Migraine is a type of headache that occurs mostly on one side of the head. It occurs frequently and sometimes causes what the medical fraternity calls an "aura" - disturbances in vision or other senses. The aura occurs just before the headache or after it. This disorder which has a strong genetic component affects more women than men.
Signs and symptoms
If the following symptoms show up, it's likely that the patient is suffering from migraine.
• Excruciating headache that starts and stops quickly and repeatedly; worsens with physical activity
• Ache is mostly in the frontotemporal and ocular area, but may be felt at any part surrounding the head or neck.
• Long-lasting pain, up to 1 or 2 hours, that spreads from the backside of the head to the front.
• Headache lasting up to 72 hours.
• Nausea and vomiting, light-headedness, anorexia and food intolerance.
• Sensitivity to sound and light
Migraine aura - characteristics
• The aura may last for 5-60 minutes.
• Disturbances in vision; sometimes accompanied by disturbances in other senses or motor functions.
• Scintillating scotoma - Flashy zigzag lines in vision
A migraine headache may also have the following conditions:
• Tender muscles around Cranium/cervix
• Tachycardia or bradycardi
• Horner syndrome (ie, relative miosis with 1-2 mm of ptosis on the same side as the headache)
• Hemisensory or hemiparetic neurologic deficits (ie, complicated migraine)
• Adie-type pupil (ie, severe light sensitivity)
• Hypertension or hypotension
According to International Headache society, if the patient has had a minimum of five episodes of headache that lasted from 4 to 72 hours and if the headache had any two characteristics listed below, he or she is having migraine.
• Localised headache, mostly on one side of the head.
• Severe or moderate pain that starts and stops quickly and repeatedly
• Inability to perform routine activities-even climbing stairs or walking. Pain increases with body movement.
To categorise the headache as migraine, it is mandatory that one of the following symptoms also shows up:
• Vomiting and/or nausea
• Phonophobia and photophobia
Migraine can be classified as follows:
• Migraine with aura (formerly known as classic migraine)
• Probable migraine with aura
• Migraine without aura (formerly known as common migraine)
• Probable migraine without aura
• Childhood periodic syndromes that may not be precursors to or associated with migraine
• Chronic migraine
• Chronic migraine associated with analgesic overuse
• Migrainous disorder not fulfilling above criteria
Different types of migraine are:
• Childhood periodic syndromes
• Basilar-type migraine
• Late-life migrainous accompaniments
• Status migrainosus
• Hemiplegic migraine
• Retinal migraine
• Ophthalmoplegic migraine
Depending on the focal neurologic findings listed below, the doctor determines the type of migraine. These symptoms may show up during the headache. It may even last for hours after the pain subsides.
• Localised weakness or paralysis, mostly on one side - Hemiplegic migraine
• Difficulty in balancing the body, syncope and aphasia - Basilar-type migraine
• Oculomotor nerve palsy - ocular muscle paralysis and ptosis, damage to the third cranial nerve, affectomg the pupillary response - Ophthalmoplegic migraine
Tests and imaging
Lab tests may be performed to find out if any condition other than migraine is causing the pain. For example, erythrocyte sedimentation rate and C-reactive protein may rule out temporal/giant cell arteritis.
Neuroimaging may not be needed if the patient has a history of recurring migraine. A normal neurologic examination might suffice.
The FDA recently approved sumatriptan iontophoretic transdermal system (Zecuity, NuPathe Inc), a transdermal triptan patch, for treating migraine with or without aura in adults. The patch can be used only once and relieves migraine-related nausea. In an 800-patient trial, the patch was found to be effective in reliving migraine pain, sonophobia, migraine-related nausea and photophobia within 2 hours.
Treatment using drugs
Abortives (to alleviate the symptoms in the acute phase) or preventive agents are used to manage migraine.
If given within 15 minutes of the onset of headache, abortives are very effective and prevents the ache from spreading to other parts of the head.
The following abortives are found to be effective in treating migraine:
• Serotonin receptors (for example, 5-hydroxytryptamine–1 or 5-HT1) or agonists (triptans)
• Ergot alkaloids (eg, ergotamine, dihydroergotamine [DHE])
• Combination products
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
Prophylactic migraine therapy may be needed if the following symptoms show up:
• More than 2 migraine episodes per month
• A single migraine attack lasts longer than 24 hours
• Patient's lifestyle is affected. Unable to perform routine activities for two-three days
• Symptomatic medications show no results or are contraindicated
• Abortive therapy fails or is overused
• Abortive medications are taken more than twice in a week
• Risk of permanent neurologic injury - for example in hemiplegic migraine
Prophylactic medications include the following:
• Antiepileptic drugs
• Beta blockers
• Calcium channel blockers
• Tricyclic antidepressants
• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin antagonists
• Botulinum toxin
The treatment may also focus on reducing the triggers of migraine. (For example, insomnia, stress, fatigue, and certain types of foods). Nonpharmacologic therapy (such as biofeedback, cognitive-behavioral therapy) may also prove useful. Integrative medicines such as riboflavin, feverfew, magnesium, butterbur and coenzyme Q10 are also used to treat migraine.
Dr. Sanjiv C.C is a senior neurologist who is an expert in Parkinsons diagnosis and management. He is available for consultation in the city of Bangalore at Apollo Hospital, Jayanagar.