Migraine

A migraine is a headache that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head.

It is often accompanied by nausea, vomiting, and sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with daily activities. Risk factors for migraines include family history, age, and female gender. Migraines typically begin in childhood or adolescence and peak in young to mid adulthood but can be a lifelong disease. It is estimated that 37 million Americans have migraines, with 148 million people worldwide suffering from migraines. The World Health Organization (WHO) ranks migraine as one of the top 10 causes of disability worldwide. It is estimated that industry loses $31 billion per year due to absenteeism, lost productivity, and medical expenses caused by migraine.

Symptoms

A typical migraine “attack” involves four phases: (1) prodrome, (2) aura, (3) headache, and (4) postdrome. The exact progression and symptoms differ from person to person.

Prodrome: Many people start having symptoms 24 to 48 hours before a migraine headache begins. These may include increased yawning, a feeling of euphoria, depression, irritability, food cravings, constipation, and neck stiffness.

Aura: Approximately 25% of people with migraines experience an “aura” before the headache. Flashing lights, bright spots, zigzag lines, changes in vision, numbness or tingling in the fingers, lips, tongue, or lower face are examples of an aura. You may have one or more of these aura symptoms. Auras may also involve other senses and can occasionally cause temporary weakness or changes in speech. Aura symptoms typically last five to twenty minutes and rarely more than an hour in duration. The headache usually occurs soon after the aura stops, although some people experience aura without a headache.

Headache: The pain of the migraine headache usually begins gradually, intensifies over one to several hours, and resolves gradually at the end of the attack. It normally affects only one side of the head but can be bilateral. The headache pain is typically dull and steady when mild to moderate in severity but escalates to throbbing and pulsating pain when more severe. Migraine headaches may be aggravated by light, loud noises, physical activity, and motion. Many people try to get relief by lying down in a dark, quiet room. Migraines usually last a few hours, but in some cases, a migraine can last up to 72 hours in duration. Migraines are often accompanied by nausea and vomiting, as well as sensitivity to light and noise. Some people also feel very sensitive to touch and may find normal activities impossible to perform.

Postdrome: Also known as the recovery phase, a postdrome occurs after the end of the actual head pain. It is often described as a “hangover-like” experience which may take 24 to 48 hours to fully resolve. Symptoms may include poor concentration, extreme fatigue, body aches, depressed mood, and confusion.

Migraine Triggers

Migraines can be triggered by a variety of things and can vary from person to person. Examples include stress, physical exertion, fatigue, lack of sleep, hunger, odors, weather changes, certain foods or medications, and environmental factors. In females, migraines can be brought on by the normal decrease in estrogen levels which occur before menstruation each month.

Migraine Treatment

The treatment of migraines depends on frequency, severity, and symptoms of migraine and is individualized based on patient need. Many people who experience regular migraines need both acute and preventative treatment. Acute treatment refers to medicines you can take when you have a migraine to relieve the pain immediately. Preventative treatment refers to medicines you take regularly (usually daily) to avoid migraines in the future.

Acute Treatment: The pain of migraines can be tough to get rid of and the first step in proper migraine management is to treat promptly.

Pain relievers – Mild migraine attacks may respond to pain relievers, some of which are available without a prescription and include aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen. Combination medications such as Excedrin which contain acetaminophen, aspirin, and caffeine are also recommended and can effectively abort a headache. However, none of these medications should be used on a frequent basis (more than two or three times a week) because this can lead to medication overuse headaches. People with gastritis, ulcers, kidney disease, and bleeding conditions should not take products containing aspirin or anti-inflammatories.
Triptans – If over-the-counter medications do not abort your headache, the next step is usually a triptan (such as sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan, and frovatriptan). These medications are migraine specific and available in pill, nasal spray, and injection forms. You cannot take triptans if you have a history of stroke, heart disease, or uncontrolled blood pressure.
Ditans (lasmiditan) – Serotonin (5-HT) 1F receptor agonist used during an acute migraine attack. Lasmiditan is a tablet that this is available as an alternative to triptans and can be used in people who have history of heart disease or stroke.
CGRP antagonists – These medications aim to block the transmission of pain and include ubrogepant and rimegepant.
Ergots – Dihydroergotamine and ergotamine (available in oral form, nasal spray, infusion, and injection).
Steroids – Given as an infusion, injection, or tablet form to break headache cycle.
Anti-emetics – Medications used for nausea and vomiting which is associated with migraines.

Preventative Treatment: Preventive therapies are used to help reduce the frequency and severity of migraines and are generally recommended in individuals who have frequent, long-lasting, or severe migraines that impact quality of life and ability to function. There are various strategies used to prevent migraines and may include the following medications:

Anti-hypertensives – Beta blockers and calcium channel blockers were originally developed to treat high blood pressure; however, researchers have found that these medications can also help control migraines. Commonly used beta blockers include metoprolol, propranolol, and timolol. Examples of calcium channel blockers are verapamil and nifedipine.
Anti-depressants – Tricyclic anti-depressants and certain other anti-depressants are often recommended for migraine prevention and include amitriptyline, nortriptyline, venlafaxine, and duloxetine. Amitriptyline in particular has been studied extensively and found to be beneficial in preventing migraines.
Anti-epileptics – Seizure medications have been found to successfully treat migraines and include topiramate and divaloproex sodium, both of which have FDA approval for migraine prevention.
CGRP antagonists – These medications aim to block the transmission of pain and inflammation in nerve cells and were the first medications developed specifically for migraine prevention. They are available as once monthly subcutaneous injections, orally as tablets, and once quarterly intravenous infusions. Erenumab, fremanezumab, galcanezumab, eptinezumab, atogepant, and rimegepant are presently available.
Botulinum toxin – Botox is a brand of botulinum toxin produced by a species of bacteria and that temporarily paralyzes muscles and has been proven to effectively block migraine pain, receiving FDA approval for chronic migraine prevention in 2010. Injections are given in a precise pattern at 90-day intervals to mitigate migraine occurrence.

Lifestyle modifications: Certain lifestyle changes can improve migraines and should be incorporated into daily living. Examples include the following:

Practice good “sleep hygiene” (set consistent bedtimes and wake times; avoid caffeine, alcohol, and smoking before bed; and do not look at electric devices right before bed).
Eat healthy meals around the same time each day.
Get regular exercise.
Maintain adequate hydration.
Minimize caffeine consumption.
Avoid known migraine triggers.
Reduce stress.

References:
The Mayo Clinic, The National Institutes of Health, UptoDate.com