Migraines Are Much More Than Just Headaches! A Comprehensive Review On The Occasion of Migraine Awareness Month of June

By Jaivir S. Rathore, MD, FAES & Vaishnavi Sharma (MBBS Candidate, Hull York Medical School, UK)

WHAT IS A MIGRAINE?

A migraine is a complex neurological disease, not “just a headache” that has a significant impact on the lives of those that suffer from it. The pain is caused by the activation of nerve fibers within the wall of brain blood vessels traveling inside the meninges. It is recognized as the leading cause of years lived with disability in people under the age of 50 years. It directly affects more than 1 billion people worldwide and is the 3rd most prevalent disease and has a massive socioeconomic impact. Migraines are three times more common in women than men but are equally disabling in both genders and is the second leading cause of disability worldwide. Migraine often starts at puberty and mostly affects adults in their productive years but can also affect children and the elderly. It affects someone in nearly 1 in 4 American households, with an estimated 40 million people suffering from migraine headaches. Those with migraine have 2-3 times the rate of depression, 5 times the rate of anxiety and 2.5 times the rate of suicide when compared to the general population.

A migraine is usually a throbbing pain on one side of the head lasting 4 to 72 hours. Associated features include sensitivity to light or sound, nausea, vomiting, dizziness etc. Visual disturbances such as kaleidoscopic flashing colors or “squiggly or zigzag lines” may be present as well. There are several types of migraines including migraine with or without aura or even without a headache (acephalgic migraine). About 15% of the worldwide population suffers from some type of migraine. Migraine and chronic headaches are the second highest cause of short-term absence for non-manual employees and amongst the five top reasons for patient visits to the emergency department.

WHAT CAUSES MIGRAINES?

The pathophysiology of migraine is explained by cortical and subcortical spreading depression (CSD) which is an electrophysiological phenomenon of spreading wave of hyper-excitation (spreading depolarisation) across the brain’s surface followed by a period of reduced blood-flow (hypoperfusion) and suppressed neural activity (spreading depression). The aura phase that precedes migraine headache in about 20–30% of migraineurs may be a direct consequence of the events of CSD. Some studies have shown sub cortical spreading depression may be the basis for neuroanatomical and functional (central hypersensitivity) changes observed in migraine patients. The mechanism of CSD involves complex molecular changes in cortical upregulation of genes involved in inflammatory processing (e.g. for cyclooxygenase-2, tumor necrosis factor-α, interleukin-1β, galanin, or metalloproteinases). Metalloproteinase activation produces leakage of the blood–brain barrier, which leads to the release of a variety of molecules (e.g. potassium, nitric oxide, adenosine) that may then sensitize the dural perivascular trigeminal afferents. CSD is reported to activate dural nociceptors; specifically, migraine with aura is initiated by waves of CSD that lead to delayed activation of the trigeminovascular pathway, thus linking a central event with peripheral nociceptive pathways. It is known that genetics and environmental factors play a role. Current cutting-edge research is investigating the role of serotonin and calcitonin gene related peptide (CGRP) in migraines.

ARE THERE TRIGGERS FOR MIGRAINES?

Absolutely! Migraines have a number of triggers. Hormonal changes in women such as fluctuations in estrogen, hormonal medications such as the combined oral contraceptives, drinks including alcohol and those containing excessive caffeine, sensory stimuli such as bright or flashing lights, loud noise and strong smells or even lack of sleep or hunger can trigger migraines. Other triggers include stress, increased physical activity, sudden weather changes, foods such as aged cheeses and salty processed food and food additives such as the sweetener aspartame and the preservative monosodium glutamate (MSG). Risk factors that make individuals more at risk of migraines include a family history of migraines and female sex.

WHAT ARE THE EARLY SIGNS OF A MIGRAINE?

The early signs of a migraine can differ amongst different individuals. In-fact, some patients can experience no warning signs. Common symptoms occurring days to hours before a migraine include an aura, fatigue, neck stiffness, food cravings or changes in appetite, increased urge to urinate and increased thirst. A migraine aura can present in many different ways including visual phenomena such as seeing bright lights, temporary vision loss, pins and needles sensation in limbs, weakness or numbness in certain areas of the body (hemiplegic migraine) and difficulty speaking. Mood changes such as irritability, sadness or excitement can also occur prior to a migraine.

HOW DOES A MIGRAINE PROGRESS?

After the early signs as noted above, patients may experience the phase characterized by one sided throbbing or pounding headache with associated symptoms including nausea, vomiting, sensitivity to light and sound and dizziness. This phase is variable in duration lasting from a couple of hours to multiple days (status migrainosus if 72 hours or more). The final phase occurs after the headache has receded. Patients may suffer from fatigue, poor concentration and mood fluctuations during this period.

WHAT MIMICS MIGRAINES?

Tension headaches can be mistaken for migraines. They feature a dull ache that is bilateral and is characteristically a band-like pressure around the head. They do not have an aura like migraines and a migraine is usually not a bilateral headache, at least to begin with.

Cluster headaches are another type of headache that can be mistaken for a migraine. The pain is incredibly severe in a cluster headache and patients often describe this as the worst headache of their life. The pain typically occurs around the eye. There is redness, swelling and lacrimation.

Sinus headaches are headaches that occur due to inflammation of the mucous membranes of the paranasal sinuses and usually coincide with infections or a history of sinus problems. This typically presents with frontal pressure pain which is worse on bending forward.

HOW DO YOU DIAGNOSE MIGRAINES?

The diagnosis of migraine is mostly clinical based on history and examination. Patients are asked about the onset and duration of the migraine, whether it is recurring, aura symptoms and any triggers for the migraine amongst other questions. Not every case of migraine needs a brain imaging but in certain cases, especially atypical ones and if there are focal neurological findings on exam, a MRI Brain may be considered. Additionally, patients are advised to maintain a headache diary where they can keep a record of the frequency, length, severity and any triggers of the headache. A headache diary can help healthcare professionals with making a diagnosis and its treatment plan.

HOW DO YOU TREAT MIGRAINES?

While there is no cure for migraines, there are several ways to manage its symptoms and reduce its intensity, frequency and associated suffering to improve the quality of life of the patients. Medications for migraines are divided into two categories including pain relieving rescue or abortive medications and preventive medications. Rescue or abortive medications includes NSAIDs (nonsteroidal anti-inflammatory drugs), triptans, opioids, oral calcitonin gene-related peptide receptor antagonist and anti-nausea drugs amongst others. Preventive medications include beta blockers, calcium channel blockers, antidepressants, anti-seizure drugs, botox injections and CGRP monoclonal antibodies. Lifestyle changes such as relaxation techniques, developing a sleeping and eating routine, staying hydrated and exercising regularly can help control symptoms. Magnesium, manganese, vitamin B complex etc supplements are also helpful in prevention of migraines.

Botox therapy once every 3 months can reduce the frequency and intensity of migraines. Cutting edge research demonstrates that monoclonal antibodies targeting the CGRP protein, receptor and/or ligand can be effective for migraine prophylaxis as well as treatment of acute headache episodes.

Courtesy sources: American migraine foundation, International headache society, Science direct Mayo Clinic, Pubmed/NCBI/NIH and JAMA network.

Dr. Jaivir Rathore, a triple board-certified toprated neurologist trained at the Johns Hopkins and the Cleveland Clinic, Harvard University journal published neuroscientist and the Medical Director of Falcon Advanced Neurology & Epilepsy Freedom Center (FANEFC) in Orlando FL with additional clinics serving the largest retirement community of the world in The Villages FL provides comprehensive neurology care including chronic and episodic migraines. FANEFC is “Care Connected” with the Mayo Clinic, Jacksonville FL for surgical cases.