| Migraine is a type of headache characterized by narrowing (constriction) of vessels in the brain followed by painful dilation and inflammation of the same blood vessels. It is described as a "sick headache," not only because there may be nausea and vomiting, but also because the individual typically feels completely disabled throughout the duration of the headache.
The pain is moderate to severe, throbbing or pulsating, and usually localized to one side of the head. Migraines can last from hours to days, and may also be associated with sensitivity to light and sound. The headaches can be preceded by an aura or warning symptoms related to the blood vessel narrowing and may include visual disturbances, limb numbness, tingling, or hyperactivity. Migraine with aura now is an official classification replacing what was known as classic migraine. A designation of migraine without aura, representing about 80% of all migraines, has replaced the former classification of common migraine (Blanda).
Coexisting medical conditions such as seizures, sleep disorders, high blood pressure (hypertension), and depression may be related to migraine. Migraines can be triggered or made worse by certain foods (chocolate, aged cheeses, peanuts, red wine, food additives [monosodium glutamate (MSG), nitrates]), alcohol, insufficient sleep, stress, and hormonal changes associated with the menstrual cycle.Risk: About 70% of patients have a first-degree family member with migraine history. Before puberty, migraine prevalence tends to be similar in males and females; in individuals older than 12 years, prevalence increases in both sexes; finally, a decline occurs in individuals older than 40 years (Sahai-Srivasta). Incidence and Prevalence: In the US, an estimated 10% to 20% of the population suffers from migraine headaches. Frequency of headaches varies greatly by individual. An estimated 6% of men and 15% to 17% of women in the US have migraine. Migraine is the second most common type of headache syndrome in the US. The most common are tension headaches (Blanda).
In the US, white women have the highest incidence of migraine, while Asian women have the lowest incidence. The female-to-male ratio increases from 2.5:1 at puberty to 3.5:1 at the age of 40 years, after which it declines (Sahai-Srivasta).
Nearly 25% of women and 15% of men are thought to have migraine headaches at some point in their lifetime (Baloh). |
Source: Medical Disability Advisor
| History: Individuals may report symptoms associated with the headache such as nausea, vomiting, pale skin, dizziness, or sensitivity to light (photophobia) and sound (sonophobia). The individual should be questioned about duration, location, pulsating quality, intensity, presence of aura, and frequency of headaches. Visual disturbances account for most symptoms that may be associated with the aura, including bright spots resembling stars, sparks, geometric patterns, or lightning bolts (fortification spectra). When the bright spots disappear, blind spots (scotoma) or decreased vision may follow. Other symptoms associated with the aura may include numbness especially of the hand and lower face. Weakness, clumsiness, or speech disturbances are less common. The aura usually lasts about 30 minutes followed by a brief period of normalcy before the headache begins.
Some individuals may report behavioral changes before or after attacks that include depression, anxiety, irritability, excitability, or a change in sexual appetite. Identifying possible triggers may help distinguish migraine from headache caused by other disorders such as a brain tumor. Investigating family history and obtaining details of previous headaches may be essential to the diagnosis. Physical exam: The exam may reveal abnormalities such as recent head or neck trauma and muscle spasms that can help establish diagnosis and aid in selecting treatment. Neurological examination includes evaluation of brain and nerve function, sensory discrimination, reflexes, strength, coordination, and cognitive abilities. Eye examination may reveal neurologic disease, diabetes, high blood pressure (hypertension), and other coexisting medical conditions. Tests: Tests are performed if there are other suspected causes of headache like a brain tumor or aneurysm. Imaging studies (CT or MRI) may reveal brain abnormalities that can mimic migraine. If history suggests seizures, a test of the brain's electrical activity (electroencephalogram or EEG) may help diagnose epilepsy that may coexist with migraine. These cases are rare, and therefore the tests are not routinely done unless warranted by history and physical examination findings. Spinal fluid may be sampled (lumbar puncture or LP) to test for infection or hemorrhage. Laboratory tests may also be done if an organic condition is suspected. |
Source: Medical Disability Advisor
| During a sudden (acute) episode, it may help the individual to rest in a quiet, darkened room. Acute episodes may be treated with medications once the headache has begun. The main classes of drugs available to treat acute migraine are agents that narrow blood vessels (triptans, ergotamines) and painkillers such as naproxen sodium, acetaminophen, aspirin, and ibuprofen. Painkillers can relieve mild to moderate migraine. Cyclooxygenase-2 (COX-2) inhibitors are a group of newer drugs that reduce pain and inflammation with fewer gastrointestinal side effects, although their association with an increased likelihood of coronary artery disease has caused some manufacturers to withdraw their medications from the marketplace. In general, in situations where COX-2 medications are felt to be necessary, use of the lowest dose for the shortest time period is recommended. Combination painkillers that contain caffeine may be helpful.
Once the headache is underway, treatment usually requires a drug that narrows the opening of blood vessels (vasoconstrictor) such as an ergot alkaloid to stop the attack. These medications are most helpful if given during the aura. With availability of new types of vasoconstrictor taken by mouth or injection, pain relief may begin within a few minutes. If nausea and vomiting occur, medication may have to be administered under the tongue, by injection, or rectally. Migraine attacks that are severe, prolonged, or unresponsive to self-administered medications may have to be treated in the doctor's office or emergency room.
Prevention of migraine is an important part of treatment. Avoiding precipitating factors may decrease the frequency of acute episodes. If episodes occur more than 2 or 3 times a month, a variety of drugs can be taken for prevention including agents that lower blood pressure (beta-blockers, calcium antagonists), anticonvulsants, tricyclic antidepressants, an agent that narrows openings of blood vessels and prevents inflammatory responses (methysergide), and agents that inhibit release of certain chemicals in the brain (selective serotonin reuptake inhibitors or SSRIs). The individual may have to try several different drugs, one at a time, before the headaches are brought under control. Naproxen sodium has also been used for short-term prevention of migraine, especially menstrual migraine. Drug combinations may be used for individuals who do not respond to a single therapy. Beta-blockers and antidepressants may be used together. Once an effective drug or combination is found, it should be continued for at least 6 months and then tapered off after the disappearance of headaches. Medication for acute episodes may be occasionally used with preventive medication if breakthrough headaches occur, e.g., menstrual migraine. |
Source: Medical Disability Advisor
| Occasionally migraine headaches may spontaneously disappear especially as individuals reach middle age. Self-care is very important, and the migraine sufferer can increase the chance of successful outcome by taking medications as directed by the doctor and modifying lifestyle factors such as diet, exercise, avoidance of migraine triggers, stress control, and proper rest. Any changes in headache frequency or severity should be communicated to the doctor and treatment should be adjusted to improve outcome. |
Source: Medical Disability Advisor
| Migraine sufferers are more prone to develop tension-type headaches that result in mixed headache syndrome. Excessive use of painkillers may cause rebound headaches when the drug's effects wear off, and episodic headaches may be transformed into chronic daily headaches. Coexisting medical conditions may complicate the disorder by limiting treatment options. Many medications used to treat headaches affect the cardiovascular system. The relative risk of thrombotic stroke may be higher in women with migraine. Stroke risk in migraine sufferers is further increased by smoking or the use of birth control pills. Migraine may also be associated with epilepsy or depression. |
Source: Medical Disability Advisor
| Often the migraine sufferer may be unable to work or perform job responsibilities during a migraine headache episode. Heavy physical activity may also be limited. Providing a dark, quiet room where the individual can rest until the attack passes may be helpful. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has diagnosis of migraine been confirmed?
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Have other conditions with similar symptoms been ruled out?
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Has individual experienced complications related to migraine headaches, such as mixed headache syndrome, rebound headaches from excessive use of painkillers, chronic daily headaches, or thrombotic stroke?
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Does individual have a coexisting condition that may limit treatment options or impact recovery?
Regarding treatment:
- Does individual require medical intervention for most episodes of migraine headaches?
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Is a change in medication or combination therapy warranted?
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Would individual benefit from self-administered medication?
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Have headache triggers (certain foods, alcohol, insufficient sleep, stress, hormonal changes associated with the menstrual cycle) been identified and eliminated, if possible?
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Is individual on prevention therapy?
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Would a combination-drug prevention therapy be more effective?
Regarding prognosis:
- Is individual compliant with prescribed treatment plan?
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Does individual self-administer medication during aura phase whenever possible?
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Has individual modified lifestyle factors that may trigger migraine episodes?
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Does individual communicate changes in headache frequency or severity to the doctor so that treatment adjustments can be made?
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Source: Medical Disability Advisor
| Baloh, Robert W., and Lee A. Harker. "Central Vestibular Disorders." Otolaryngology: Head and Neck Surgery. Ed. T. J. Cummings. 3rd ed. 5 vols. St. Louis: Mosby-Year Book, Inc., 1998. 2706-2711. MD Consult. Elsevier, Inc. 12 Nov. 2004 <http://home.mdconsult.com/das/book/42434392-4/view/1033?sid=281408995>.Blanda, Michelle, and Jeff Wright. "Headache, Migraine." eMedicine. Eds. Edward A. Michelson, et al. 13 Oct. 2004. Medscape. 12 Nov. 2004 <http://emedicine.com/EMERG/topic230.htm>. Sahai-Srivastava, Soma, Robert Cowan, and David Y. Ko. "Pathophysiology and Treatment of Migraine and Related Headache." eMedicine. Eds. Joseph R. Carcione, et al. 13 Oct. 2004. Medscape. 12 Nov. 2004 <http://emedicine.com/neuro/topic517.htm>. |
Source: Medical Disability Advisor
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