Gemma is a 40-year old executive who experiences frequent, severe headaches. Every time she has an attack, she is unable to perform her daily activities and often has to stay in bed the whole day, with curtains drawn and nothing but the sound of silence. In severe episodes, her headaches are often accompanied by uncontrollable retching and vomiting. Resting and taking regular pain medications used to work for her but unfortunately, the more recent episodes have not responded well, if at all, to her pain relievers. After consulting with her specialist and undergoing some tests, she was diagnosed to have migraines.
Defining and describing a migraine
In a comprehensive article published in The New England Journal of Medicine, specialists define migraines as a common, chronic, incapacitating neurovascular disorder, characterized by severe headache, autonomic nervous system dysfunction, which when left untreated, may last for 4 to 72 hours. In some individuals, an aura involving neurologic symptoms is experienced a few hours prior to a migraine attack. This aura or cluster of warning symptoms may occur before or with the headache and can manifest as flashes of light, blind spots or tingling on one side of the face, arm or leg. Other aura symptoms may include weakness or numbness in the face or one side of the body, difficulty in speaking, and in severe cases even vision loss and limb weakness. Unlike tension- or stress-type headaches, migraine attacks are usually preceded or accompanied by transient focal neurologic symptoms which are usually visual, with the presence of an aura described above.
Migraines often occur in stages and can even show nonspecific signs and symptoms 24 to 48 hours prior to an attack. Known as a prodrome, subtle changes that can occur include constipation, mood changes, food cravings, neck stiffness, and even frequent yawning. Followed by an aura, and an attack, those suffering from migraines can experience fatigue right after a severe episode which may or may not be accompanied by confusion, dizziness, weakness, and sensitivity to light and sound although at a much less sensitive level.
Mechanisms behind a migraine
A migraine is often understood as a disorder of a brain which results in the dilation of blood vessels supplying the brain, resulting in severe pain and nerve activation. According to studies, some migraines may be caused by changes in the brain stem that affect the trigeminal nerve, which is considered as one of the major pathways of pain. Another underlying mechanism currently being studied is the role of the brain chemical serotonin in migraines. This chemical is known to have properties responsible for pain regulation in the nervous system. In Pathophysiology, a study showed that migraine often occurs after a sudden drop in blood serotonin levels.
According to the Mayo Clinic, certain triggers mostly found in the environment have been associated with increased incidence or occurrence of migraine attacks. Some of the associated factors include:
- Food or diet. Chocolate, cheese, salty and processed food have been shown to trigger severe migraines.
- Hormonal changes in women. Often experienced before or during their monthly periods, the sudden drop in estrogen levels has been shown to trigger migraines in women.
- Food additives such as MSG or aspartame
- Alcohol, wine, and highly caffeinated drinks
- Presence of extreme sensory stimuli such as bright or flashing lights
- Lack of sleep and sudden changes in the environment
- Medications such as nitroglycerin, which affect or lead to dilation of blood vessels in the brain.
Although known to trigger migraines, the presence of such factors does not always equate to severe headaches as experienced by others.
Migraines are often diagnosed based on clinical manifestations and a specialist known as a neurologist should be able to diagnose it based purely on medical history, symptoms, and a thorough physical and neurologic examination. Although migraines are easily detected when the presentation is typical, doctors would often recommend other tests to rule out possible causes of frequent, severe headaches such as the presence of tumors, stroke, hemorrhage, infection or any other underlying condition. Some common diagnostic procedures include blood tests, Magnetic Resonance Imaging (MRI), Computerized tomography (CT) scan, and spinal or lumbar tap which can help detect any underlying medical conditions leading to migraines.
Migraines are primarily treated with medications that help relieve pain and prevent further attacks.
- Pain relievers are best taken as soon as one experiences pain. Medications such as aspirin, ibuprofen, and acetaminophen are just some examples of drugs used to relieve mild migraines. Other medications can now be found in combination with other drugs such as aspirin or acetaminophen with caffeine and can be used to relieve moderate to severe migraines because of their synergistic effect.
- Triptans are medications often used in treating migraines. These drugs are selective serotonin inhibitors that when taken, can lead to constriction of blood vessels and help block pain receptors in the brain.
- Ergots or ergotamine and caffeine combinations are still occasionally used but were found to worsen nausea and vomiting.
- Opioid medications containing narcotics such as codeine are sometimes given in severe cases or in those who cannot take triptans or ergotamines. Because addiction is often associated with such drugs, it is no longer advised in the majority of patients experiencing migraines.
- Anti-nausea medications, when combined with other pain relievers, seemed to be beneficial to those experiencing severe vomiting episodes with their migraines. Because of this, the role of anti-emetics in this condition is now being carefully considered. In a study published in Cephalalgia, the anti-emetic domperidone when combined with paracetamol or acetaminophen in the treatment of migraines greatly reduced the duration of a migraine attack and intensity of pain and nausea. Fewer central nervous system side effects were also reported when compared with other types of anti-emetics such as metoclopramide. Incidentally, in another study determining the role of domperidone in migraines, The Journal of Head and Face Pain also recognized its role not only as an anti-emetic but also as a preventive agent in migraine attacks especially when taken at the very first appearance of warning signals.
Although not often recommended, preventive medication may be given to those who meet the following categories:
- Individuals experiencing 4 or more debilitating attacks a month
- Attacks lasting more than 12 hours
- Unresponsiveness to pain medications
- Presence of prolonged aura, numbness or weakness
Although taking such medications do not guarantee non-occurrence of migraines, these drugs have been shown to reduce the frequency, severity, and duration of migraines in the long run and even increase the effectiveness of pain relievers when taken during attacks. Commonly prescribed preventive medications include cardiovascular drugs, anti-depressants, anti-seizure drugs, and NSAIDs. Because one drug may not be appropriate for everyone and may vary from one person to another, consulting a specialist would be best. Although medications play an important role in the treatment and prevention of migraines, once triggers or predisposing factors are identified, avoiding them could not only be life-changing but life-preserving as well.