Migraine

Imagine a throbbing, pounding headache so intense that it disrupts your entire day. This is a common experience for many who suffer from migraine, a neurological condition characterised by recurrent episodes of moderate to severe headache, often accompanied by other debilitating symptoms. More than just a bad headache, a migraine can be a truly disabling condition, impacting work, social life, and overall well-being. 

Migraine is a complex neurological disorder that manifests primarily as recurrent headaches. These headaches are typically moderate to severe in intensity and often have a pulsating or throbbing quality. A key characteristic of migraine is its association with other symptoms, which can include nausea, vomiting, and increased sensitivity to light (photophobia) and sound (phonophobia). The pain is frequently unilateral (on one side of the head) but can occur on both sides or shift between sides.

Migraine attacks can vary significantly in frequency, duration, and severity from person to person and even within the same individual over time. Some individuals may experience migraines only a few times a year, while others may have them several times a month or even more frequently. An untreated migraine attack can last anywhere from four to 72 hours.

Unlike a typical tension-type headache, which is often described as a dull, pressing pain across the head, migraine pain is usually more intense and can be significantly aggravated by routine physical activity. This often leads individuals experiencing a migraine to seek a quiet, dark place to rest.

The exact mechanisms underlying migraine are still being researched, but it is understood to involve changes in nerve pathways, brain chemicals (neurotransmitters like serotonin), and blood vessels in the brain. 

Worldwide Prevalence:

Globally, migraine is estimated to affect more than one billion people, making it the third most prevalent illness in the world. The World Health Organization (WHO) classifies migraine as one of the top causes of disability worldwide. The peak prevalence is typically between the ages of 25 and 55 years, the most productive years of life.

Prevalence in India:

Studies in India have also shown a high prevalence of migraine. Estimates suggest that around 15% of the adult population in India suffers from migraine. Similar to global trends, migraine is more common in women in India. The prevalence rates can vary across different regions and socioeconomic groups within the country, with some studies indicating higher rates in urban areas.

Migraine is not a single entity but encompasses several subtypes, the two main categories being migraine with aura and migraine without aura.

• Migraine without Aura (Common Migraine): This is the most common type of migraine, accounting for approximately 70-80% of all migraine attacks. The headache phase is not preceded by an aura. The diagnostic criteria include having at least five attacks that last 4-72 hours, have at least two of the following characteristics (unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or avoidance of routine physical activity), and during the headache, at least one of the following (nausea and/or vomiting, photophobia and phonophobia).
   
• Migraine with Aura (Classic Migraine): This type of migraine is characterised by transient neurological symptoms, known as aura, that typically precede or accompany the headache. Aura symptoms usually develop gradually over 5-20 minutes and last for less than 60 minutes. Common aura symptoms include:
  
  
  • Visual Aura: This is the most common type of aura, involving visual disturbances such as flashing lights, zigzag lines, blurred vision, or temporary vision loss.
  • Sensory Aura: This can involve sensations like tingling or numbness, often starting in a limb and spreading gradually.
  • Speech or Language Aura: Difficulty finding words or speaking clearly (dysphasia).
  • Motor Aura: Muscle weakness, although this is less common in typical migraine aura and more often associated with a rarer type called hemiplegic migraine.

Other less common types of migraine include:

• Hemiplegic Migraine: This rare type involves temporary weakness on one side of the body (hemiplegia) as part of the aura. It can be familial (FHM) due to specific genetic mutations or sporadic (SHM).
• Basilar-Type Migraine (Migraine with Brainstem Aura): This type of migraine involves aura symptoms originating from the brainstem, such as vertigo, double vision, poor coordination, and altered level of consciousness.
• Chronic Migraine: This is defined as having headaches on 15 or more days per month for more than three months, with at least eight of these days meeting the criteria for migraine headache. It can evolve from episodic migraine.
• Menstrual Migraine: This type of migraine is specifically linked to a woman's menstrual cycle, typically occurring in the days leading up to or during menstruation due to hormonal fluctuations.
• Abdominal Migraine: This type primarily affects children and is characterised by recurrent episodes of moderate to severe abdominal pain, often accompanied by nausea, vomiting, and pallor, with headache being less prominent or absent.

Several factors are thought to play a significant role in the development and triggering of migraine attacks:

• Genetics: There is a strong genetic component to migraine, with many individuals having a family history of the condition. Specific genes have been identified that are associated with certain types of migraine, such as familial hemiplegic migraine.
• Brain Chemicals (Neurotransmitters): Imbalances in brain chemicals, particularly serotonin, are thought to be involved in migraine. Serotonin levels can fluctuate during a migraine attack, potentially affecting blood vessels in the brain.
• Trigeminal Nerve: This major sensory nerve in the head and face is believed to play a key role in migraine pain. Activation of the trigeminal nerve can release neuropeptides, such as CGRP (calcitonin gene-related peptide), which can cause inflammation and vasodilation (widening of blood vessels) in the brain's meninges (the membranes surrounding the brain and spinal cord), leading to pain.
• Changes in Brainstem and Its Interaction with the Trigeminal Nerve: The brainstem, which controls many autonomic functions, is thought to be involved in the initiation of migraine attacks.
• Hormonal Changes in Women: Fluctuations in oestrogen levels, such as those occurring during menstruation, pregnancy, and menopause, are a significant trigger for many women with migraine.
• Environmental Factors and Triggers: A wide range of triggers can precipitate migraine attacks in susceptible individuals. These triggers vary from person to person but can include:
  • Dietary Factors: Certain foods and drinks, such as aged cheeses, processed meats, chocolate, caffeine (both withdrawal and excess), alcohol (especially red wine), and artificial sweeteners.
  • Stress: Both physical and emotional stress can trigger migraines.
  • Changes in Sleep Patterns: Too much or too little sleep, as well as changes in sleep schedule.
  • Sensory Stimuli: Bright or flashing lights, loud noises, and strong smells.
  • Changes in Weather: Barometric pressure changes, storms, and extreme temperatures.
  • Physical Exertion: Intense physical activity.
  • Skipped Meals: Irregular eating patterns can lead to drops in blood sugar.
  • Certain Medications: Oral contraceptives and vasodilators are examples of medications that can trigger migraines in some people.

The symptoms of a migraine attack can vary in intensity, duration, and combination, but typically include more than just a headache. The phases of a migraine attack are often described as prodrome, aura (in some cases), headache, and postdrome.

Prodrome (Pre-Headache Phase): This phase can occur hours or even days before the headache and may involve subtle changes in mood, energy levels, behaviour, or physical sensations. Symptoms can include:

• Fatigue or increased energy
• Changes in mood (irritability, depression, euphoria)
• Food cravings
• Increased thirst or urination
• Neck stiffness

Aura (Occurs in about 20-30% of Migraines): As described earlier, aura involves transient neurological symptoms that usually precede or accompany the headache. These can be visual (flashing lights, zigzag lines), sensory (tingling, numbness), motor (weakness), or speech-related.

 

Headache Phase: This is the main phase of the migraine attack. The headache is typically:

• Moderate to severe in intensity
• Pulsating or throbbing in quality
• Often located on one side of the head (unilateral) but can be bilateral
• Aggravated by routine physical activity

The headache is often accompanied by:

• Nausea and/or vomiting
• Photophobia (increased sensitivity to light)
• Phonophobia (increased sensitivity to sound)

Other possible symptoms during the headache phase include:

• Blurred vision
• Dizziness
• Scalp tenderness
• Feeling lightheaded

Postdrome (Post-Headache Phase): After the headache subsides, many people experience a postdrome phase, often described as a "migraine hangover." Symptoms can include:

• Fatigue and exhaustion
• Difficulty concentrating
• Mood changes (feeling depressed or elated)
• Muscle aches
• Sensitivity to light and sound

The entire migraine attack, from prodrome to postdrome, can last for several days, significantly impacting a person's ability to function.

There is no specific blood test or brain scan that can definitively diagnose migraine. Diagnosis is primarily based on a person's medical history, a detailed description of their headaches and associated symptoms, and a physical and neurological examination.

The doctor will ask questions about:

• The frequency, duration, and severity of your headaches.
• The location and quality of the pain (e.g., throbbing, pressing).
• Any associated symptoms such as nausea, vomiting, sensitivity to light and sound.
• Whether you experience aura and, if so, what type and how long it lasts.
• Potential triggers for your migraines.
• Your family history of headaches or migraine.
• How your headaches affect your daily life.

The doctor will also perform a physical examination, including a neurological exam to check vision, reflexes, coordination, and sensation, to rule out other potential causes of the headaches.

In most cases of typical migraine, further diagnostic tests like brain scans (MRI or CT) are not necessary. However, the doctor may recommend imaging if there are atypical features, such as sudden onset of severe headache, neurological symptoms that persist, or if the examination suggests another underlying condition.

It is often helpful for individuals to keep a headache diary, tracking the frequency, severity, duration, associated symptoms, and potential triggers of their headaches. This information can be invaluable in helping the doctor make an accurate diagnosis and develop an effective treatment plan.

The treatment of migraine aims to relieve acute symptoms during an attack and to prevent future attacks. Treatment strategies can be broadly divided into acute (abortive) treatments and preventive (prophylactic) treatments.

Acute (Abortive) Treatments: These medications (Brand available: Vasograine) are taken at the first sign of a migraine attack to try to stop or lessen its severity and associated symptoms. They include:

• Over-the-Counter (OTC) Pain Relievers: Mild to moderate migraines can often be relieved with OTC pain relievers such as ibuprofen, naproxen, paracetamol (acetaminophen), and aspirin. Combination pain relievers that include caffeine or codeine may also be used but should be used cautiously due to the risk of medication-overuse headache.
• Triptans: These are prescription medications specifically designed to treat migraine. They work by constricting blood vessels in the brain and blocking pain pathways. Examples include sumatriptan, rizatriptan, eletriptan, and others. Triptans are most effective when taken early in the migraine attack.
• Gepants: These are newer prescription medications that block the action of CGRP, a molecule involved in migraine pain. Examples include rimegepant and ubrogepant. They can be effective for acute treatment and may have fewer cardiovascular contraindications than triptans.
• Ditans: These are another class of prescription medications that specifically target serotonin 5-HT1F receptors, which are involved in migraine. Lasmiditan is an example. They may be an option for individuals with cardiovascular risk factors who cannot use triptans.
• Anti-Nausea Medications (Antiemetics): These can help relieve nausea and vomiting associated with migraine. They can be used alone or in combination with pain relievers. Examples include metoclopramide and prochlorperazine.

Preventive (Prophylactic) Treatments: These medications are taken regularly, even when a migraine is not present, to reduce the frequency, severity, and duration of migraine attacks. Preventive treatment is usually considered if migraines are frequent (e.g., more than four per month), severe, or significantly interfere with daily life, or if acute treatments are not effective or well-tolerated. Preventive medications include:

• Beta-Blockers: These medications, such as propranolol and metoprolol, are often used to treat high blood pressure but can also be effective in preventing migraines.
• Antidepressants: Certain tricyclic antidepressants (e.g., amitriptyline) and serotonin-norepinephrine reuptake inhibitors (SNRIs) (e.g., venlafaxine) can help prevent migraines.
• Anticonvulsants: Some medications originally used to treat seizures, such as topiramate and valproate, have also been shown to be effective in migraine prevention.
• CGRP Monoclonal Antibodies: These are newer, injectable medications that target CGRP or its receptor. Examples include erenumab, fremanezumab, galcanezumab, and eptinezumab. They have shown significant efficacy in reducing migraine frequency and severity with generally good tolerability.
• Botulinum Toxin (Botox) Injections: These injections are approved for the prevention of chronic migraine (15 or more headache days per month).

Some individuals with migraine explore alternative or complementary therapies to help manage their symptoms. While the scientific evidence supporting the effectiveness of many of these therapies for migraine specifically is limited, some may offer benefits for overall well-being and stress reduction, which can indirectly help with migraine management. Examples of alternative therapies that some people with migraine have explored include:

• Herbal Remedies and Supplements: Butterbur, feverfew, magnesium, and riboflavin (vitamin B2) are some supplements that have been studied for migraine prevention, with varying degrees of evidence.
• Acupuncture: Some studies suggest that acupuncture may be helpful in reducing migraine frequency and intensity for some individuals.
• Massage Therapy: Regular massage may help reduce stress and muscle tension, potentially providing some relief from migraine symptoms.
• Yoga and Tai Chi: These mind-body practices can promote relaxation and reduce stress, which may be beneficial for migraine management.
• Chiropractic Care: Some people with migraine seek chiropractic treatment, particularly for neck pain, although the evidence for its effectiveness in preventing migraines is not strong.

• Family History: Having one or more close relatives with migraine significantly increases the risk.
• Sex: Women are about three times more likely to experience migraine than men, likely due to hormonal influences.
• Age: Migraine often begins during adolescence or early adulthood, and prevalence peaks between the ages of 25 and 55.
• Hormonal Changes: Fluctuations in oestrogen levels, such as during menstruation, pregnancy, and menopause, are a major trigger for many women.
• Stress: High levels of stress, anxiety, and depression are strongly associated with an increased risk of migraine.
• Certain Medical Conditions: Some conditions, such as epilepsy, sleep disorders, and certain mood disorders, are more common in people with migraine.
• Dietary Factors: Sensitivity to certain foods and drinks can increase migraine risk in susceptible individuals.

• Chronic Migraine: Episodic migraine can evolve into chronic migraine, a more debilitating condition with headaches on 15 or more days per month.
• Medication-Overuse Headache (Rebound Headache): Frequent use of over-the-counter or prescription pain relievers for acute migraine can paradoxically lead to more frequent and severe headaches.
• Status Migrainosus: This is a severe and prolonged migraine attack lasting longer than 72 hours, which can be very difficult to treat and may require hospitalisation.
• Persistent Aura without Infarction: In rare cases, an aura symptom may persist for longer than a week without evidence of a stroke.
• Migrainous Infarction (Stroke): This is a very rare complication where a stroke occurs during or immediately following a migraine attack with aura.
• Psychological Problems: People with migraine are at a higher risk of developing anxiety, depression, and other mood disorders due to the chronic pain and disability associated with the condition.
• Sleep Disturbances: Migraines can disrupt sleep, and conversely, poor sleep can trigger migraines, creating a vicious cycle.
• Reduced Quality of Life: Frequent and severe migraines can significantly interfere with work, social life, family activities, and overall well-being.
• Increased Risk of Other Conditions: Some studies suggest a possible association between migraine and an increased risk of certain cardiovascular events, although more research is needed.

Living well with migraine requires proactive management, self-care, and a supportive environment:

• Be Prepared: Always have your acute migraine medications readily available.
• Create a Migraine "First Aid Kit": Include your medications, a cold pack, earplugs, and an eye mask to use at the first sign of an attack.
• Find a Quiet, Dark Place: During a migraine, retreat to a calm, dark, and quiet environment to rest.
• Apply Cold or Heat: Experiment with applying cold packs or warm compresses to your head or neck to see if they provide relief.
• Stay Hydrated: Continue to sip water even if you feel nauseous.
• Maintain a Consistent Routine: Stick to regular sleep, meal times, and exercise patterns.
• Manage Stress Effectively: Find healthy ways to cope with stress, such as relaxation techniques or hobbies.
• Communicate Your Needs: Let family, friends, and colleagues know about your migraine condition and how it affects you.
• Track Your Migraines: Continue to keep a detailed headache diary to identify triggers and monitor the effectiveness of your treatment plan.

Misconception 1: Migraine is just a bad headache.

Reality: Migraine is a distinct neurological disorder with specific diagnostic criteria and often involves a range of debilitating symptoms beyond head pain.

Misconception 2: Migraine is all in your head (psychological).

Reality: Migraine has a biological basis involving changes in the brain, nerves, and blood vessels. While stress and emotional factors can be triggers, the pain is very real.

Misconception 3: Only women get migraines.

Reality: While migraine is more prevalent in women, men also experience migraines.

It is important to consult a doctor if you experience frequent or severe headaches, or if you suspect you might be having migraines. Seek medical attention if you experience any of the following:

• Sudden onset of a severe headache ("thunderclap headache").
• Headache with fever, stiff neck, rash, confusion, seizures, double vision, numbness, or weakness.
• Headache that worsens over days or weeks.
• Headache after a head injury.
• Changes in the pattern, frequency, or severity of your headaches.
• Headaches that do not respond to over-the-counter pain relievers.
• Headaches that interfere with your daily activities.
• If you are using over-the-counter pain relievers frequently (more than 2-3 times per week).

• What type of headache do I have? Is it migraine?
• What are the possible causes or triggers for my migraines?
• What are the treatment options for my acute migraine attacks?
• What are the potential side effects of these medications?
• Should I consider preventive treatment? What are the options?
• How can I identify my migraine triggers? Should I keep a headache diary?
• Are there any lifestyle changes that might help?
• Are there any red flags or symptoms that should prompt me to seek immediate medical attention?

Supporting someone with migraine involves understanding, empathy, and practical assistance:

• Believe Them: Understand that migraine is a real and often debilitating condition, not just a "bad headache."
• Be Understanding and Patient: Migraine attacks can be unpredictable and can significantly impact their ability to function.
• Offer a Quiet and Dark Space: During a migraine, they may need a calm, dark, and quiet environment to rest.
• Help with Practical Tasks: Offer assistance with chores, errands, or childcare when they are experiencing a migraine.
• Educate Yourself About Migraine: Understanding the condition will help you be a more effective supporter.
• Be Flexible with Plans: Understand that they may need to cancel plans due to a migraine attack.

Migraine is a common and often disabling neurological disorder characterised by recurrent episodes of moderate to severe headache, frequently accompanied by other symptoms like nausea and sensitivity to light and sound. Understanding the different types of migraine, identifying individual triggers, and implementing appropriate acute and preventive treatment strategies are crucial for managing this condition effectively. 

While living with migraine can present challenges, with proactive self-care, a strong support system, and ongoing collaboration with healthcare professionals, individuals can learn to minimise the impact of migraine on their lives and improve their overall well-being.