Migraine
A migraine is more than a headache. It is a complicated neurological disease of recurring attacks with usually one-sided headache, occasionally accompanied by nausea, vomiting, and severe sensitivity to light or noise. To its sufferers, it’s a disabling attack that lasts from hours to several days. Symptoms vary widely between individuals and may change during different stages of an attack, and repeated migraine attacks can have a significant impact on quality of life. Although headache is the most striking symptom, migraine attacks may also impair mental function and emotional stability and interfere with work during an attack. Migraine can affect anyone but is more common in women, particularly between the ages of 25 and 55.
Who Gets Migraine and Why?
Migraines usually affect people of all ages, but are most prevalent between the ages of 18 and 44. They are much more likely to affect women than men, possibly due to hormonal fluctuations. Indeed, there is a family factor; up to 70% of headache-sufferers have a family history. Migraine is a genetic disorder, meaning most people with migraine have a family history of the disorder. Reviewing a person’s medical history is important for understanding their risk of developing migraine and for accurate diagnosis.
Lifestyle and environmental causes play a part too. Risk factors for developing migraine include genetic predisposition, hormonal changes, sleep disturbance, and other health conditions. Sleep disturbance is both a risk factor and a potential trigger for migraine, and ongoing research is exploring how conditions like obesity, depression, and sleep disturbance may influence migraine severity. The precise cause remains unclear. However, changes in brain activity are believed to temporarily affect nerve impulses, chemicals, and blood vessels within the brain.
Migraine Types and Classification
Migraine is not a one-size-fits-all condition; it comes in several distinct types, each with its own set of features and challenges. The two most common forms are migraine with aura and migraine without aura.
Migraine with Aura
Marked by warning signs, known as aura symptoms, such as visual disturbances, tingling sensations, or speech difficulties that appear before the headache phase begins. In contrast, migraine without aura skips these warning signs, with headache pain and associated symptoms like nausea and sensitivity to light coming on without notice.
Familial Hemiplegic Migraine
Other less common types include familial hemiplegic migraine, a rare genetic disorder that causes temporary weakness or paralysis on one side of the body, and retinal migraine, which involves brief episodes of vision loss or visual disturbances in one eye.
Chronic Migraine
Diagnosed when headache pain occurs on 15 or more days per month for at least three months, with at least eight days featuring migraine symptoms. The International Headache Society has established diagnostic criteria to help healthcare providers accurately diagnose migraine, taking into account the specific headache phase, presence or absence of aura, and associated symptoms. Recognizing the type of migraine is crucial for tailoring effective treatment and management strategies.
Stages of Migraine: The Four-Stage Cycle
Migraine attacks can be described in terms of four phases: prodrome phase, aura phase, headache phase, and postdrome phase, though not all four occur in every individual.
- Prodrome Phase
This phase can occur a few hours to a few days before the headache starts. Symptoms are often minor, such as fatigue, irritability, a stiff neck, mood changes, and food cravings.
- Aura Phase
Not universal, but if present, this transient neurological event occurs just before the headache phase. Aura symptoms can include visual disturbances (zigzagging, blind spots, flashing lights), changes in vision, trouble speaking, and tingling sensations.
- Headache Phase
This is the headache itself, which usually starts gradually and is often felt on one side of the head. It typically begins 4 to 72 hours after the aura phase and is generally localized, pulsating, and accompanied by nausea and sensitivity to light and sound. In some instances, it can be provoked by exertion.
- Postdrome Phase
After the pain subsides, this phase can last up to two days. Symptoms may include tiredness, difficulty concentrating, euphoria, confusion, or fatigue.
Factors That Can Potentially Trigger a Migraine
Migraine occurs when certain risk factors or triggers disrupt stable brain conditions, leading to an attack. Certain migraine causes are inherent, and their identification can be incorporated into daily disease management. The most frequent among them are:
Hormonal Alteration
More frequently with menstruation, pregnancy, or menopause. Hormonal changes, particularly fluctuations in estrogen, are significant triggers for migraine attacks in women.
Anxiety and Stress
Emotional ups and downs, or mental pressure over quite some time. Stress is a common trigger for migraine attacks, ranking first in reports for men and second for women.
Sleep Patterns
Not enough or too much sleep. Irregular sleep patterns, especially in environments like NYC where sensory overload is common, are major stressors and significant risk factors for migraines.
Sensory Stimuli
Blinding odors, dazzling light, or ear-deafening sound. Sensitivity to light, sound, and smells are often reported as migraine triggers, and these sensitivities may also be early symptoms reported in the prodrome phase, serving as warning signs of an impending attack.
Diet
Dietary factors that may trigger migraines include skipped meals, caffeine withdrawal or excess, and the consumption of alcohol, particularly red wine. Migraines can also be triggered by certain foods such as aged cheese and MSG. Fasting or missed meals are commonly perceived triggers, as they can lead to hypoglycemia and trigger stress hormone release.
Maintaining a migraine diary to identify specific triggers allows patients to start making lifestyle changes that can successfully reduce the frequency and severity of migraine attacks.
Typical Symptoms That Define a Migraine
Certain symptoms are likely to define a migraine in most individuals, though they vary from person to person. The common symptoms include an exhausting, pounding headache, often on one side of the head, visual disturbances in the form of an aura, and hypersensitivity to light, sound, and, in some cases, even smell. Severe pain is a hallmark of migraine and can be disabling.
Symptoms reported by patients can also include mood swings, food cravings, neck pain, and other sensory disturbances. They may be accompanied by mood swings, hunger, a sore neck, or constipation, and occur regularly in some individuals. Neck pain is a recognized non-headache symptom of migraine. The discomfort is extreme, such that even minimal body movements or exposure to everyday stimuli can induce the condition.
The most common type of migraine is migraine without aura, while migraine with aura can include visual disturbances and other sensory changes. Symptoms vary widely between individuals and can change through different stages of a migraine attack.
Diagnosing Migraine: Why Clarity Matters
A migraine is relatively nonspecific in its appearance compared to other neurological and systemic diseases, and a diagnosis must be made with certainty. It typically begins with a thorough history and physical exam. Reviewing a patient’s medical history is essential to accurately identify migraine and distinguish it from other conditions.
Neurological testing, MRI or CT imaging, and judicious laboratory testing are used to rule out other illnesses. Sometimes, when symptoms suggest migraine but do not fully meet the diagnostic criteria, a diagnosis of probable migraine may be made. It is also important to distinguish migraine from other neurological disorders.
The more accurate the history, the easier it will be to distinguish migraine from other headache disorders, such as tension-type headache or cluster headache.
Treatment Options for Chronic Migraine
There are various ways to treat migraine, including both acute and preventive treatment options. No two migraine attacks are ever treated the same. Drugs are generally divided into two broad categories: those used at an attack to provide relief, and those used preventively to head them off.
Episodic migraine differs from chronic migraine in the frequency of attacks, as episodic migraine involves fewer than 15 headache days per month, while chronic migraine involves 15 or more. This difference impacts management strategies and disease burden.
Preventive treatment is a proactive approach to reducing the frequency and severity of migraine attacks. Preventive medications for migraine include beta blockers, topiramate, and CGRP inhibitors, all of which have shown significant efficacy in clinical studies.
Acute drugs consist of triptans, which are recommended as a first-line therapy for moderate to severe migraine attacks, as well as NSAIDs and anti-nausea medications. Over-the-counter medications such as ibuprofen and acetaminophen are often recommended for mild to moderate migraine attacks.
Added to the preventive arsenal are the CGRP inhibitors—monoclonal antibodies targeting a new migraine-sigma peptide, which has just been approved as a feature of migraine prevention.
Living with Migraine
A migraine attack can have a significantly negative impact on quality of life when it occurs frequently and remains uncontrolled. Migraine can be a chronic disease, and repeated migraine attacks can lead to significant medical costs and lost productivity, making it one of the most costly neurological disorders. Chronic patients tend to retreat, become irritable, or feel helpless. Lost time at work, social withdrawal, and the necessity of avoiding daily stimuli may lead to depression and anxiety. Migraine disease is a complex neurological disorder that requires comprehensive management and support.
Support groups, whether live or online, are great places to gain experience and coping mechanisms from others. Emotional support and medical control are a promising strategy that treats the physical and psychological aspects of the disorder.
Migraine Research: What’s New and What’s Next?
The field of migraine research is rapidly evolving, offering new hope for those affected by this challenging condition. Scientists now understand that migraine is a complex disorder involving multiple systems, including the nervous system, blood vessels, and immune pathways. Recent breakthroughs have led to the development of targeted preventive medications, such as CGRP inhibitors, which block specific molecules involved in migraine attacks and offer new options for those with chronic or severe migraines.
Ongoing research is exploring the use of genetic testing and biomarkers to personalize migraine treatment, aiming to predict which therapies will work best for each individual. Studies are also investigating the benefits of relaxation techniques and mindfulness-based therapies in reducing migraine symptoms and improving quality of life. By staying informed about the latest advances in pain research and integrative health, people with migraine and their healthcare providers can work together to manage symptoms more effectively and look forward to even better treatment options in the future.
Migraine in Children and Adolescents
Although migraine attacks are more common in adults, they can happen in children and teenagers. This is where they most often differ:
- Short Attack Duration: Migraine attacks in children typically last less than four hours.
- Headache Location: Both sides of the head, not on one side.
- Other Signs: Headache, abdominal discomfort, nausea, or dizziness.
- Behavioral Presentation: Tantrum, pale face, or refusal to engage.
Symptoms vary widely in children and adolescents, and some may experience silent migraine (migraine without headache), which can include symptoms like visual disturbances and nausea.
Because younger patients are unable to persistently complain about what is happening, parents and caregivers must observe changes in behavior and illness complaints to identify potential issues.
When to Seek Emergency Evaluation
Most migraines are severe, sudden headaches, as opposed to other headaches that accompany fever, a stiff neck, confusion, seizure, or loss of consciousness. Severe attacks can sometimes lead to complications such as seizures, decreased consciousness, or even coma. Severe pain is a hallmark of migraine and should prompt urgent evaluation. In some emergency settings, probable migraine may be diagnosed when symptoms suggest migraine but do not fully meet all criteria. They could also be life-threatening diseases like stroke, meningitis, or brain tumours. In a state of doubt, it is always wise to have immediate medical evaluation rather than delaying.
If you or the person you care for is facing too many and severe migraine attacks that hamper activities, don’t neglect the symptoms. Early treatment not only could ease the current load but also avoid future complications. Even if it’s not a migraine, there may be another treatable condition underlying it.
Our skilled team is dedicated to learning what’s going on and developing a plan of care specifically designed for you. From testing and treatment using the latest technology to simply discussing your questions, we’re by your side every step of the way.
Call us today at (914) 816-1941 or email info@chesterneurology.com to schedule an appointment.
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