, unilateral headaches of a piercing quality. The duration of the common attack is 15 minutes to three hours. Onset of an attack is rapid, and most often without the preliminary signs that are characteristic of a migraine.
Prodrome Phase
Prodromal symptoms occur in 40–60% of migraineurs (migraine sufferers). This phase may consist of altered mood, irritability, depression or euphoria, fatigue, yawning, excessive sleepiness, craving for certain food (e.g. chocolate), stiff muscles (especially in the neck), constipation or diarrhea, increased urination, and other visceral symptoms. These symptoms usually precede the headache phase of the migraine attack by several hours or days, and experience teaches the patient or observant family how to detect that a migraine attack is near.
Aura Phase
For the 20–30% of individuals who suffer migraine with aura, this aura comprises focal neurological phenomena that precede or accompany the attack. They appear gradually over 5 to 20 minutes and generally last fewer than 60 minutes. The headache phase of the migraine attack usually begins within 60 minutes of the end of the aura phase, but it is sometimes delayed up to several hours, and it can be missing entirely. Symptoms of migraine aura can be visual, sensory, or motor in nature
Visual aura is the most common of the neurological events. There is a disturbance of vision consisting usually of unformed flashes of white and/or black or rarely of multicolored lights (photopia) or formations of dazzling zigzag lines (scintillating scotoma; often arranged like the battlements of a castle, hence the alternative terms "fortification spectra" or "teichopsia Some patients complain of blurred or shimmering or cloudy vision, as though they were looking through thick or smoked glass, or, in some cases, tunnel vision and hemianopsia. The somatosensory aura of migraine consists of digitolingual or cheiro-oral paresthesias, a feeling of pins-and-needles experienced in the hand and arm as well as in the nose-mouth area on the same side. Paresthesia migrates up the arm and then extend to involve the face, lips and tongue.
Other symptoms of the aura phase can include auditory or olfactory hallucinations, temporary dysphasia, vertigo, tingling or numbness of the face and extremities, and hypersensitivity to touch.
Pain phase
The typical migraine headache is unilateral, throbbing, moderate to severe and can be aggravated by physical activity. Not all of these features are necessary. The pain may be bilateral at the onset or start on one side and become generalized, and usually alternates sides from one attack to the next. The onset is usually gradual. The pain peaks and then subsides, and usually lasts between 4 and 72 hours in adults and 1 and 48 hours in children. The frequency of attacks is extremely variable, from a few in a lifetime to several times a week, and the average migraineur experiences from one to three headaches a month. The head pain varies greatly in intensity.
The pain of migraine is invariably accompanied by other features. Nausea occurs in almost 90 percent of patients, while vomiting occurs in about one third of patients. Many patients experience sensory hyperexcitability manifested by photophobia, phonophobia, osmophobia and seek a dark and quiet room. Blurred vision, nasal stuffiness, diarrhea, polyuria, pallor or sweating may be noted during the headache phase. There may be localized edema of the scalp or face, scalp tenderness, prominence of a vein or artery in the temple, or stiffness and tenderness of the neck. Impairment of concentration and mood are common. Lightheadedness, rather than true vertigo and a feeling of faintness may occur. The extremities tend to be cold and moist.Postdrome phase
Postdrome phase
The patient may feel tired, have head pain, cognitive difficulties, "hungover", gastrointestinal symptoms, mood changes and weakness. Some people feel unusually refreshed or euphoric after an attack, whereas others note depression and malaise. Often, some of the minor headache phase symptoms may continue, such as loss of appetite, photophobia, and lightheadedness. For some patients, a 5 to 6 hour nap may reduce the pain, but slight headaches may still occur when standing or sitting quickly. Normally these symptoms go away after a good night's rest
Migraines are under diagnosed and misdiagnosed. The diagnosis of migraine without aura, according to the International Headache Society, can be made according to the following criteria, the "5, 4, 3, 2, 1 criteria":
· 5 or more attacks
· 4 hours to 3 days in duration
· 2 or more of - unilateral location, pulsating quality, moderate to severe pain, aggravation by or avoidance of routine physical activity
· 1 or more accompanying symptoms - nausea and/or vomiting, photophobia, phonophobia
Pathophysiology
Migraines were once thought to be initiated exclusively by problems with blood vessels. The vascular theory of migraines is now considered secondary to brain dysfunction and claimed to have been discredited by others. Trigger points can be at least part of the cause, and perpetuate most kinds of headaches. The effects of migraine may persist for some days after the main headache has ended. Many sufferers report a sore feeling in the area where the migraine was, and some report impaired thinking for a few days after the headache has passed.
Depolarization Theory
A phenomenon known as cortical spreading depression can cause migraines In cortical spreading depression, neurological activity is depressed over an area of the cortex of the brain. This situation results in the release of inflammatory mediators leading to irritation of cranial nerve roots, most particularly the trigeminal nerve, which conveys the sensory information for the face and much of the head.
This view is supported by neuroimaging techniques, which appear to show that migraine is primarily a disorder of the brain (neurological), not of the blood vessels (vascular). A spreading depolarization (electrical change) may begin 24 hours before the attack, with onset of the headache occurring around the time when the largest area of the brain is depolarized. A French study in 2007, using the Positron Emission Tomography (PET) technique identified the hypothalamus as being critically involved in the early stages.
Vascular Theory
Migraines can begin when blood vessels in the brain contract and expand inappropriately. This may start in the occipital lobe, in the back of the brain, as arteries spasm. The reduced flow of blood from the occipital lobe triggers the aura that some individuals who have migraines experience because the visual cortex is in the occipital area.
When the constriction stops and the blood vessels dilate, they become too wide. The once solid walls of the blood vessels become permeable and some fluid leaks out. This leakage is recognized by pain receptors in the blood vessels of surrounding tissue. In response, the body supplies the area with chemicals which cause inflammation. With each heart beat, blood passes through this sensitive area causing a throb of pain.
Rotonin is a type of neurotransmitter, or "communication chemical" which passes messages between nerve cells. It helps to control mood, pain sensation, sexual behaviors, sleep, as well as dilation and constriction of the blood vessels among other things. Low serotonin levels in the brain may lead to a process of constriction and dilation of the blood vessels which trigger a migraine. Trip tans activate serotonin receptors to stop a migraine attack.
Neural theory
When certain nerves or an area in the brain stem become irritated, a migraine begins. In response to the irritation, the body releases chemicals which cause inflammation of the blood vessels. These chemicals cause further irritation of the nerves and blood vessels and results in pain. Substance P is one of the substances released with first irritation. Pain then increases because substance P aids in sending pain signals to the brain.
Unifying theory
Both vascular and neural influences cause migraines.
1. stress triggers changes in the brain
2. these changes cause serotonin to be released
3. blood vessels constrict
4. chemicals including substance P irritate nerves and blood vessels causing pain
Migraine is an extremely common condition which will affect 12–28% of people at some point in their lives however this figure — the lifetime prevalence — does not provide a very clear picture of how many patients there are with active migraine at any one time. Typically, therefore, the burden of migraine in a population is assessed by looking at the one-year prevalence — a figure that defines the number of patients who have had one or more attacks in the previous year. The third figure, which helps to clarify the picture, is the incidence — this relates to the number of first attacks occurring at any given age and helps understanding of how the disease grows and shrinks over time
Based on the results of a number of studies, one year prevalence of migraine ranges from 6–15% in adult men and from 14–35% in adult women. These figures vary substantially with age: approximately 4–5% of children aged fewer than 12 suffer from migraine, with little apparent difference between boys and girls. There is then a rapid growth in incidence amongst girls occurring after puberty, which continues throughout early adult life.] By early middle age, around 25% of women experience a migraine at least once a year, compared with fewer than 10% of men After menopause, attacks in women tend to decline dramatically, so that in the over 70s there are approximately equal numbers of male and female sufferers, with prevalence returning to around 5%.At all ages, migraine without aura is more common than migraine with aura, with a ratio of between 1.5:1 and 2:1 Incidence figures show that the excess of migraine seen in women of reproductive age is mainly due to migraine without aura Thus in pre-pubertal and post-menopausal populations, migraine with aura is somewhat more common than amongst 15–50 year olds. There is a strong relationship between age, gender and type of migraine. Geographical differences in migraine prevalence are not marked. Studies in Asia and
Triggers
A migraine trigger is any factor that, on exposure or withdrawal, leads to the development of an acute migraine headache. Triggers may be categorized as behavioral, environmental, infectious, dietary, chemical, or hormonal. In the medical literature, these factors are known as 'precipitants.'
The Medline Plus Medical Encyclopedia, for example, offers the following list of migraine triggers:
Migraine attacks may be triggered by:
· Allergic reactions
· Bright lights, loud noises, and certain odors or perfumes
· Physical or emotional stress
· Changes in sleep patterns
· Smoking or exposure to smoke
· Skipping meals
· Alcohol
· Menstrual cycle fluctuations, birth control pills, hormone fluctuations during the menopause transition
· Tension headaches
· Foods containing tyramine (red wine, aged cheese, smoked fish, chicken livers, figs, and some beans), monosodium glutamate (MSG) or nitrates (like bacon, hot dogs, and salami)
· Other foods such as chocolate, nuts, peanut butter, avocado, banana, citrus, onions, dairy products, and fermented or pickled foods.
Sometimes the migraine occurs with no apparent "cause". The trigger theory supposes that exposure to various environmental factors precipitates, or triggers, individual migraine episodes. Migraine patients have long been advised to try to identify personal headache triggers by looking for associations between their headaches and various suspected trigger factors and keeping a "headache diary" recording migraine incidents and diet to look for correlations in order to avoid trigger foods. It must be mentioned, that some trigger factors are quantitative in nature, i.e., a small block of dark chocolate may not cause a migraine, but half a slab of dark chocolate almost definitely will, in a susceptible person. In addition, being exposed to more than one trigger factor simultaneously will more likely cause a migraine, than a single trigger factor in isolation, e.g., drinking and eating various known dietary trigger factors on a hot, humid day, when feeling stressed and having had little sleep will probably result in a migraine in a susceptible person, but consuming a single trigger factor on a cool day, after a good night's rest with minimal environmental stress may mean that the sufferer will not develop a migraine after all. Migraines can be complex to avoid, but keeping an accurate migraine diary and making suitable lifestyle changes can have a very positive effect on the sufferer's quality of life. Some trigger factors are virtually impossible to avoid, e.g. the weather or emotions, but by limiting the avoidable trigger factors, the unavoidable ones may have less of an impact on the sufferer.
Food
Many migraine sufferers report reduced incidence of migraines due to identifying and avoiding their individual food triggers. However, more studies are needed.
Gluten
One food elimination that has proven to reduce or eliminate migraines in a percentage of patients is gluten. For those with (often undiagnosed) celiac disease or other forms of gluten sensitivity, migraines may be a symptom of gluten intolerance. One study found that migraine sufferers were ten times more likely than the general population to have celiac disease, and that a gluten-free diet eliminated or reduced migraines in these patients. Another study of 10 patients with a long history of chronic headaches that had recently worsened or were resistant to treatment found that all 10 patients were sensitive to gluten. MRI scans determined that each had inflammation in their central nervous systems caused by gluten-sensitivity. Seven out of nine of these patients that went on a gluten-free diet stopped having headaches completely.
Aspartame
Some people may develop migraines from consuming aspartame. In a
MSG
In a large and definitive study monosodium glutamate (MSG) in large doses (2.5 grams) was associated with adverse symptoms including headache more often than was placebo.
Tyramine
The National Headache Foundation has a specific list of triggers based on the tyramine theory, detailing allowed, with caution and avoid triggers.
Weather
Several studies have found some migraines are triggered by changes in weather. One study noted 62% of the subjects thought weather was a factor but only 51% were sensitive to weather changes. Among those whose migraines did occur during a change in weather, the subjects often picked a weather change other than the actual weather data recorded. Most likely to trigger a migraine were, in order:
1. Temperature mixed with humidity. High humidity plus high or low temperature was the biggest cause.
2. Significant changes in weather
3. Changes in barometric pressure
Another study examined the effects of warm Chinook winds on migraines, with many patients reporting increased incidence of migraines immediately before and/or during the Chinook winds. The number of people reporting migrainous episodes during the Chinook winds was higher on high-wind Chinook days. The probable cause was thought to be an increase in positive ions in the air.
Other
One study found that for some migraineurs in
Treatment
Conventional treatment focuses on three areas: trigger avoidance, symptomatic control, and prophylactic pharmacological drugs. Patients who experience migraines often find that the recommended migraine treatments are not 100% effective at preventing migraines, and sometimes may not be effective at all. Pharmological treatments are considered effective if they reduce the frequency or severity of migraine attacks by 50%.Children and adolescents are often first given drug treatment, but the value of diet modification should not be overlooked. The simple task of starting a diet journal to help modify the intake of trigger foods like hot dogs, chocolate, cheese and ice cream could help alleviate symptoms. For patients who have been diagnosed with recurring migraines, migraine abortive medications can be used to treat the attack, and may be more effective if taken early, losing effectiveness once the attack has begun. Treating the attack at the onset can often abort it before it becomes serious, and can reduce the near-term frequency of subsequent attacks
Paracetamol or non-steroidal anti-inflammatory drug (NSAIDs)
The first line of treatment is over-the-counter abortive medication.
· Regarding non-steroidal anti-inflammatory drugs, a randomized controlled trial found that naproxen can abort about one third of migraine attacks, which was 5% less than the benefit of sumatriptan.
· Paracetamol, at a dose of 1000 mg, benefited over half of patients with mild or moderate migraines in a randomized controlled trial.
· Simple analgesics combined with caffeine may help.] During a migraine attack, emptying of the stomach is slowed, resulting in nausea and a delay in absorbing medication. Caffeine has been shown to partially reverse this effect. Excedrin is an example of an aspirin with caffeine product. Caffeine is recognized by the U.S. Food and Drug Administration as an Over The Counter Drug (OTC) treatment for migraine when compounded with aspirin and paracetamol
· Patients themselves often start off with paracetamol (known as acetaminophen in
Analgesics combined with antiemetics
Anti-emetics by mouth may help relieve symptoms of nausea and help prevent vomiting, which can diminish the effectiveness of orally taken analgesia. In addition some antiemetics such as metoclopramide are prokinetics and help gastric emptying which is often impaired during episodes of migraine. In the
Some patients find relief from taking other sedative antihistamines which have anti-nausea properties, such as Benadryl which in the
Serotonin agonists
Sumatriptan and related selective serotonin receptor agonists are excellent for severe migraines or those that do not respond to NSAIDsor other over-the-counter drugs Triptans are a mid-line treatment suitable for many migraineurs with typical migraines. They may not work for atypical or unusually severe migraines, transformed migraines, or status (continuous) migraines.
Anti-depressants
In addition to SSRIs, anti-depressant drugs such as tricyclics have been long established as highly efficacious prophylactic treatments. Despite not being approved by the FDA for this purpose, these drugs are widely prescribed Other anti-depressant drugs, such as bupropion and venlafaxine, have also been shown to be clinically efficacious These drugs, however, may give rise to undesirable side effects, such as insomnia, sedation or sexual dysfunction. They do offer advantages for treating patients with coexistent depression.
Ergot alkaloids
Until the introduction of sumatriptan in 1991, ergot derivatives were the primary oral drugs available to abort a migraine once it is established.
Ergot drugs can be used either as a preventive or abortive therapy, though their relative expense and cumulative side effects suggest reserving them as an abortive rescue medicine. However, ergotamine tartrate tablets (usually with caffeine), though highly effective, and long lasting (unlike triptans), have fallen out of favour due to the problem of egotisms. Oral ergotamine tablet absorption is reliable unless the patient is nauseated. Anti-nausea administration is available by ergotamine suppository (or Ergostat sublingual tablets made until circa 1992). Ergot drugs themselves can be so nauseating it is advisable for the sufferer to have something at hand to counteract this effect when first using this drug. Ergotamine-caffeine 1/100 mg fixed ratio tablets (like Cafergot, Ercaf, etc.) are much less expensive per headache than triptans, and are commonly available in
Other agents
If over-the-counter medications do not work, or if triptans are unaffordable, the next step for many doctors is to prescribe Fioricet or Fiorinal, which is a combination of butalbital (a barbiturate), paracetamol (in Fioricet) or acetylsalicylic acid (more commonly known as aspirin and present in Fiorinal), and caffeine. While the risk of addiction is low, butalbital can be habit-forming if used daily, and it can also lead to rebound headaches. Barbiturate-containing medications are not available in many European countries.
Amidrine, Duradrin, and Midrin is a combination of acetaminophen, dichloralphenazone, and isometheptene often prescribed for migraine headaches. Some studies have recently shown that these drugs may work better than sumatriptan for treating migraines.
Anti-emetics may need to be given by suppository or injection where vomiting dominates the symptoms.
Recently it has been found that calcitonin gene related peptides (CGRPs) play a role in the pathogenesis of the pain associated with migraine as triptans also decrease its release and action. CGRP receptor antagonists such as olcegepant and telcagepant are being investigated both in vitro and in clinical studies for the treatment of migraine.
Status migrainosus
Status migrainosus is characterized by migraine lasting more than 72 hours, with not more than four hours of relief during that period. It is generally understood that status migrainosus has been refractory to usual outpatient management upon presentation.
Treatment of status migrainosus consists of managing comorbidities (i. e. correcting fluid and electrolyte abnormalities resulting from anorexia and nausea/vomiting often accompanying status migr.), and usually administering parenteral medication to "break" (abort) the headache.
Although the literature is full of many case reports concerning treatment of status migrainosus, first line therapy consists of intravenous fluids, metoclopramide, and triptans
Herbal treatment
The herbal supplement feverfew is marketed by the as an OTC migraine abortive, administered sublingually (under the tongue) in a mixture with ginger. An open-label study found some tentative evidence of the treatment's effectiveness, but no scientifically sound study has been done. Cannabis in addition to prevention is also known to relieve pain during the onset of a migraine.
Preventive treatment
Preventive treatment of migraines can be an important component of migraine management. Such treatments can take many forms, including everything from taking certain drugs or nutritional supplements, to lifestyle alterations such as increased exercise and avoidance of migraine triggers. One such book that outlines these preventative measures quite well is "7 Steps To A Healthy Brain" by Dr. Winner.
The goals of preventive therapy are to reduce the frequency, painfulness, and/or duration of migraines, and to increase the effectiveness of abortive therapy Another reason to pursue these goals is to avoid medication overuse headache (MOH), otherwise known as rebound headache, which is a common problem among migraneurs. This is believed to occur in part due to overuse of pain medications, and can result in chronic daily headache
Many of the preventive treatments described below are quite effective: Even with a placebo (sham treatment), one-quarter of patients find that their migraine frequency is reduced by half or more and actual treatments often far exceed this figure
Trigger avoidance
Patients should attempt to identify and avoid factors that promote or precipitate migraine episodes. Moderation in alcohol and caffeine intake, consistency in sleep habits, and regular meals may be helpful. General dietary restriction has not been demonstrated to be an effective approach to treating migraine. However, eliminating particular foods that are known to trigger migraines in an individual can be very effective.
Gluten-Free Diet
Some individuals have a condition called celiac disease that results in the body incorrectly processing gluten. Studies have suggested that many migraine sufferers have celiac disease, and for those who do, decreasing gluten intake may significantly reduce migraine frequency. Celiac disease and gluten sensitivity may be an underlying cause of migraines in some patients, and a gluten-free diet has been demonstrated to reduce, if not completely eliminate, migraines in these individuals. A study of 10 patients with a long history of chronic headaches that had recently worsened or were resistant to treatment found that all 10 patients were sensitive to gluten. MRI scans determined that each had inflammation in their central nervous systems caused by gluten-sensitivity. Seven out of nine of these patients that went on a gluten-free diet stopped having headaches completely Another study showed that migraneurs were 10 times more likely than the general population to have celiac disease, and that for migraneurs with celiac disease, a gluten-free diet improved blood-flow to the brain and either eliminated migraines or reduced migraine frequency, duration, and intensity
Prescription drugs
A 2006 review article by
Following appropriate management of acute migraine, patients should be evaluated for initiation of preventive therapy. Factors that should prompt consideration of preventive therapy include the occurrence of two or more migraines per month with disability lasting three or more days per month; failure of, contraindication for, or adverse events from acute treatments; use of abortive medication more than twice per week; and uncommon migraine conditions (e.g., hemiplegic migraine, migraine with prolonged aura, migrainous infarction). Patient preference and cost also should be considered.
...Therapy should be initiated with medications that have the highest levels of effectiveness and the lowest potential for adverse reactions; these should be started at low dosages and titrated slowly. A full therapeutic trial may take two to six months. After successful therapy (e.g., reduction of migraine frequency by approximately 50 percent or more) has been maintained for six to 12 months, discontinuation of preventive therapy can be considered.
Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. Supervision by a neurologist is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next. Often preventive medications do not have to be taken indefinitely. Sometimes as little as six months of preventive therapy is enough to "break the headache cycle" and then they can be discontinued.
The most effective prescription medications include several drug classes:
· Beta blockers such as propranolol and atenolol. A meta-analysis by the Cochrane Collaboration of nine randomized controlled trials or crossover studies, which together included 668 patients, found that propranolol had an "overall relative risk of response to treatment (here called the 'responder ratio')" was 1.94. Anticonvulsants such as valproic acid and topiramate. A meta-analysis by the Cochrane Collaboration of ten randomized controlled trials or crossover studies, which together included 1341 patients, found anticonvulsants had an "2.4 times more likely to experience a 50% or greater reduction in frequency with anticonvulsants than with placebo" and a number needed to treat of 3.8. However, concerns have been raised about the marketing of gabapentin. Antidepressants include tricyclic antidepressants (TCAs) such as amitriptyline and the newer selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine. A meta-analysis by the Cochrane Collaboration found selective serotonin reuptake inhibitors are no more effective than placebo. Another meta-analysis found benefit from SSRIs among patients with migraine or tension headache; however, Sthe effect of SSRIs on only migraines was not separately reported. A randomized controlled trial found that amitriptyline was better than placebo and similar to propranolol. A wide range of pharmacological drugs have been evaluated to determine their efficacy in reducing the frequency or severity of migraine attacks. These drugs include beta-blockers, calcium antagonists, neurostabalizers, nonsteroidal anti-inflammatory drugs (NSAIDs),tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), other antidepressants, and other specialized drug therapies. The US Headache Consortium lists five drugs as having medium to high efficacy: amitriptyline, divalproex, timolol, propranolol and topiramate. Lower efficacy drugs listed include aspirin, atenolol, fenoprofen, flurbiprofen, fluoxetine, gabapentin, ketoprofen, metoprolol, nadolol, naproxen, nimodipine, verapamil and Botulinum A. Additionally, most antidepressants (tricyclic, SSRIs and others such as Bupropion) are listed as "clinically efficacious based on consensus of experience" without scientific support Many of these drugs may give rise to undesirable side-effects, or may be efficacious in treating comorbid conditions, such as depression.
Other drugs:
· Methysergide was withdrawn from the
· Memantine, which is used in the treatment of Alzheimer's disease, is beginning to be used off label for the treatment of migraines. It has not yet been approved by the FDA for the treatment of migraines.
· Aspirin can be taken daily in low doses such as 80 mg, the blood thinners in ASA have been shown to help some migrainures, especially those who have an aura.
HERBAL AND NUTRITIONAL SUPPLEMENTS
Butterbur
50 mg or 75 mg/day of butterbur (Petasites hybridus) rhizome extract was shown in a controlled trial to provide 50% or more reduction in the number of migraines to 68% of participants in the 75 mg dose group, 56% in the 50 mg dose group and 49% in the placebo group after four months. Native butterbur contains some carcinogenic compounds, but a purified version, Petadolex, does not.
Cannabis
Cannabis was a standard treatment for migraines from 1874 to 1942 has been reported to help people through an attack by relieving the nausea and dulling the head pain, as well as possibly preventing the headache completely when used as soon as possible after the onset of pre-migraine symptoms, such as aura.
Coenzyme Q10
Supplementation of coenzyme Q10 has been found to have a beneficial effect on the condition of some sufferers of migraines. In an open-label trial Young and Silberstein found that 61.3% of patients treated with 100 mg/day had a greater than 50% reduction in number of days with migraine, making it more effective than most prescription prophylactics. Less than 1% reported any side effects. A double-blind placebo-controlled trial has also found positive results.
Feverfew
The plant feverfew (Tanacetum parthenium) is a traditional herbal remedy believed to reduce the frequency of migraine attacks. A number of clinical trials have been carried out to test this claim, but a 2004 review article concluded that the results have been contradictory and inconclusive However, since then, more studies have been carried out. As well as its prophylactic properties, feverfew is also touted as a migraine abortative.
Magnesium citrate
Magnesium citrate has reduced the frequency of migraine in an experiment in which the magnesium citrate group received 600 mg per day oral of trimagnesium dicitrate. In weeks 9–12, the frequency of attacks was reduced by 41.6% in the magnesium citrate group and by 15.8% in the placebo group.
Riboflavin
The supplement Riboflavin (also called Vitamin B2) has been shown (in a placebo-controlled trial) to reduce the number of migraines, when taken at the high dose of 400 mg daily for three months
Vitamin B12
There is tentative evidence that Vitamin B12 may be effective in preventing migraines In particular, in an open-label pilot study, 1 mg of intranasal hydroxocobalamin (a form of Vitamin B12), taken daily for three months, was shown to reduce migraine frequency by 50% or more in 10 of 19 participants Although the study was not placebo-controlled, this response is larger than the typical placebo effect in migraine prophylaxis.
Melatonin
Melatonin has been studied in migraine and other headache disorders. In an open label study, migraine patients taking melatonin 3 mg before bedtime with a good headache response and tolerability. Melatonin has multiple mechanisms affecting migraine
Surgical Treatments
Surgery may be used to treat migraines by severing the corrugators’ supercilious muscle and zygomaticotemporal nerve. The treatment may reduce or eliminate headaches in some individuals. In 2005, researchwas published indicating that some people with a patent foramen ovale (PFO), a hole between the upper chambers of the heart, suffer from migraines which may have been caused by the PFO. The migraines reduce in frequency if the hole is patched. Several clinical trials are currently under way in an effort to determine if a causal link between PFO and migraine can be found. Early speculation as to this relationship has centered on the idea that the lungs detoxify blood as it passes through. The PFO allows uncleaned blood to go directly from the right side of the heart to the left without passing through the lungs.
Botulin toxin has been used to treat individuals with frequent or chronic migraines. It appears to be effective for chronic migraines but not useful in the treatment of episodic migraine. Spinal cord stimulators are an implanted medical device sometimes used for those who suffer severe migraines several days each month.
Behavioral treatments
Many physicians believe that exercise for 15–20 minutes per day is helpful for reducing the frequency of migraines Specific exercises have been developed that are believed to effectively reduce the severity and frequency of migrainesSleep is often a good solution if a migraine is not so severe as to prevent it, as when a person awakes the symptoms will have most likely subsided.
Diet, visualization, and self-hypnosis are also alternative treatments and prevention approaches.
Sexual activity has been reported by a proportion of male and female migraine sufferers to relieve migraine pain significantly in some cases
In many cases where a migraine follows a particular cycle, attempting to interrupt the cycle may prolong the symptoms. Letting a headache "run its course" by not using
Painkillers can sometimes decrease the length of an episode. This is especially true of cases where vomiting is common, as often the headache will subside immediately after vomiting. Curbing the pain may delay vomiting, and prolong the headache
Alternative medicine
A number of forms of alternative medicine, particularly bodywork, are used in preventing migraines.
Clinical trials have suggested that chiropractic care may be an efficacious treatment for migraine headaches Likewise, Massage therapy, physical therapy, and Bowen Techniqueare often very effective forms of treatment to reduce the frequency and intensity of migraines] These initial studies are limited by lack of control subjects, poor control subjects, lack of blind study design, small sample sizes, and other methodological flaws. Chiropractic researchers have argued that the current evidence for chiropractic treatment of migraines indicates that "evidence is steadily increasing to the point where there is now seen to be a moderate level of efficacy for chiropractic SMT in the treatment of headaches or migraines The effect of chiropractic treatment may be mediated by stress release, and may be more efficacious for tension-type headaches than migraines
A review of the literature until 2004 found that "Chiropractic manipulation demonstrated a trend toward benefit in the treatment of TTH, but evidence is weak. ... In the absence of clear evidence regarding their role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of physical treatments for headache management; in most cases, the use of these modalities should complement rather than supplant better-validated forms of therapy." Frequent migraines can leave the sufferer with a stiff neck which can cause stress headaches that can then exacerbate the migraines. Claims have been made that Myofascial Release can relieve this tension and in doing so reduce or eliminate the stress headache element
Some migraine sufferers find relief through acupuncture, which is usually used to help prevent headaches from developing. Sometimes acupuncture is used to relieve the pain of an active migraine headache in one controlled trial of acupuncture with a sham control in migraine; the acupuncture was not more effective than the sham acupuncture but was
MIASMSMATIC BACKGROUND
Miasm is a Greek word. It means pollution or contagious foul exhalation from human body or any infective material.
There are three types of Miasms
v Psori
v Syphilis
v Sycotic
v Tubercular
In the case of Migrine the symptoms that covers,
v Frequent one sided headache even from moderate emotion disturbances - Psora, Tubercular.
v Vertige – Psora
v Dizziness inability to think or perform mental Labour – Psora
v Headache of various types Frontal, Temporil, Tempro parietal – Psora
v One sided headache – Psora
v Morning headache – Psora
v <>
v Visual Halluciladions – Psora
v Photophobia – Psora, Tubercular, Syphilis
v Nausea, Vomiting – Psora
v <>
v Frontal / Vertex headache - Tubercular
All most all of the symptoms covers Psora.
So DOMINANT MIASM – PSORA.
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