Migraine

Headache is the most significant complaint that we come across in our medical practice. Headache can be a symptom of another disease which means secondary to some other illness or it could be the disease itself. But in any case it needs immediate medical attention.

When do we say headache is secondary?

When there is a disease or illness like brain tumour, meningitis, temporal arteritis, glaucoma, intracranial haemorrhage and hypertension or even sinusitis & simple common cold could be a reason for head ache. In this situation when there is a cause for the headache we call it secondary headache.

When do we say headache is primary?

There is no organic cause i.e. no systemic illness or any health related issue that could provoke this headache. According to the International classification of the primary headache disorders are classified as following

1. Migraine
2. Tension type headache
3. Cluster headache and other trigeminal autonomic cephalalgia
4. Other primary headaches

In this post we will discuss about migraine which is the second most common cause of headache.

Migraine

It is a primary headache which is provoked by various stimuli. Stimuli of minute strength which do not incite headache in normal people could provoke headache in individual susceptible to migraine.

Stimuli can be

Loud noise

Bright lights

Stress

Weather change

Menstrual cycle

Alcohol

Excess/less sleep

Hunger

What is the mechanism of headache?

Migraine does not have any particular cause. Genetic factors may play a role. Migraine headaches are usually due to dilatation of the blood vessels which stimulates the nerve endings. Serum 5-hydroxytryptamine is increased before the onset of headache and decreases during headache. Medication which blocks 5-hydroxytryptamine have been developed which could help to prevent the attack.

How do you diagnose migraine?

Migraine can usually be divided into phases.

First phase Patient is healthy and does not have any complaints.

Second phase Patient will have a period of aura which consists of symptoms like nausea, vomiting, photophobia, vertigo, alteration of consciousness, flashing of lights or other symptoms . This prodromal phase lasts 15 minutes to one hour or more.

Third phase Headache

Fourth phase After headache, patient will feel tired and irritated.

Types of Migraine

Migraine with aura

Migraine without aura

Abdominal migraine

Menstrual migraine

Basilar migraine

Hemiparetic migraine

Opthalmoplegic migraine

Facioplegic migraine

Migraine does occur in children as well. Especially abdominal migraine, in which the child has abdominal pain for several hours but there is no headache may be mild. These patients experience the same episode with certain subset of symptoms like nausea, vomiting or any other aura symptoms. Children who experience this abdominal migraine are prone to develop migraine in their later years of life.

Diagnosing Migraine

Criteria

Headache lasts for 4-72hours in patient. Physical examination will be normal and no cause for the headache can be found.

At least 2 of the following

Unilateral pain

Throbbing pain

Aggravation by movement

Moderate or severe intensity

Any 1 of the following

Nausea/vomiting

Photophobia and phonophobia

Headache must be differentiated from other primary headaches especially tension type headache. The most significant feature of migraine is the presence of a second phase with a subset of symptoms before the onset of headache.

Treatment:

Patient should keep a diary of the number of attacks and the medications used during an acute attack.

MIDAS which stands for Migraine Disability Assessment Score is a questionnaire with number of questions regarding the headache and the limitations in your daily activity you had during an attack. This would facilitate the doctor to assess the extent of the disease.

Patient must learn about all possible activities that will elicit the headache and must try to avoid those circumstances.

We can also prevent migraine. But to whom do we prescribe preventive medications?

1. Patient who do not respond to treatment during an attack

2. Patient who respond poorly to drug therapy during an attack

3. Patients who have very frequent attacks i.e. >5 attacks in a month.

Treatment of acute attacks

Usually treatment of acute attack depends on the severity. If it is a mild attack then oral agent can be used but in case of severe attack parenteral therapy must be used.

Treatment of migraine includes drugs from the following three groups of drugs.

1. Anti Inflammatory agents

2. 5HT_1B/1D receptor agonists

3. Dopamine receptor antagonists.

In case of menses related headache ergotamine or oestrogen patches can be used.

In children, the reasons of migraine are due to hunger and dehydration. So it is necessary to have regulated meal timings and sleeping habit in children with migraine. For the treatment of migraine in children, we can use paracetamol or ibuprofen. Aspirin should not be used in children. Domperidone and prochlorperazine is suitable for children under 12years of age.

None of the medication should be used without proper counselling with your family doctor.

We will discuss about the various other kinds of headache in our future posts.

Reference

Fauci As, Kasper DL, Braunwald E, HauserSL, Longo DL, Jameson JL,Loscalzo:Headache in Harrison’s Principles of Internal Medicine, 17^th Edition.