Migraine

Definition

A migraine is a type of primary headache that some people get repeatedly over time. Migraines are different from other headaches because they occur with symptoms such as nausea, vomiting, or sensitivity to light. In most people, a throbbing pain is felt only on one side of the head.

Migraines are classified as either "with aura" or "without aura." An aura is a group of neurological symptoms, usually vision disturbances, that serve as warning sign. Patients who get auras typically see a flash of brightly colored or blinking lights shortly before the headache pain begins. However, most people with migraines do not such warning signs. See also:

• Migraine without aura (no warning symptoms)
• Migraine with aura (visual disturbances before the headache starts)
• Mixed tension migraine (features of both migraines and tension headache)

Causes, incidence, and risk factors

A lot of people get migraines -- about 11 out of 100. The headaches tend to start between the ages of 10 and 46 and may run in families. Migraines occur more often in women than men. Pregnancy may reduce the number of migraines attacks. At least 60 percent of women with a history of migraines have fewer such headaches during the last two trimesters of pregnancy.

Until the 1980s, scientists believed that migraines were due to changes in blood vessels within the brain. Today, most believe the attack actually begins in the brain itself, and involves various nerve pathways and chemicals inthe brain. A migraine attack can be triggered by stress, food, environmental changes, or some other factor. However, the exact chain of events remains unclear.

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 or caffeine
• Menstrual cycle fluctuations, birth control pills
• 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

Symptoms

Migraine headaches, which can be dull or severe, usually:

• Feel throbbing, pounding, or pulsating
• Are worse on one side of the head
• Last 6 to 48 hours

Symptoms accompanying migraines include:

• Nausea and vomiting
• Sensitivity to light or sound
• Loss of appetite
• Fatigue
• Numbness, tingling, or weakness

Warning signs (auras) that can precede a migraine include seeing stars or zigzag lines, tunnel vision, or a temporary blind spot.

Symptoms that may linger even after the migraine has gone away include:

• Feeling mentally dull, like your thinking is not clear or sharp
• Increased need for sleep
• Neck pain

Signs and tests

Migraine headache may be diagnosed by your doctor based on your symptoms, history of migraines in the family, and your response to treatment. Your doctor will take a detailed history to make sure that your headaches are not due to tension, sinus inflammation, or a more serious underlying brain disorder. During the physical exam, your doctor will probably not find anything wrong with you.

Sometimes an MRI or CT scan is obtained to rule out other causes of headache like sinus inflammation or a brain mass. In the case of a complicated migraine, an EEG may be needed to exclude seizures. Rarely, a lumbar puncture (spinal tap) might be performed.

Treatment

There is no specific cure for migraine headaches. The goal is to prevent symptoms by avoiding or altering triggers. When you do get migraine symptoms, try to treat them right away. The headache may be less severe.

A good way to identify triggers is to keep a headache diary. See headache.

When migraine symptoms begin:

• Rest in a quiet, darkened room
• Drink fluids to avoid dehydration (especially if you have vomited)
• Try placing a cool cloth on your head

Over-the-counter pain medications like acetaminophen, ibuprofen, or aspirin are often helpful, especially when your migraine is mild. (Be aware, however, that chronic usage of such pain medications may result in rebound headaches.) If these don't help, ask your doctor about prescription medications.

Your doctor will select from several different types of medications, including:

• Ergots like dihydroergotamine or ergotamine with caffeine (Cafergot)
• Triptans like sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova), and zolmitriptan (Zomig); these are available as a tablet, nasal spray, or self-administered injection
• Isometheptene (Midrin)
• Stronger pain relievers (narcotics)

Many of the prescription medications for migraines narrow your blood vessels. Therefore, these drugs should not be used if you have heart disease, unless specifically instructed by your doctor.

If you wish to consider an alternative, feverfew is a popular herb for migraines. Several studies, but not all, support using feverfew for treating migraines. If you are interested in trying feverfew, make sure your doctor approves. Also, know that herbal remedies sold in drugstores and health food stores are not regulated. Work with a trained herbalist when selecting herbs.

Support Groups

American Council for Headache Education - www.achenet.org

The National Migraine Association -www.migraine.org

National Headache Foundation - www.headaches.org

Expectations (prognosis)

Every person responds differently to treatment. Some people have rare headaches that require little to no treatment. Others require the use of several medications or even occasional hospitalization.

Complications

Migraine headaches generally represent no significant threat to your overall health. However, they can be chronic, recurrent, frustrating, and they may interfere with your day-to-day life.

Stroke is an extremely rare complication from severe migraines. This risk may be due to prolonged narrowing of the blood vessels, limiting blood flow to parts of the brain for an extended period of time.

Calling your health care provider

Call 911 if:

• You have unusual symptoms not experienced with a migraine before, like speech or vision problems, loss of balance, or difficulty moving a limb
• You are experiencing "the worst headache of your life"

Call your doctor immediately if:

• Your headache pattern or intensity is different
• Your headache gets worse when you lie down

Also, call your doctor if:

• Previously effective treatments no longer help
• Side effects from medication occurs (irregular heartbeat, pale or blue skin, extreme sleepiness, persistent cough, depression, fatigue, nausea, vomiting, diarrhea, constipation, stomach pain, cramps, dry mouth, extreme thirst, or others)
• You are likely to become pregnant -- some medications should not be taken when pregnant

Prevention

• Avoid smoking, caffeine, and alcohol
• Exercise regularly
• Get enough sleep each night
• Learn to relax and reduce stress -- try progressive muscle relaxation (contracting and releasing muscles throughout your body), meditation, biofeedback, or joining a support group

If you get at least three headaches per month, your doctor may prescribe medication for you to prevent recurrent migraines.

Such prescription drugs include:

• Beta-blockers such as propranolol (Inderal)
• Anti-depressants, including tricyclics like amitriptyline (Elavil) or selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac, Sarafem), paroxetine (Paxil), or sertraline (Zoloft)
• Anti-convulsants such as valproic acid (Depacon, Depakene), divalproex sodium (Depakoate), or topiramate (Topamax)
• Calcium channel blockers such as verapamil

References

Morantz C. Practice Guideline Briefs. Am Fam Physician. Mar 2005; 71(5); 1019-899.

Schroeder BM . AAFP/ACP-ASIM release guidelines on the management and prevention of migraines.  Am Fam Physician. Mar 2003; 67(6): 1392, 1395-7.

Noble J, ed. Textbook of Primary Care Medicine. 3rd ed. St. Louis, MO: Mosby; 2001.

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, MO: Mosby; 2002.

Goetz CG, Pappert EJ. Textbook of Clinical Neurology. 2nd ed. Philadelphia, PA: Saunders; 2003.

Illustrations

Migraine headache

Vascular headaches

Migraine cause

CT scan of the brain

Central nervous system

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