Migraine headache

Definition

Migraine is a type of headache marked by severe head pain lasting several hours or more.

Description

Migraine is an intense and often debilitating type of headache. The term migraine is derived from the Greek word hemikrania, meaning "half the head," because the classic migraine headache affects only one side of the person's head. Migraines affect as many as 24 million people in the United States, and are responsible for billions of dollars in lost work, poor job performance, and direct medical costs. Approximately 18% of women and 6% of men experience at least one migraine attack per year. Currently, one American in 11 now suffers from migraines, more than three times as many are women, with most of them being between the ages of 30 and 49. Migraines often begin in adolescence, and are rare after age 60.

Two types of migraine are recognized. Eighty percent of migraine sufferers experience "migraine without aura" (common migraine). In "migraine with aura," or classic migraine, the pain is preceded or accompanied by visual or other sensory disturbances, including hallucinations, partial obstruction of the visual field, numbness or tingling, or a feeling of heaviness. Symptoms are often most prominent on one side of the head or body, and may begin as early as 72 hours before the onset of pain.

Causes & symptoms

Causes

The physiological basis of migraine has proved difficult to uncover. There are a multitude of potential triggers for a migraine attack, and recognizing one's own set of triggers is the key to prevention.

PHYSIOLOGY. The most widely accepted hypothesis of migraine suggests that a migraine attack is precipitated when pain-sensing nerve cells in the brain (called nociceptors) release chemicals called neuropeptides. At least one of the neurotransmitters, substance P, increases the pain sensitivity of nearby nociceptors. This process is called sensitization.

Other neuropeptides act on the smooth muscle surrounding cranial blood vessels. This smooth muscle regulates blood flow in the brain by relaxing or contracting, thus dilating (enlarging) or constricting the enclosed blood vessels. At the onset of a migraine headache, neuropeptides are thought to cause muscle relaxation , allowing vessel dilation and increased blood flow. Other neuropeptides increase the leakiness of cranial vessels, allowing fluid leak, and promote inflammation and tissue swelling. The pain of migraine is thought to result from this combination of increased pain sensitivity, tissue and vessel swelling, and inflammation. The aura seen during a migraine may be related to constriction in the blood vessels that dilate in the headache phase.

GENETICS. Susceptibility to some types of migraine is inherited. A child of a migraine sufferer has as much as a 50% chance of developing migraines. If both parents are affected, the chance rises to 70%. In 2002, a team of Australian researchers identified a region on human chromosome 1 that influences susceptibility to migraine. It is likely that more than one gene is involved in the inherited forms of the disorder. Many cases of migraine, however, have no obvious familial basis. It is likely that the genes that are involved set the stage for migraine, and that full development requires environmental influences, as well.

Two groups of Italian researchers have recently identified two loci on human chromosomes 1 and 14 respectively that are linked to migraine headaches. The locus on chromosome 1q23 has been linked to familial hemiplegic migraine type 2, while the locus on chromosome 14q21 is associated with migraine without aura.

TRIGGERS. A wide variety of foods, drugs, environmental cues, and personal events are known to trigger migraines. It is not known how most triggers set off the events of migraine, nor why individual migraine sufferers are affected by particular triggers but not others.

Common food triggers include:

• alcohol
• caffeine products, as well as caffeine withdrawal
• chocolate
• foods with an extremely high sugar content
• dairy products
• fermented or pickled foods
• citrus fruits
• nuts
• processed foods, especially those containing nitrites, sulfites, or monosodium glutamate (MSG)

Environmental and event-related triggers include:

• stress or time pressure
• menstrual periods, menopause
• sleep changes or disturbances, including oversleeping
• prolonged overexertion or uncomfortable posture
• hunger or fasting
• odors, smoke, or perfume
• strong glare or flashing lights

Drugs that may trigger migraine include:

• oral contraceptives
• estrogen replacement therapy
• Theophylline
• Reserpine
• Nifedipine
• Indomethicin
• Cimetidine
• oversuse of decongestants
• analgesic overuse
• benzodiazepine withdrawal

Symptoms

Migraine without aura may be preceded by elevations in mood or energy level for up to 24 hours before the attack. Other pre-migraine symptoms may include fatigue, depression , and excessive yawning.

Aura most often begins with shimmering, jagged arcs of white or colored light progressing over the visual field in the course of 10–20 minutes. This may be preceded or replaced by dark areas or other visual disturbances. Numbness and tingling are common, especially of the face and hands. These sensations may spread, and may be accompanied by a sensation of weakness or heaviness in the affected limb.

Migraine pain is often present only on one side of the head, although it may involve both, or switch sides during attacks. The pain is usually throbbing, and may range from mild to incapacitating. It is often accompanied by nausea or vomiting , painful sensitivity to light and sound, and intolerance of food or odors. Blurred vision is also common.

The pain tends to intensify over the first 30 minutes to several hours, and may last from several hours to a day, or longer. Afterward, the affected person is usually weary, and sensitive to sudden head movements.

Diagnosis

Ideally, migraine is diagnosed by a careful medical history. Unfortunately, migraine is underdiagnosed because many doctors tend to minimize its symptoms as "just a headache." According to a 2003 study, 64% of migraine patients in the United Kingdom and 77% of those in the United States never receive a correct medical diagnosis for their headaches.

So far, laboratory tests and such imaging studies as computed tomography (CT scan) or magnetic resonance imaging (MRI) scans have not been useful for identifying migraine. However, these tests may be necessary to rule out a brain tumor or other structural causes of migraine headache in some patients.

Treatment

At the onset of symptoms, the migraine sufferer should seek out a quiet, dark room and attempt to sleep. Placing a cold, damp cloth or a cold pack on the fore-head may help. Additionally, tying a headband tightly around the head can relieve migraines.

Migraine headaches are often linked with food allergies or intolerances. Identification and elimination of the offending food or foods can decrease the frequency of migraines and/or alleviate these headaches altogether.

Alternative treatments for migraine include:

• Acupressure. Pressing on the Gates of Consciousness (GB 20) points can relieve migraine.
• Acupuncture . A National Institutes of Health (NIH) panel concluded that acupuncture may be a useful treatment for headache.
• Aromatherapy. The essential oil rosemary eases migraine pain.
• Autogenic training. Autogenic training is a form of self-hypnosis developed in Germany in the 1930s that has been shown in several studies to relieve the pain of migraine.
• Cognitive behavior therapy.
• Herbals. Valerian (Valeriana officinalis ), passion-flower (Passiflora incarnata ), feverfew (Chrysanthemum parthenium ), ginger , ginkgo (Ginkgo biloba ), goldenseal (Hydrastis canadensis ), hawthorn (Crataegus oxyacantha ), linden, wood betony (Stachys officinalis ), skullcap (Scutellaria lateriflora ), or cramp bark (Viburnum opulus ) may relieve migraines.
• Hydrotherapy. Contrast showers, in which a short hot shower is followed by a longer cold shower, may halt an oncoming migraine. A hot enema can temporarily relieve migraine pain.
• Naturopathy. Migraine headaches are one of the most common reasons for consulting naturopathic practitioners. Naturopaths typically treat migraine with a combination of nutritional therapy and mind/body techniques.
• Relaxation techniques. Meditation, yoga , hypnosis, visualization, breathing exercises, or progressive muscular relaxation may halt the progression of a migraine.
• Supplements. Clinical studies have shown that vitamin B₂ (riboflavin ), magnesium, 5-HTP , or melatonin can reduce the severity of migraines.
• Transcutaneous electrical nerve stimulation (TENS).

Allopathic treatments

Nonsteroidal anti-inflammatory drugs (NSAIDs) acetaminophen (Tylenol), ibuprofen (Motrin), and naproxen (Aleve) are helpful for early and mild headache. Excedrin Migraine is a combination product that is indicated for migraine headache.

More severe or unresponsive attacks may be treated with ergotamine (botulinum toxin), dihydroergotamine, sumatriptan (Imitrex), beta-blockers and calcium channel-blockers, antiseizure drugs, antidepressants (SSRIs), meperidine, or metoclopramide. Some of these drugs are also available as nasal sprays, intramuscular injections, or rectal suppositories when vomiting prevents taking the drug by mouth.

Sumatriptan and other triptan drugs (zolmitriptan, rizatriptan, naratriptan, almotriptan, and frovatriptan) should not be taken by people with any kind of vascular disease because they cause coronary artery narrowing. Otherwise these drugs have been shown to be very safe.

Continued use of some antimigraine drugs can lead to "rebound headache," marked by frequent or chronic headaches, especially in the early morning hours. Rebound headache can be avoided by using antimigraine drugs under a doctor's supervision, with the minimum dose necessary to treat symptoms. Tizanidine (Zanaflex) has been reported to be effective in treating rebound headaches when taken together with an NSAID.

Expected results

Most people can control migraines through recognizing and avoiding triggers, and by using effective treatments. Some people with severe migraines do not respond to preventive or drug therapy. Migraines usually wane in intensity by age 60 and beyond.

Prevention

The frequency of migraine headaches may be lessened by avoiding triggers. It is useful to track these triggers by keeping a headache journal.

One substance that is being studied as a possible migraine preventive is coenzyme Q₁₀ , a compound used by cells to produce energy needed for cell growth and maintenance. Coenzyme Q₁₀ has been studied as a possible complementary treatment for cancer . Its use in preventing migraines is encouraging and merits further study.

A study published in early 2003 reported that three drugs currently used to treat disorders of muscle tone are being explored as possible preventive treatments for migraine. They are botulinum toxin type A (Botox), baclofen (Lioresal), and tizanidine (Zanaflex). Early results of open trials of these medications are positive.

Anti-epileptic drugs, which are also known as anti-convulsants, are also being studied as possible migraine preventives. As of 2003, sodium valproate (Epilim) is the only drug approved by the Food and Drug Administration (FDA) for prevention of migraine. Such newer anticonvulsants as gabapentin (Neurontin) and topiramate (Topamax) are presently being evaluated as migraine preventives.

A natural preparation made from butterbur root (Petasites hybridus ) has been sold in Germany since the 1970s as a migraine preventive under the trade name Petadolex. Petadolex has been available in the United States since December 1998 and has passed several clinical safety and postmarketing surveillance trials.

Other possible preventive measures include: eating at regular times, not skipping meals, reducing the use of caffeine and pain-relievers, restricting physical exertion (especially on hot days), and keeping regular sleep hours, but not oversleeping. Other measures include:

• Aerobic exercise , which can reduce the frequency of migraines.
• Biofeedback thermal control was found to be as effective as medications in preventing migraines.
• Celery juice consumed twice daily may help to prevent migraines.
• Feverfew was shown to reduce the severity and frequency of migraines. This herb should not, however, be used during pregnancy or by people taking blood-thinning medications.
• Ginger may help prevent migraines.
• Pulsing electromagnetic fields. A preliminary study found that pulsing electromagnetic fields reduced the frequency of migraines.
• Relaxation techniques can reduce migraine frequency.
• Supplementation with magnesium and riboflavin was shown to prevent migraines.

Resources

BOOKS

American Council on Headache Education. Migraine: The Complete Guide. New York: Dell, 1994.

"Migraine. " Section 14, Chapter 168 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Headaches." New York: Simon & Schuster, 2002.

PERIODICALS

Bendtsen, L. "Sensitization: Its Role in Primary Headache." Current Opinion in Investigational Drugs 3 (March 2002): 449–453.

Corbo, J. "The Role of Anticonvulsants in Preventive Migraine Therapy." Current Pain and Headache Reports 7 (February 2003): 63–66.

Danesch, U., and R. Rittinghausen. "Safety of a Patented Special Butterbur Root Extract for Migraine Prevention." Headache 43 (January 2003): 76–78.

Diamond, S., and R. Wenzel. "Practical Approaches to Migraine Management." CNS Drugs 16 (2002): 385–403.

Freitag, F. G. "Preventative Treatment for Migraine and Tension-Type headaches : Do Drugs Having Effects on Muscle Spasm and Tone Have a Role?" CNS Drugs 17 (2003): 373–381.

Lea, R. A., A. G. Shepherd, R. P. Curtain, et al. "A Typical Migraine Susceptibility Region Localizes to Chromosome 1q31." Neurogenetics 4 (March 2002): 17–22.

Lipton, R. B., A. I. Scher, T. J. Steiner, et al. "Patterns of Health Care Utilization for Migraine in England and in the United States." Neurology 60 (February 11, 2003): 441–448.

Marconi, R., M. De Fusco, P. Aridon, et al. "Familial Hemiplegic Migraine Type 2 is Linked to 0.9Mb Region on Chromosome 1q23" Annals of Neurology 53 (March 2003): 376–381.

Pryse–Phillips, William E.M., et al. "Guidelines for the Nonpharmacologic Management of Migraine in Clinical Practice." Canadian Medical Association Journal 159 (July 14, 1998): 47–54.

Rozen, T. D., M. L. Oshinsky, C. A. Gebeline, et al. "Open Label Trial of Coenzyme Q₁₀ as a Migraine Preventive." Cephalalgia 22 (March 2002): 137–141.

Sheftell, F. D., and S. J. Tepper. "New Paradigms in the Recognition and Acute Treatment of Migraine." Headache 42 (January 2002): 58–69.

Sinclair, Steven. "Migraine Headaches: Nutritional, Botanical and Other Alternative Approaches." Alternative Medicine Review 4 (1999): 86–95.

Soragna, D., A. Vettori, G. Carraro, et al. "A Locus for Migraine Without Aura Maps on Chromosome 14q21.2-q22.3." American Journal of Human Genetics 72 (January 2003): 161–167.

Stetter, F., and S. Kupper. "Autogenic Training: A Meta-Analysis of Clinical Outcome Studies." Applied Psychophysiology and Biofeedback 27 (March 2002): 45–98.

Tepper, S. J., and D. Millson. "Safety Profile of the Triptans." Expert Opinion on Drug Safety 2 (March 2003): 123–132.

ORGANIZATIONS

American Council for Headache Education. 19 Mantua Road, Mt. Royal, NJ 08061. (609) 423-0043 or (800) 255-2243. <http://www.achenet.org>.

National Headache Foundation. 428 West St. James Place, Chicago, IL 60614. (773) 388-6399 or (800) 843-2256. <http://www.headaches.org>.

U. S. Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville, MD 20857. (888) 463-6332. <http://www.fda.gov>.

OTHER

"Migraine." American Medical Association. (cited December 2002). <http://www.ama-assn.org/special/migraine>.

Belinda Rowland

Rebecca J. Frey, PhD

Migraine Headache

Definition

Migraine is a type of headache marked by severe head pain lasting several hours or more.

Description

Migraine is an intense and often debilitating type of headache. Migraines affect as many as 24 million people in the United States, and are responsible for billions of dollars in lost work, poor job performance, and direct medical costs. Approximately 18% of women and 6% of men experience at least one migraine attack per year. More than three million women and one million men have one or more severe headaches every month. Migraines often begin in adolescence, and are rare after age 60.

Two types of migraine are recognized. Eighty percent of migraine sufferers experience "migraine without aura" (common migraine). In "migraine with aura," or classic migraine, the pain is preceded or accompanied by visual or other sensory disturbances, including hallucinations, partial obstruction of the visual field, numbness or tingling, or a feeling of heaviness. Symptoms are often most prominent on one side of the head or body, and may begin as early as 72 hours before the onset of pain.

Causes and symptoms

Causes

The physiological basis of migraine has proved difficult to uncover. Genetics appear to play a part for many, but not all, people with migraine. There are a multitude of potential triggers for a migraine attack, and recognizing one's own set of triggers is the key to prevention.

PHYSIOLOGY. The most widely accepted hypothesis of migraine suggests that a migraine attack is precipitated when pain-sensing nerve cells in the brain (called nociceptors) release chemicals called neuropeptides. At least one of the neurotransmitters, substance P, increases the pain sensitivity of other nearby nociceptors.

Other neuropeptides act on the smooth muscle surrounding cranial blood vessels. This smooth muscle regulates blood flow in the brain by relaxing or contracting, thus constricting the enclosed blood vessels and stimulating adjacent pain receptors. At the onset of a migraine headache, neuropeptides are thought to cause muscle relaxation, allowing vessel dilation and increased blood flow. Other neuropeptides increase the leakiness of cranial vessels, allowing fluid leak, and promote inflammation and tissue swelling. The pain of migraine is though to result from this combination of increased pain sensitivity, tissue and vessel swelling, and inflammation. The aura seen during a migraine may be related to constriction in the blood vessels that dilate in the headache phase.

GENETICS. Susceptibility to some types of migraine is inherited. A child of a migraine sufferer has as much as a 50% chance of developing migraines. If both parents are affected, the chance rises to 70%. In 2002, a team of Australian researchers identified a region on human chromosome 1 that influences susceptibility to migraine. It is likely that more than one gene is involved in the inherited forms of the disorder. Many cases of migraine, however, have no obvious familial basis. It is likely that the genes that are involved set the stage for migraine, and that full development requires environmental influences, as well.

Two groups of Italian researchers have recently identified two loci on human chromosomes 1 and 14 respectively that are linked to migraine headaches. The locus on chromosome 1q23 has been linked to familial hemiplegic migraine type 2, while the locus on chromosome 14q21 is associated with migraine without aura.

TRIGGERS. A wide variety of foods, drugs, environmental cues, and personal events are known to trigger migraines. It is not known how most triggers set off the events of migraine, nor why individual migraine sufferers are affected by particular triggers but not others.

Common food triggers include:

• cheese
• alcohol
• caffeine products, and caffeine withdrawal
• chocolate
• intensely sweet foods

• dairy products
• fermented or pickled foods
• citrus fruits
• nuts
• processed foods, especially those containing nitrites, sulfites, or monosodium glutamate (msg)

Environmental and event-related triggers include:

• stress or time pressure
• menstrual periods, menopause
• sleep changes or disturbances, oversleeping
• prolonged overexertion or uncomfortable posture
• hunger or fasting
• odors, smoke, or perfume
• strong glare or flashing lights

Drugs which may trigger migraine include:

• oral contraceptives
• estrogen replacement therapy
• nitrates
• theophylline
• reserpine
• nifedipine
• indomethicin
• cimetidine
• decongestant overuse
• analgesic overuse
• benzodiazepine withdrawal

Symptoms

Migraine without aura may be preceded by elevations in mood or energy level for up to 24 hours before the attack. Other pre-migraine symptoms may include fatigue, depression, and excessive yawning.

Aura most often begins with shimmering, jagged arcs of white or colored light progressing over the visual field in the course of 10-20 minutes. This may be preceded or replaced by dark areas or other visual disturbances. Numbness and tingling is common, especially of the face and hands. These sensations may spread, and may be accompanied by a sensation of weakness or heaviness in the affected limb.

The pain of migraine is often present only on one side of the head, although it may involve both, or switch sides during attacks. The pain is usually throbbing, and may range from mild to incapacitating. It is often accompanied by nausea or vomiting, painful sensitivity to light and sound, and intolerance of food or odors. Blurred vision is common.

Migraine pain tends to intensify over the first 30 minutes to several hours, and may last from several hours to a day or longer. Afterward, the affected person is usually weary, and sensitive to sudden head movements.

Diagnosis

Ideally, migraine is diagnosed by a careful medical history. Unfortunately, migraine is underdiagnosed because many doctors tend to minimize its symptoms as "just a headache." According to a 2003 study, 64% of migraine patients in the United Kingdom and 77% of those in the United States never receive a correct medical diagnosis for their headaches.

So far, laboratory tests and such imaging studies as computed tomography (CT scan) or magnetic resonance imaging (MRI) scans have not been useful for identifying migraine. However, these tests may be necessary to rule out a brain tumor or other structural causes of migraine headache in some patients.

Treatment

Once a migraine begins, the person will usually seek out a dark, quiet room to lessen painful stimuli. Several drugs may be used to reduce the pain and severity of the attack.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful for early and mild headache. NSAIDs include acetaminophen, ibuprofen, naproxen, and others. A recent study concluded that a combination of acetaminophen, aspirin, and caffeine could effectively relieve symptoms for many migraine patients. One such over-the-counter preparation is available as Exedrin Migraine.

More severe or unresponsive attacks may be treated with drugs that act on serotonin receptors in the smooth muscle surrounding cranial blood vessels. Serotonin, also known as 5-hydroxytryptamine, constricts these vessels, relieving migraine pain. Drugs that mimic serotonin and bind to these receptors have the same effect. The oldest of them is ergotamine, a derivative of a common grain fungus. Ergotamine and dihydroergotamine are used for both acute and preventive treatment. Derivatives with fewer side effects have come onto the market in the past decade, including sumatriptan (Imitrex). Some of these drugs are available as nasal sprays, intramuscular injections, or rectal suppositories for patients in whom vomiting precludes oral administration. Other drugs used for acute attacks include meperidine and metoclopramide.

Studies are showing that rizatriptan is a promising drug for the treatment of migraines. One study showed that 10mg of rizatriptan provided relief to 90% of the patients in the study group and kept 50% of them pain-free 2 hours after taking the medication. Sumatriptan has been on the market since 1993, while rizatriptan became available in 1998.

Sumatriptan and other triptan drugs (zolmitriptan, rizatriptan, naratriptan, almotriptan, and frovatriptan) should not be taken by people with any kind of vascular disease because they cause coronary artery narrowing. Otherwise these drugs have been shown to be very safe.

Continued use of some antimigraine drugs can lead to "rebound headache," marked by frequent or chronic headaches, especially in the early morning hours. Rebound headache can be avoided by using antimigraine drugs under a doctor's supervision, with the minimum dose necessary to treat symptoms. Tizanidine (Zanaflex) has been reported to be effective in treating rebound headaches when taken together with an NSAID.

Alternative treatments

Alternative treatments are aimed at prevention of migraine. Migraine headaches are often linked with food allergies or intolerances. Identification and elimination of the offending food or foods can decrease the frequency of migraines and/or alleviate these headaches altogether. Herbal therapy with feverfew (Chrysanthemum parthenium ) may lessen the frequency of attacks. Learning to increase the flow of blood to the extremities through biofeedback training may allow a patient to prevent some of the vascular changes once a migraine begins. During a migraine, keep the lights low; put the feet in a tub of hot water and place a cold cloth on the occipital region (the back of the head). This treatment draws the blood to the feet and decreases the pressure in the head.

Prognosis

Most people with migraines can bring their attacks under control through recognizing and avoiding triggers, and by use of appropriate drugs when migraine occurs. Some people with severe migraines do not respond to preventive or drug therapy. Migraines usually wane in intensity by age 60 and beyond.

Prevention

The frequency of migraine may be lessened by avoiding triggers. It is useful to keep a headache journal, recording the particulars and noting possible triggers for each attack. Specific measures which may help include:

• Eating at regular times, and not skipping meals.
• Reducing the use of caffeine and pain-relievers.
• Restricting physical exertion, especially on hot days.
• Keeping regular sleep hours, but not oversleeping.
• Managing one's time efficiently in order to avoid stress at work and home.

Some drugs can be used for migraine prevention, including specific members of these drug classes:

• beta blockers
• tricyclic antidepressants
• calcium channel blockers
• selective serotinin reuptake inhibitors (SSRIs)
• monoamine oxidase inhibitors (MAOIs)
• serotonin antagonists

One substance that is being studied as a possible migraine preventive is coenzyme Q₁₀, a compound used by cells to produce energy needed for cell growth and maintenance. Coenzyme Q₁₀ has been studied as a possible complementary treatment for cancer. Its use in preventing migraines is encouraging and merits further study.

KEY TERMS

Aura— A group of visual or other sensations that precedes the onset of a migraine attack.

Coenzyme Q₁₀— A substance used by cells in the human body to produce energy for cell maintenance and growth. It is being studied as a possible preventive for migraine headaches.

Nociceptor— A specialized type of nerve cell that senses pain.

A study published in early 2003 reported that three drugs currently used to treat disorders of muscle tone are being explored as possible preventive treatments for migraine. They are botulinum toxin type A (Botox), baclofen (Lioresal), and tizanidine (Zanaflex). Early results of open trials of these medications are positive.

Anti-epileptic drugs, which are also known as anticonvulsants, are also being studied as possible migraine preventives. As of 2003, sodium valproate (Epilim) is the only drug approved by the Food and Drug Administration (FDA) for prevention of migraine. Such newer anticonvulsants as gabapentin (Neurontin) and topiramate (Topamax) are presently being evaluated as migraine preventives.

A natural preparation made from butterbur root (Petasites hybridus ) has been sold in Germany since the 1970s as a migraine preventive under the trade name Petadolex. Petadolex has been available in the United States since December 1998 and has passed several clinical safety and postmarketing surveillance trials.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Migraine." Section 14, Chapter 168. In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Headaches." New York: Simon & Schuster, 2002.

Rakel, Robert. Conn's Current Therapy: Latest Approved Methods of Treatment for the Practicing Physician. Philadelphia: W.B. Saunders Company, 2001.

Tierney, Lawrence, et al. Current Medical Diagnosis and Treatment. Los Altos, CA: Lange Medical Publications, 2001.

PERIODICALS

Bendtsen, L. "Sensitization: Its Role in Primary Headache." Current Opinion in Investigational Drugs 3 (March 2002): 449-453.

Corbo, J. "The Role of Anticonvulsants in Preventive Migraine Therapy." Current Pain and Headache Reports 7 (February 2003): 63-66.

Danesch, U., and R. Rittinghausen. "Safety of a Patented Special Butterbur Root Extract for Migraine Prevention." Headache 43 (January 2003): 76-78.

Diamond, S., and R. Wenzel. "Practical Approaches to Migraine Management." CNS Drugs 16 (2002): 385-403.

Freitag, F. G. "Preventative Treatment for Migraine and Tension-Type Headaches: Do Drugs Having Effects on Muscle Spasm and Tone Have a Role?" CNS Drugs 17 (2003): 373-381.

Lea, R. A., A. G. Shepherd, R. P. Curtain, et al. "A Typical Migraine Susceptibility Region Localizes to Chromosome 1q31." Neurogenetics 4 (March 2002): 17-22.

Lipton, R. B., A. I. Scher, T. J. Steiner, et al. "Patterns of Health Care Utilization for Migraine in England and in the United States." Neurology 60 (February 11, 2003): 441-448.

Marconi, R., M. De Fusco, P. Aridon, et al. "Familial Hemiplegic Migraine Type 2 is Linked to 0.9Mb Region on Chromosome 1q23." Annals of Neurology 53 (March 2003): 376-381.

Rozen, T. D., M. L. Oshinsky, C. A. Gebeline, et al. "Open Label Trial of Coenzyme Q₁₀ as a Migraine Preventive." Cephalalgia 22 (March 2002): 137-141.

Sheftell, F. D., and S. J. Tepper. "New Paradigms in the Recognition and Acute Treatment of Migraine." Headache 42 (January 2002): 58-69.

Sinclair, Steven. "Migraine Headaches: Nutritional, Botanical and Other Alternative Approaches." Alternative Medicine Review 4 (1999): 86-95.

Soragna, D., A. Vettori, G. Carraro, et al. "A Locus for Migraine Without Aura Maps on Chromosome 14q21.2-q22.3." American Journal of Human Genetics 72 (January 2003): 161-167.

Tepper, S. J., and D. Millson. "Safety Profile of the Triptans." Expert Opinion on Drug Safety 2 (March 2003): 123-132.

ORGANIZATIONS

American Council for Headache Education. 19 Mantua Road, Mt. Royal, NJ 08061. (609) 423-0043 or (800) 255-2243. 〈http://www.achenet.org〉.

National Headache Foundation. 428 West St. James Place, Chicago, IL 60614. (773) 388-6399 or (800) 843-2256. 〈http://www.headaches.org〉.

U. S. Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville, MD 20857. (888) 463-6332. 〈http://www.fda.gov〉.

OTHER

American Medical Association. "Migraine." 〈http://www.ama-assn.org/special/migraine/〉.

Migraine Headache

Causes and symptoms

Diagnosis

Treatment

Alternative treatments

Prognosis

Prevention

Resources

Migraine is a type of headache marked by severe head pain lasting several hours or more.

Migraine is an intense, often debilitating type of headache. Migraines affect as many as 24 million people in the United States, and are responsible for billions of dollars in lost work, poor job performance, and direct medical costs. Approximately 18% of women and 6% of men experience at least one migraine attack per year. More than three million women and one million men have one or more severe headaches every month. Migraines often begin in adolescence, and are rare after age 60.

Two types of migraine are recognized. Eighty percent of migraine sufferers experience “migraine without aura,” formerly called common migraine. In “migraine with aura,” formerly called classic migraine, pain is preceded or accompanied by visual or other sensory disturbances, including hallucinations, partial obstruction of the visual field, numbness or tingling, or a feeling of heaviness. Symptoms are often most prominent on one side of the body, and may begin as early as 72 hours before the onset of pain.

Causes and symptoms

Causes

The physiological basis of migraine has proved difficult to uncover. Genetics appear to play a part for many, but not all, people with migraine. There are a multitude of potential triggers for a migraine attack, and recognizing one’s own set of triggers is the key to prevention.

Physiology

The most widely accepted hypothesis of migraine suggests that a migraine attack is precipitated when pain-sensing nerve cells in the brain (called nociceptors) release chemicals called neuropeptides. At least one of the neurotransmitters, substance P, increases the pain sensitivity of other nearby nociceptors.

Other neuropeptides act on the smooth muscle surrounding cranial blood vessels. This smooth

muscle regulates blood flow in the brain by relaxing or contracting, thus dilating (enlarging) or constricting the enclosed blood vessels. At the onset of a migraine headache, neuropeptides are thought to cause muscle relaxation, allowing vessel dilation and increased blood flow. Other neuropeptides increase the leakiness of cranial vessels, allowing fluid leak, and promote inflammation and tissue swelling. The pain of migraine is thought to result from this combination of increased pain sensitivity, tissue and vessel swelling, and inflammation. The aura seen during a migraine may be related to constriction in the blood vessels that dilate in the headache phase.

Genetics

Susceptibility to migraine may be inherited. A child of a migraine sufferer has as much as a 50% chance of developing migraine. If both parents are affected, the chance rises to 70%. However, the gene or genes responsible have not been identified, and many cases of migraine have no obvious familial basis. It is likely that whatever genes are involved set the stage for migraine, and that full development requires environmental influences as well.

Triggers

A wide variety of foods, drugs, environmental cues, and personal events are known to trigger migraines. It is not known how most triggers set off the events of migraine, nor why individual migraine sufferers are affected by particular triggers but not others.

Common food triggers include:

• cheese
• alcohol
• caffeine products, and caffeine withdrawal
• chocolate
• intensely sweet foods
• dairy products
• fermented or pickled foods
• citrus fruits
• nuts
• processed foods, especially those containing nitrites, sulfites, or monosodium glutamate (MSG)

Environmental and event-related triggers include:

• stress or timepressure
• menstrual periods, menopause
• sleep changes or disturbances, oversleeping
• prolonged overexertion or uncomfortable posture
• hunger or fasting
• odors, smoke, or perfume
• strong glare or flashing lights

Drugs that may trigger migraine include:

• oral contraceptives
• estrogen replacement therapy
• nitrates
• theophylline
• reserpine
• nifedipine
• indomethicin
• cimetidine
• decongestant overuse
• analgesic overuse
• benzodiazepine withdrawal

Symptoms

Migraine without aura may be preceded by elevations in mood or energy level for up to 24 hours before the attack. Other pre-migraine symptoms may include fatigue, depression, and excessive yawning.

Aura most often begins with shimmering, jagged arcs of white or colored light progressing over the visual field in the course of 10-20 minutes. This may be preceded or replaced by dark areas or other visual disturbances. Numbness and tingling is common, especially of the face and hands. These sensations may spread, and may be accompanied by a sensation of weakness or heaviness in the affected limb.

The pain of migraine is often present only on one side of the head, although it may involve both, or switch sides during attacks. The pain is usually throbbing, and may range from mild to incapacitating. It is often accompanied by nausea or vomiting, painful sensitivity to light and sound, and intolerance of food or odors. Blurred vision is common.

Migraine pain tends to intensify over the first 30 minutes to several hours, and may last from several hours to a day or longer. Afterward, the affected person is usually weary, and sensitive to sudden head movements.

Diagnosis

Migraine is diagnosed by a careful medical history. Lab tests and imaging studies such as computed tomography (CT scan) or magnetic resonance imaging (MRI) scans have not been useful for identifying migraine. However, for some patients, those tests may be needed to rule out a brain tumor or other structural causes of migraine headache.

Treatment

Once a migraine begins, the person will usually seek out a dark, quiet room to lessen painful stimuli. Several drugs may be used to reduce the pain and severity of the attack.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful for early and mild headache. NSAIDs include acetaminophen, ibuprofen, naproxen, and others. A recent study concluded that a combination of acetaminophen, aspirin, and caffeine could effectively relieve symptoms for many migraine patients. One such over-the-counter preparation is available as Exedrin Migraine.

More severe or unresponsive attacks may be treated with drugs that act on serotonin receptors in the smooth muscle surrounding cranial blood vessels. Serotonin, also known as 5-hydroxytryptamine, constricts these vessels, relieving migraine pain. Drugs that mimic serotonin and bind to these receptors have the same effect. The oldest of them is ergotamine, a derivative of a common grain fungus. Ergotamine and dihydroergotamine are used for both acute and preventive treatment. Derivatives with fewer side effects have come onto the market in the past decade, including sumatriptan (Imitrex). Some of these drugs are available as nasal sprays, intramuscular injections, or rectal suppositories for patients in whom vomiting precludes oral administration. Other drugs used for acute attacks include meperidine and metoclopramide.

Continued use of some anti-migraine drugs can lead to “rebound headache,” marked by frequent or chronic headaches, especially in the early morning hours. Rebound headache is avoided by using anti-migraine drugs under a doctor’s supervision, with the minimum dose necessary to treat symptoms. Patients with frequent migraines may need preventive therapy.

Alternative treatments

Alternative treatments are aimed at prevention of migraine. Migraine headaches are often linked with food allergies or intolerances. Identification and elimination of the offending food or foods can decrease the frequency of migraines and/or alleviate these headaches altogether. Herbal therapy with feverfew (Chrysanthemum parthenium ) may lessen the frequency of attacks. Learning to increase the flow of blood to the extremities through biofeedback training may allow a patient to prevent some of the vascular changes once a migraine begins. During a migraine, keep the lights low; put the feet in a tub of hot water and place a cold cloth on the occipital region (the back of the head). This draws the blood to the feet and decreases the pressure in the head.

Prognosis

Most people with migraines can bring their attacks under control through recognizing and avoiding triggers, and by use of appropriate drugs when migraine occurs. Some people with severe migraines do not respond to preventive or drug therapy. Migraines usually wane in intensity by age 60 and beyond.

Prevention

The frequency of migraine may be lessened by avoiding triggers. It is useful to keep a headache journal, recording the particulars and noting possible triggers for each attack. Specific measures that may help include:

• Eating at regular times, and not skipping meals.
• Reducing the use of caffeine and pain-relievers.
• Restricting physical exertion, especially on hot days.
• Keeping regular sleep hours, but not oversleeping.
• Managing time to avoid stress at work and home.

Some drugs can be used for migraine prevention, including specific members of these drug classes:

• Beta blockers
• Tricyclic antidepressants
• Calcium channel blockers
• Anticonvulsants
• Prozac
• Monoamine oxidase inhibitors (MAO)
• Serotonin antagonists

For most patients, preventive drug therapy is not an appropriate option, since it requires continued use of powerful drugs. However, for women whose migraines coincide with the menstrual period, limited preventive treatment may be effective. Since these drugs are appropriate for patients with other medical conditions, the decision to prescribe them for migraine may be influenced by expected benefit elsewhere.

Resources

BOOKS

The American Council on Headache Education. Migraine: The Complete Guide. New York: Dell, 1994.

Sacks, O. Migraine. Berkeley: University of California Press, 1992.

PERIODICALS

Binder, W.J. “Botulinum Toxin Type A (Botox) For Treatment of Migraine Headache.” Otolaryngology And Head And Neck Surgery 123, no. 6 (2000): 669-676.

“Drug Treatment of Migraine: Part I.” American Family Physician (15 November 1997): 2039-2048.

“Drug Treatment of Migraine: Part II.” American Family Physician (December 1997): 2279-2286.

“Guidelines for the Diagnosis and Management of Migraine in Clinical Practice.” Canadian Medical Association Journal 156 (May 1997): 1273-1287.

OTHER

Mayo Clinic. “Migraine Headache” <http://www.mayoclinic.com/health/migraine-headache/DS00120> (accessed December 4, 2006).

Neurology Channel. “Migraine” <http://www.neurologychannel.com/migraine/> (accessed December 4, 2006).

Richard Robinson

Migraine Headache

Definition

Migraine is a type of headache marked by severe head pain lasting several hours or more.

Description

A migraine is an intense, often debilitating type of headache. Migraines affect as many as 24 million people in the United States, and are responsible for approximately $17 billion in lost work, poor job performance, and direct medical costs. Approximately 18% of women and 6% of men experience at least one migraine attack per year. More than three million women and one million men have one or more severe headaches every month. Migraines often begin in adolescence, and are uncommon after age 60.

Two types of migraine are recognized. Eighty percent of migraine sufferers experience migraine without aura, formerly called common migraine. In migraine with aura, formerly called classic migraine, pain is preceded or accompanied by visual or other sensory disturbances, including hallucinations, partial obstruction of the visual field, numbness or tingling, or a feeling of heaviness. Symptoms are often more prominent on one side of the body, and may begin as early as 72 hours before the onset of pain.

Causes and symptoms

Causes

The physiological basis of migraine has proved difficult to uncover. Genetics appear to play a part for many, but not all, people with migraine. There are many potential triggers for a migraine attack, and discovering one's own set of triggers is often the key to prevention.

PHYSIOLOGY. The most widely accepted hypothesis suggests that a migraine attack is precipitated when pain-sensing nerve cells in the brain (called nociceptors) release chemicals called neuropeptides. Another brain chemical, a neurotransmitter called substance P, increases the pain sensitivity of nearby nociceptors. Neuropeptides act on the smooth muscle that surrounds cranial blood vessels. This smooth muscle regulates blood flow in the brain by relaxing or contracting, which dilates (enlarges) or constricts (narrows) the enclosed blood vessels.

At the onset of a migraine headache, neuropeptides are thought to cause muscle relaxation, which allows vessel dilation and increased blood flow. Other neuropeptides increase the leakiness of cranial vessels, allowing fluid leak, and promote inflammation and tissue swelling. The pain of migraine is thought to result from this combination of increased pain sensitivity, tissue and vessel swelling, and inflammation. The aura seen during a migraine may be related to constriction in the blood vessels that dilate in the headache phase.

GENETICS. Susceptibility to migraine may be inherited. A child of a migraine sufferer has as much as a 50% chance of developing migraine. If both parents are affected, the probability rises to 70%. However, the gene or genes responsible have not been identified, and many cases of migraine have no obvious familial basis. It is likely that whatever genes are involved set the stage for migraine, and that full development requires environmental influences as well.

TRIGGERS. A wide variety of foods, drugs, environmental cues, and personal events are known to trigger migraines. It is not known how most triggers set off the events of migraine, nor why individual migraine sufferers are affected by particular triggers but not others.

Common food triggers include:

• aged cheese
• alcohol, especially red wine
• caffeine and caffeine withdrawal
• chocolate
• intensely sweet foods
• dairy products
• fermented or pickled foods
• citrus fruits
• nuts
• aspartame
• processed foods, especially those containing nitrites, sulfites, or monosodium glutamate (MSG)

Environmental and event-related triggers include:

• stress or time pressure
• menstrual periods, menopause
• sleep changes or disturbances, oversleeping
• prolonged overexertion or uncomfortable posture
• hunger or fasting
• odors, smoke, or perfume
• strong glare or flashing lights

Drugs that may trigger migraine include:

• oral contraceptives
• estrogen replacement therapy
• nitrates, often found in cured meats such as bacon and ham
• theophylline, an asthma drug
• reserpine, a tranquilizer
• nifedipine, a calcium channel blocker
• indomethacin, an NSAID
• cimetidine, a histamine H₂ antagonist
• decongestant overuse
• analgesic overuse
• benzodiazepine (a type of tranquilizer) withdrawal

Symptoms

Migraine without aura may be preceded by elevations in mood or energy level for up to 24 hours before the attack. Other premigraine symptoms may include fatigue, depression, and excessive yawning.

Aura most often begins with shimmering, jagged arcs of white or colored light progressing through the visual field over the course of 10-20 minutes. This may be preceded or replaced by dark areas or other visual disturbances. Numbness and tingling is common, especially of the face and hands. These sensations may spread, and may be accompanied by a sensation of weakness or heaviness in the affected limb.

The pain of migraine is often present only on one side of the head, although it may involve both, or switch sides during attacks. The pain is usually throbbing, and may range from mild to incapacitating. It is often accompanied by nausea or vomiting, painful sensitivity to light (photophobia) and sound (phonophobia), and intolerance of food or odors. Blurred vision is common.

Migraine pain tends to intensify over the first 30 minutes to several hours, and may last from several hours to a day or longer. Afterward, the affected person is usually weary, and sensitive to sudden head movements.

Diagnosis

Migraine is diagnosed by a careful medical history. Lab tests and imaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) scans have not been useful for identifying migraine. However, for some patients, those tests may be needed to rule out a brain tumor or other structural causes of migraine headache.

Treatment

Once a migraine begins, the person will usually seek out a dark, quiet room to lessen painful stimuli. Several drugs may be used to reduce the pain and severity of the attack, and many people with migraines learn to prevent attacks altogether by recognizing and avoiding their triggers.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful for early and mild headache. NSAIDs include acetaminophen, ibuprofen, naproxen, and others. A recent study concluded that a combination of acetaminophen, aspirin, and caffeine could effectively relieve symptoms for many migraine patients. One such over-the-counter preparation is Excedrin Migraine.

More severe or unresponsive attacks may be treated with drugs that act on serotonin receptors in the smooth muscle surrounding cranial blood vessels. Serotonin, also known as 5-hydroxytryptamine, constricts these vessels, relieving migraine pain. Drugs that mimic serotonin and bind to these receptors have the same effect. The oldest of them is ergotamine, a derivative of a common grain fungus. Ergotamine and dihydroergotamine are used for both acute relief and preventive treatment. Derivatives with fewer side effects have come onto the market in the past decade, including sumatriptan (Imitrex). Some of these drugs are available as nasal sprays, intramuscular injections, or rectal suppositories for patients in whom vomiting precludes oral administration. Other drugs used for acute attacks include meperidine (Demerol) and metoclopramide (Reglan).

Continued use of some antimigraine drugs can lead to "rebound headache," marked by frequent or chronic headaches, especially in the early morning hours. This can be avoided by using antimigraine drugs under a health care provider's supervision, with the minimum dose necessary to treat symptoms. Patients with frequent migraines may need preventive therapy.

Alternative treatments are aimed at prevention. Since migraines are often linked with food allergies or intolerances, identifying and eliminating the offending food or foods can decrease the frequency of migraines and/or alleviate these headaches altogether. Herbal therapy with feverfew (Chrysanthemum parthenium) may lessen the frequency of attacks. Learning to increase the flow of blood to the extremities through biofeedback training may allow a patient to prevent some of the vascular changes once a migraine begins. Relaxation using focused breathing techniques can also be useful. During a migraine, keep the lights low; put the feet in a tub of hot water and place a cold cloth on the occipital region (the back of the head). This draws the blood to the feet and decreases the pressure in the head.

Prognosis

Most people with migraines can bring their attacks under control by recognizing and avoiding their triggers, and by using the appropriate drugs when migraines occur. There are, unfortunately, some people with severe migraines that do not respond to either preventive or drug therapy. Migraines usually wane in intensity after age 60.

Health care team roles

The advanced practice nurse (APN) can play a pivotal role in helping patients control migraine symptoms. One of the most important screening questions for a patient with a headache is "Do you think that this is the worst headache you have ever had?" If the answer is yes, a more thorough diagnostic work up is justified in order to rule out any tumor or brain bleed. Imaging studies, like CT and/or MRI scanning, which are performed by a radiologist technician, should be considered.

The APN must recognize that many people with migraines are underdiagnosed and unhappy with the practitioner's treatment plan. Knowing this will help the APN focus on both quick pain relief methods and complementary therapies.

The registered nurse (RN) and licensed practical nurse (LPN) can also contribute to a patient's successful migraine management by reinforcing the concept of rapid medication administration at the initial onset of migraine symptoms.

Patient education

The importance of teaching patients about their migraine medications and any potential side effects cannot be overstated. Explaining the expected time frame for relief before administering the next medication is helpful. Nurses can also advise patients about nonpharmacological interventions that may also be beneficial for migraine sufferers. Finally, the RN or LPN can demonstrate breathing relaxation techniques for patient to reinforce their proper use and understanding.

Prevention

The frequency of migraine may be lessened by avoiding triggers. It is useful to keep a headache journal, recording the particulars and noting possible triggers for each attack. Specific measures which may help include:

• eating at regular times, and not skipping meals
• reducing the use of caffeine and pain relievers
• restricting physical exertion, especially on hot days
• keeping regular sleep hours, but not oversleeping
• managing time to avoid stress at work and home

Some drugs can be used for migraine prevention, including specific members of these drug classes:

• beta blockers
• tricyclicantidepressants
• calcium channel blockers
• anticonvulsants
• fluoxetine (Prozac)
• monoamine oxidase inhibitors (MAOIs)
• serotonin antagonists

For most patients, preventive drug therapy is not an appropriate option, since it requires continued use of powerful drugs. However, for women whose migraines coincide with their menstrual periods, limited preventive treatment may be effective. Since these drugs are appropriate for patients with other medical conditions, the decision to prescribe them for migraine may be influenced by expected benefit elsewhere.

KEY TERMS

Migraine— A type of headache marked by severe head pain lasting several hours or more.

Neuropeptide— A peptide (chemical derived from protein) that affects nerves and their functions. Endorphins and enkephalins are neuropeptides.

Neurotransmitter— Chemical produced by nerve cells that sends an impulse across a synapse to a muscle, organ, or another nerve cell. Norepinephrine and acetylcholine are types of neurotransmitters.

Nociceptors— Nerve cells in the brain that are responsible for the sensation of pain.

Phonophobia— Sensitivity to sound.

Photophobia— Sensitivity to light.

Resources

PERIODICALS

Clinch, C. Randall. "Evaluation of Acute Headaches in Adults." American Family Physician 63 (February, 2001): 685-692.

Kunkel, Robert. "Managing Primary Headache Syndromes." Patient Care 34 (January, 2000): 100 ff.

Lipton, Richard B. "Sumatriptan for the Range of Headaches in Migraine Sufferers: Results of the Spectrum Study." Headache 40 (2000): 783-791.

Scholz, Mary. "Treatment Options for Acute Migraine." RN 63 (October, 2000): 99.

OTHER

American Medical Association. Journal of the American Medical Association: Migraine Information Center. 〈http://www.ama-assn.org/special/migraine〉.

Matchar, David B., Douglas C. McCrory, and Rebecca N. Gray. "Toward Evidence-Based Management of Migraines." 〈http://jama.ama-assn.org/issues/v284n20/ffull/jed00081.html〉. (April 27, 2001).

Migraine

Definition

A migraine is an extremely painful type of throbbing headache.

Description

Migraines are a type of vascular headache, meaning that they result from an abnormal reaction of the arteries that supply blood to the brain (cerebral arteries). People who experience migraines overwhelmingly describe them as intensely painful with an onset often characterized by an “aura,” which is a sensory warning described as seeing flashes of light, or spots, or feeling a tingling in limbs. Migraines can be extremely incapacitating and can last for hours or even days. For instance, “status migrainosus” is a severe migraine that can last 72 hours or longer and often results in hospitalization. For many sufferers, migraine is associated with other illnesses such as depression , anxiety , stroke , irritable bowel syndrome , epilepsy, and hypertension .

Demographics

The World Health Organization (WHO) considers migraines to be one of the most debilitating diseases in the world. In the United States, some 17% of women and 6% of men have experienced a migraine. According to the National Headache Foundation, an estimated 28 million Americans have migraine headaches . A 2005 survey, sponsored by the National Headache Foundation, reported that 90% of people with migraines could not function normally on the day of a migraine attack, 80% experienced abnormal sensitivity to light and noise, 75% experienced nausea and vomiting, 30% required bed rest, and 25% missed at least 1 day of work due to migraine in past 3 months. In Canada, more than 3 million people suffer from migraine headaches. Women tend to develop migraines three times more often than men. Migraine headaches start in childhood or adolescence and continue throughout adult life.

Causes and symptoms

The cause of migraines is presently unknown. They are believed to be sparked by spasms in the cerebral arteries which constrict or widen abnormally as a result of serotonin imbalance. Although the precise cause is still being researched, migraine-triggering factors have been documented. For example, women often report that their migraine occurs during or right before the onset of their menstrual cycle. Other triggers include:

• stress
• lack of sleep
• changes in weather
• use of contraceptives
• use of hormone replacement therapies
• environmental chemicals
• liver problems
• dental infections
• some foods including cured meats, red wine, onion, freshly baked yeast products, eggs, alcohol, nuts, and aged cheese
• medical conditions
• medications

Migraines commonly develop in three distinct stages:

• The aura phase: This stage marks the onset of migraine and commonly lasts from 15 to 30 minutes with symptoms that may involve visual disturbances, numbness, dizziness, ringing in the ear, weakness on one side of the body, and sensitivity to light, smells, and noises.
• The headache phase: This phase is characterized by an excruciating headache that may last from hours to days with symptoms such as nausea, sensitivity to light, diarrhea, vomiting, excessive perspiration and chills. It often occurs only on one side of the head.
• The post—headache phase: After the headache has subsided, the skull often remains very tender and the person feels totally exhausted.

Diagnosis

Diagnosis is commonly established on the basis of the patient's medical history and a physical exam. The following tests may also be prescribed to rule out other possible causes of headache:

• Computerized tomography (CT) scan: A CT scan uses computer-directed x rays that provide a view of the brain to identify possible conditions that may also cause headache, such as tumors, infections and other medical problems.
• Magnetic resonance imaging (MRI): This imaging technique uses radio waves and a powerful magnet to produce very detailed views of the brain and its blood vessels. It may also help diagnose tumors, strokes, aneurysms, and other brain abnormalities.
• Spinal tap: In this procedure, a thin needle is inserted between two vertebrae in the lower back to extract a sample of cerebrospinal fluid for laboratory analysis. It may eliminate other diseases such as meningitis that also cause intense headaches.

Treatment

Treatment of migraine starts by removing the afflicted person from noisy, or brightly lit rooms to a dark, quiet room. Bed rest in a dark, quiet room helps to decrease the intensity of the headache. The application of an ice pack or a cold, wet cloth to the forehead is also beneficial.

QUESTIONS TO ASK YOUR DOCTOR

• What is the cause of my migraine?
• Is there a cure?
• Are there any side effects associated with the medications?
• How can I best prevent migraine attacks?
• Is nutrition a factor?
• Can medicine help prevent migraines?

The medications used to treat mild to moderate migraine include pain-relieving nonsteroidal anti-inflammatory drugs (NSAIDs), such as Aspirin or ibuprofen (Advil, Motrin), as well as Tylenol or Anaprox. An anti-nausea medication is often prescribed in conjunction with a NSAID medication. Some medications are available specifically for migraine, such as the combination of acetaminophen , aspirin and caffeine (Excedrin Migraine). These medications can be obtained over-the-counter, or by prescription for stronger dosage. Triptans are another class of medications used for severe migraine attacks. Other prescribed medications include beta-blockers, anti-depressants, and divalproex Sodium .

Nutrition/Dietetic concerns

Magnesium and calcium have been shown to be of benefit to migraine sufferers, as these minerals maintain healthy blood vessels. Pantothenic acid is also considered helpful, as it helps the body produce serotonin. Care should accordingly be taken to ensure that the diet includes their daily recommended intake.

Therapy

Migraine sufferers are encouraged to keep track of their personal triggering factors since avoiding them can decrease the occurrence of migraine attacks. For some people, it may mean avoiding certain foods associated with previous migraine headaches, for others it may mean the avoidance of stressful situations. Stress management therapies, such as relaxation and biofeedback , may also reduce the occurrence and intensity of migraine headaches.

Prognosis

As of today, there is no cure for migraines. Taking a combination of medications when migraine attacks occur brings some amount of relief to most people and allows them to limit the disabling effects of these headaches. In some persons, migraine can resolve on its own and disappear completely as they age. Some researchers believe that women after menopause may experience fewer migraines due to the decline in estrogen levels.

KEY TERMS

Anti—inflammatory —A drug used to reduce inflammation, the body's response to surgery, injury, irritation, or infection,

Anti—nausea —A drug that is effective against vomiting and nausea.

Aura —A sensation of a cold breeze or bright light that precedes the onset of disorders such as a migraine attack or epileptic episode.

Beta—blockers —Drugs that act on the nervous system by blocking certain receptors at nerve endings.

Cerebral arteries —The arteries carrying oxygen—carrying blood to the brain.

Epilepsy —A brain disorder involving recurrent seizures.

Meningitis —An infection of the lining of the brain.

Serotonin —A substance produced by the body that regulates many functions, including mood, appetite, and sensory perception.

Spinal tap —A procedure used to isolate cerebrospinal fluid for evaluation or diagnosis of disease.

Prevention

Lifestyle changes can help prevent migraine. Besides avoiding triggers, regular aerobic exercise has been shown to help reduce stress. Women who have identified estrogen as a trigger may select to avoid this type of medication or consult with their physician to modify dosage.

Caregiver concerns

Treatment of migraine presents special problems in the elderly. The presence of other diseases may prevent the use of some medications. Another concern is that older patients are more likely than younger ones to experience adverse side effects. Older migraine patients accordingly require cautious treatment that takes into account possible pharmacological interactions associated with their greater use of drugs for other medical conditions. Paracetamol (acetaminophen) is considered the safest medication for symptomatic treatment of migraine in the elderly.

The increase in the number of persons in older age groups is expected to also lead to an increase in the total number of migraine patients. However, migraine in older age groups has been neglected, although many subjects older than 50, 60 and even 70 years old suffer from migraine. Drug efficacy studies are also lacking for this age group.

Resources

books

Delaune, Valerie. Trigger Point Therapy for Headaches & Migraines: Your Self-Treatment Workbook for Pain Relief. Ypsilanti, MI: New Harbinger Publications, 2008.

Diamond, Seymour. Conquering Your Migraine: The Essential Guide to Understanding and Treating Migraines for all Sufferers and Their Families. New York, NY: Fireside, 2001.

Foster, Carol A. Migraine: Your Questions Answered. New York, NY: DK Publishing, 2007.

Marcus, Dawn A. 10 Simple Solutions to Migraines: Recognize Triggers, Control Symptoms, And Reclaim Your Life. Ypsilanti, MI: New Harbinger Publications, 2006.

Quinn, V. R. Check-Up Chart Migraine Journal & Workbook. Zebulon, NC: Concise Concepts, 2004.

Robert, Teri. Living Well with Migraine Disease and Headaches: What Your Doctor Doesn't Tell You…That You Need to Know. New York, NY: Harper Collins Publishers, 2005.

Sharp, Michelle. The Migraine Cookbook: More than 100 Healthy and Delicious Recipes for Migraine Sufferers. Washington, DC: Marlowe & Company, 2002.

Young, William B., and Stephen D. Silberstein. Migraine and Other Headaches. New York, NY: Demos Medical Publishing, 2004.

periodicals

Evans, R. W., and K. Bruining. “New onset migraine in the elderly.” Headache 42, no. 9 (October 2002): 946–947.

Haan, J., et al. “Migraine in the elderly: a review.” Cephalagia 27, no. 2 (February 2007): 97–106.

Jelicic, M., et al. “Does migraine headache affect cognitive function in the elderly?” Headache 40, no. 9 (October 2000): 715–719.

Martins, K. M., at al. “Migraine in the elderly: a comparison with migraine in young adults.” Headache 46, no. 2 (February 2006): 312–316.

Mosek, A., et al. “A history of migraine is not a risk factor to develop an ischemic stroke in the elderly.” Headache 41, no. 4 (April 2001): 399–401.

Rankin, L. M., and M. Bruhl. “Migraine in older patients: a case report and management strategies.” Geriatrics 55, no. 7 (July 2000): 70–74.

Sarchielli, P., et al. “Practical considerations for the treatment of elderly patients with migraine.” Drugs and Aging 23, no. 6 (2006): 461–489.

other

Commonly Used Acute Migraine Treatments. American headache Society, Information Sheet. (March 08, 2008) http://www.achenet.org/education/patients/CommonlyUsedAcuteMigraineTreatments.asp

Migraine. Mayo Clinic, Information Page. (March 08, 2008) http://www.mayoclinic.com/print/migraineheadache/DS00120/DSECTION=all&METHOD= print

Migraine. NINDS Information Page. http://www.ninds.nih.gov/disorders/migraine/migraine.htm

Migraine Headaches: Ways to Deal With the Pain. American Academy of Family Physicians, FamilyDoctor.org Information (March 08, 2008) http://familydoctor.org/online/famdocen/home/common/brain/disorders/127.printerview.html

Trigger Avoidance Information. American Headache Society, Information Page (March 08, 2008) http://www.achenet.org/tools/TriggerAvoidanceInformation.asp

Triptans: Summary of affordable alternatives. Consumer Reports (March 08, 2008) http://www.consumerreports.org/health/treatment-centers/brain-and-nervous-system/migraine-in-adults/best-buy-drugs/triptan.htm#Migraine%20Drugs

organizations

American Headache Society (AHS), 19 Mantua Road, Mount Royal, NJ, 08061, (856)423-0258, (856)423-0082, http://www.achenet.org.

American Pain Foundation, 201 North Charles St., Suite 710, Baltimore, MD, 21201-4111, (888)615-PAIN, [email protected], http://www.painfoundation.org.

National Institute of Neurological Disorders and Stroke (NINDS), P.O. Box 5801, Bethesda, MD, 20824, (301) 496-5751, (800) 352-9424, http://www.ninds.nih.gov.

Monique Laberge Ph.D.