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Migraine

Definition


Disease: Migraine Migraine
Category: Neurological diseases
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Disease Definition:

The chronic headaches that can cause significant pain for hours or even days are called migraines. Sometimes all the patient can think about is finding a dark, quiet place to lie down when the symptoms are so severe.

Tingling in the arm or leg, blind spots or flashes of light are some of the sensory warning signs or symptoms (auras) that some migraines are preceded or accompanied by. Extreme sensitivity to light and sound, nausea and vomiting also accompany a migraine.

In reducing the frequency and severity of migraines, medications can help, despite the fact that there's no cure for migraines. Talking to the doctor about trying a different migraine medication is worth it if treatment hasn't worked for the patient in the past. A tremendous difference may be achieved by the right medicines combined with lifestyle changes and self-help remedies.

Work Group:


Prepared by: Scientific Section

Symptoms, Causes

Symptoms:

In childhood, adolescence or early adulthood is when migraines usually begin. Some or all of the following signs and symptoms can be produced by a typical migraine attack:

 

  • Nausea with or without vomiting
  • Sensitivity to light and sound
  • Head pain with a throbbing or pulsating quality
  • Moderate to severe pain, which may be confined to one side of the head or may affect both sides
  • Pain that worsens with physical activity
  • Pain that interferes with the regular activities of the patient


Though the frequency with which headaches occur varies from one person to another, migraines typically last from four to 72 hours when the condition is left untreated. The patient may have migraines several times a month or much less frequently.

"Classic migraines" was previously the name of migraines with auras that some people have, and "common migraines" was previously the name of migraines without auras that most people experience. Feeling pins and needles in an arm or leg and changes in the vision of the patient like seeing flashes of light can be included in auras. So, not all migraines are the same.

Before the headache actually strikes, the patient may have one or more sensations of premonition (prodrome) whether or not he/she has auras; these sensations of premonition include the following:

 

  • Drowsiness
  • Irritability or depression
  • Cravings for sweets
  • Feelings of elation or intense energy
  • Thirst


The patient may keep a record of the attacks and how he/she treated them if he/she experiences signs and symptoms of migraine. After that, the headaches as well as a treatment plan may be discussed with the doctor.
The patient should seek a medical help if the pattern of the headaches changes suddenly feels different, even if the patient has a history of headaches.

Having any of the following signs and symptoms that may indicate other more serious medical problems, one should immediately go to the emergency room or see the doctor:

 

  • A chronic headache that is worse after straining, a sudden movement, exertion or coughing
  • Headache after a head injury, especially if the headache gets worse
  • An abrupt, severe headache like a thunderclap
  • New headache pain if one is older than 50
  • Headache with mental confusion, fever, rash, stiff neck, trouble speaking, seizures, double vision, numbness or weakness.

Causes:

Environmental factors and genetics seem to play a role, though much about the cause of migraines is not really known.

Changes in the trigeminal nerve which is a major pain pathway may be the cause of migraines. Imbalances in brain chemicals may also be involved such as serotonin, a chemical that helps regulate pain in the nervous system.

The trigeminal system may be triggered to release substances called neuropeptides which travel to the brain's outer covering (meninges); this may be caused when serotonin levels drop during migraines. Headache pain is the result of this.

Migraine triggers:
A number of things may trigger headaches, whatever the exact mechanism of these headaches. The following are included in the common migraine triggers:

Sensory stimuli:
Migraines can be produces by loud sounds, sun glare and bright lights.  They may also be triggered by unusual smells such as unpleasant odors, like secondhand smoke and paint thinner and pleasant scents, like perfume.

Foods:
Certain foods may appear to trigger some migraines. Fasting or skipping meals can also trigger migraines. Processed foods; overuse of caffeine; salty foods; aged cheeses; alcohol, especially beer and red wine; aspartame; monosodium glutamate, which is a key ingredient in some Asian foods are included in common offenders as well.

Hormonal changes in women:
In many women with known migraines, fluctuations in estrogen seem to trigger headaches. When they have a major drop in estrogen, immediately before or during their periods, women with a history of migraines often report headaches. The tendency to develop migraines during pregnancy or menopause is increased in others. Though some women find it beneficial to take hormonal medications such as hormone replacement therapy and oral contraceptives, these medications may worsen migraines as well.

Medications:
Migraines can be aggravated by certain medications.

Changes in the environment:
A migraine may be promoted by a change of barometric pressure or weather.

Changes in wake-sleep pattern:
In some individuals, either getting too much sleep or missing sleep may serve as a trigger for migraine attacks, so can jet lag.

Stress:
Migraines can be instigated by stress at home or work.

Physical factors:  
Migraines may be provoked by intense physical exertion, including sexual activity.

One may become more prone to having migraines because of the following factors:

Being younger than 40:
In people who are between 30 and 39 years migraines are most common, and half the people who suffer from migraines started getting them before they were 20.

Having a family history:
There is a good chance that a person will have migraines if one or both of his/her parents have the condition, as many people with migraines have a family history of migraine.

Being female:
By the time of puberty, more girls are affected by headaches, despite the fact that these headaches tend to affect boys more than girls during childhood. Additionally, women are three times more likely than men to have migraines.

Complications

Complications:

Problems are sometimes caused by the efforts to control the pain, such as:

Serotonin syndrome:
If a person takes the migraine medicines called triptans, such as zolmitriptan or sumatriptan , along with antidepressants known as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs), this potentially life-threatening drug interaction can occur.

Abdominal problems:
Ulcers, bleeding and abdominal pain may be caused by nonsteroidal anti-inflammatory drugs (NSAIDs) like acetylsalicylic acid and ibuprofen, especially if these drugs are taken for a long period of time or in large doses.

Rebound headaches:
A person may be setting himself/herself up for a serious complication known as rebound headaches when taking prescription or over-the-counter headache medications in high doses or more than nine days per month. When medications not only stop relieving pain but actually begin to cause headaches, rebound headaches occur. In this case, the patient will be trapped in a vicious cycle when using more pain medication.

Treatments:

To treat migraines, a variety of drugs have been specifically designed. Some drugs commonly used to treat other conditions may help prevent or relieve migraines as well. There are two broad categories that the medications used to combat migraines are divided to:

Preventive medications:
To reduce the frequency or severity of migraines, these types of drugs are taken regularly, often on a daily basis.

Pain-relieving medications:
These types of drugs are designed to stop symptoms that have already begun and are taken during migraine. These medications are also known as acute or abortive treatment.

The degree of disability the headaches cause, the frequency and severity of the headaches and the other medical conditions of the patient are the things that choosing a strategy to manage the migraines depends on. Some medications aren't used for children. If a woman is breast-feeding or pregnant, some medications aren't recommended. The doctor can help in finding the right medication for each person.

MEDICATIONS THAT CAN RELIEVE PAIN:
In order to get the best results, pain-relieving drugs should be taken as soon as signs or symptoms of a migraine are experienced. If the patient rests or sleeps in a dark room after taking them, it may help as well. Some examples are:

Nonsteroidal anti-inflammatory drugs (NSAIDs):
Mild migraines may be relieved by these medications such as acetylsalicylic acid or ibuprofen. Moderate migraines may be eased by drugs marketed specifically for migraine, such as the combination of caffeine, acetaminophen and acetylsalicylic acid; however, these drugs aren't effective alone for severe migraines. NSAIDs can lead to rebound headaches, ulcers and gastrointestinal bleeding in case they are taken for long periods of time or too often.

Triptans:
Triptans are the drug of choice for many people with severe migraine attacks. In relieving sensitivity to light and sound, nausea and pain that are associated with migraines, these drugs are quite affective. Naratriptan, zolmitriptan, frovatriptan, almotriptan, sumatriptan, rizatriptan and eletriptan are some examples of these medications. Muscle weakness, dizziness and nausea are included in the side effects of triptans. For people at risk of strokes and heart attacks, these medications are not recommended. In 2008, a new, single-tablet combination of sumatriptan and naproxen sodium became available. In relieving migraine symptoms, it's more effective than either medication on its own.

Ergot:
Ergotamine is less effective than triptans and it's is much less expensive. In people whose pain lasts for more than 48 hours, this medication seems most effective. An ergot derivative that is more effective and has fewer side effects than ergotamine is dihydroergotamine.

Anti-nausea medications:
Medication for nausea is appropriate and is usually combined with other medications because migraine attacks are often accompanied by nausea with or without vomiting. The medications that are usually prescribed are prochlorperazine (oral or suppository) and metoclopramide (oral).

Butalbital combinations:
Sometimes, to treat migraine attacks, medications that combine the sedative butalbital with acetylsalicylic acid or acetaminophen are used. Caffeine or codeine are included in some combinations as well. These medications should be used infrequently as they have a high risk of withdrawal symptoms and rebound headaches.

Opiates:
Sometimes when people can't take ergot or triptans, medications containing narcotics, particularly codeine, are used to treat migraine pain. Narcotics are usually used only as a last resort and are habit-forming.

PREVENTIVE MEDICATIONS:
Only about 1 in 10 people who get migraines take preventative medication, though nearly half of those with the condition could benefit from this medication. If a prolonged aura or numbness and weakness are included in the migraine signs and symptoms of the patient, if pain-relieving medications aren't helping or if the patient has two or more debilitating attacks a month, he/she may be a candidate for preventive therapy. The effectiveness of symptom-relieving medicines used during migraine attacks may be increased and the length, frequency and severity of migraines can be reduced by taking preventive medications. These medications may be recommended to be taken daily, or only when a predictable trigger is approaching, such as menstruation.

Some preventive medications cause serious side effects and in most cases, they don't eliminate headaches completely. Tapering off the medication to see if the migraines return without it may be recommended if the patient has had good results from preventative medicine and has been migraine-free for six months to a year.

For best results, the patient should take these medications exactly as recommended:

Botulinum toxin type A:
In treating chronic migraines, botulinum toxin type A is sometimes used. With respect to effectiveness, studies have had mixed results. However, some headache specialists believe that it can be helpful for some people. The injections are made In the muscles of the forehead and neck. The treatment typically needs to be repeated every 3 months in case it is effective.   

Cyproheptadine:
Serotonin activity is affected by this antihistamine in particular. It is given sometimes to children as a preventive measure.

Antidepressants:
At helping to prevent some types of headaches including migraines, certain antidepressants are good. Tricyclic antidepressants such as protriptyline, nortriptyline and amitriptyline are most effective. By affecting the level of serotonin and other brain chemicals, these medications may reduce migraines, and they're considered among the first-line treatment agents. So, to benefit from these drugs, one doesn't have to have depression. For migraine prevention, other classes of antidepressants called selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) haven't been proven as effective. However, as a preliminary research suggests, migraines may be prevented by one SNRI called venlafaxine.

Cardiovascular drugs:
The severity and frequency of migraines can be reduced by beta blockers that are commonly used to treat coronary artery disease and high blood pressure. These drugs are considered among the first-line treatment agents. In relieving symptoms from aura and preventing migraines, calcium channel blockers, which is another class of cardiovascular drugs, may be helpful, especially verapamil. Additionally, the length and severity of migraines may be reduced with the use of antihypertensive medications such as candesartan and lisinopril. Lightheadedness, dizziness and drowsiness are some of the side effects of these medications. However, researchers still don’t know why these cardiovascular medications are able to prevent migraines.

Anti-seizure drugs:
The frequency of migraines seems to be reduced by some anti-seizure drugs such as topiramate, divalproex and gabapentin. However, side effects such as diarrhea, dizziness, nausea and vomiting, cramps and hair loss may be caused by these anti-seizure drugs when they are used in high doses.

Prognosis:

Not Available

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