Migraine

·       The word "migraine" is from the Greek ἡμικρανία (hemikrania), "pain on one side of the head", from ἡμι- (hemi-), "half", and κρανίον (kranion), "skull".

      

            Migraine is a primary headache disorder characterized by recurrent headaches that are moderate to severe.   Typically, the headaches affect one half of the head, are pulsating in nature, and last from two to 72 hours.

·          Associated symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell.

·         The pain is generally made worse by physical activity.

·          Up to one-third of people have an aura: typically, a short period of visual disturbance which signals that the headache will soon occur.

·         Occasionally, an aura can occur with little or no headache following it.

·         Migraines are believed to be due to a mixture of environmental and genetic factors.

·         About two-thirds of cases run in families. Changing hormone levels may also play a role, as migraines affect slightly more boys than girls before puberty and two to three times more women than men.

·         The risk of migraines usually decreases during pregnancy.

·         The underlying mechanisms are not fully known.

·          It is, however, believed to involve the nerves and blood vessels of the brain.

·         Globally, approximately 15% of people are affected by migraines.

·         It most often starts at puberty and is worst during middle age.

·         In some women they become less common following menopause.

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Signs and symptoms:

·         Migraines typically present with self-limited, recurrent severe headache associated with autonomic symptoms.

·         About 15–30% of people with migraines experience migraines with an aura and those who have migraines with aura also frequently have migraines without aura.

·         The severity of the pain, duration of the headache, and frequency of attacks are variable.

·         A migraine lasting longer than 72 hours is termed statusmigrainosus.

There are four possible phases to a migraine, although not all the phases are necessarily experienced:

·         The prodrome, which occurs hours or days before the headache

·         The aura, which immediately precedes the headache

·         The pain phase, also known as headache phase

·         The postdrome, the effects experienced following the end of a migraine attack

Prodrome phase:

·         Prodromal or premonitory symptoms occur in about 60% of those with migraines, with an onset that can range from two hours to two days before the start of pain or the aura.

·         These symptoms may include a wide variety of phenomena, including altered mood, irritability, depression or euphoria, fatigue, craving for certain food(s), stiff muscles (especially in the neck), constipation or diarrhea, and sensitivity to smells or noise.

·         This may occur in those with either migraine with aura or migraine without aura.

 

Aura phase:

·         Enhancements reminiscent of a zigzag fort structure     Negative scotoma, loss of awareness of local structures

·         Positive scotoma, local perception of additional structures           Mostly one-sided loss of perception

·         Flickering animation a scintillating scotoma. The scintillations are of a zigzag pattern starting in the center of vision, surrounded by a somewhat larger area with distortion of shapes

·         An aura is a transient focal neurological phenomenon that occurs before or during the headache.

·         Auras appear gradually over a number of minutes and generally last less than 60 minutes.

·         Symptoms can be visual, sensory or motor in nature and many people experience more than one.

·         Visual effects occur most frequently; they occur in up to 99% of cases and in more than 50% of cases are not accompanied by sensory or motor effects.

·         Vision disturbances often consist of a scintillating scotoma (an area of partial alteration in the field of vision which flickers and may interfere with a person's ability to read or drive).

·         These typically start near the center of vision and then spread out to the sides with zigzagging lines which have been described as looking like fortifications or walls of a castle.

·          Usually the lines are in black and white but some people also see colored lines.

·         Some people lose part of their field of vision known as hemianopsia while others experience blurring.

·         Sensory aurae are the second most common type; they occur in 30–40% of people with auras.

·         Often a feeling of pins-and-needles begins on one side in the hand and arm and spreads to the nose–mouth area on the same side.

·         Numbness usually occurs after the tingling has passed with a loss of position sense.

·         Other symptoms of the aura phase can include speech or language disturbances, world spinning, and less commonly motor problems.

·         Motor symptoms indicate that this is a hemiplegic migraine, and weakness often lasts longer than one hour unlike other auras.

·         Auditory hallucinations or delusions have also been described.

Pain phase

·         Classically the headache is unilateral, throbbing, and moderate to severe in intensity.

·         It usually comes on gradually and is aggravated by physical activity.

·         In more than 40% of cases, however, the pain may be bilateral and neck pain is commonly associated with it.

·         Bilateral pain is particularly common in those who have migraines without an aura.

·         Less commonly pain may occur primarily in the back or top of the head.

·         The pain usually lasts 4 to 72 hours in adults, however in young children frequently lasts less than 1 hour.

·         The frequency of attacks is variable, from a few in a lifetime to several a week, with the average being about one a month.

·         The pain is frequently accompanied by nausea, vomiting, sensitivity to light, sensitivity to sound, sensitivity to smells, fatigue and irritability.

·         In a basilar migraine, a migraine with neurological symptoms related to the brain stem or with neurological symptoms on both sides of the body, common effects include a sense of the world spinning, light-headedness, and confusion.

·         Nausea occurs in almost 90% of people, and vomiting occurs in about one-third. Many thus seek a dark and quiet room.

·         Other symptoms may include blurred vision, nasal stuffiness, diarrhea, frequent urination, pallor, or sweating.

·         Swelling or tenderness of the scalp may occur as can neck stiffness.

·         Associated symptoms are less common in the elderly.

·         Rarely, an aura occurs without a subsequent headache.

·         This is known as an acephalgic migraine or silent migraine; however, it is difficult to assess the frequency of such cases because people who do not experience symptoms severe enough to seek treatment may not realize that anything unusual is happening to them and pass it off without reporting any problems.

 

Postdrome

·         The migraine postdrome could be defined as that constellation of symptoms occurring once the acute headache has settled.

·         Many report a sore feeling in the area where the migraine was, and some report impaired thinking for a few days after the headache has passed.

·         The person may feel tired or "hung over" and have head pain, cognitive difficulties, gastrointestinal symptoms, mood changes, and weakness.

·         According to one summary, "Some people feel unusually refreshed or euphoric after an attack, whereas others note depression and malaise." For some individuals this can vary each time.

 

Cause

·         The underlying causes of migraines are unknown.

·         However, they are believed to be related to a mix of environmental and genetic factors.

·         They run in families in about two-thirds of cases and rarely occur due to a single gene defect.

·         While migraines were once believed to be more common in those of high intelligence, this does not appear to be true.

·         A number of psychological conditions are associated, including depression, anxiety, and bipolar disorder, as are many biological events or triggers.

 

Genetics

·         Studies of twins indicate a 34% to 51% genetic influence of likelihood to develop migraine headaches.

·         This genetic relationship is stronger for migraines with aura than for migraines without aura.

·         A number of specific variants of genes increase the risk by a small to moderate amount.

·         Single gene disorders that result in migraines are rare.

·         One of these is known as familial hemiplegic migraine, a type of migraine with aura, which is inherited in an autosomal dominant fashion.

·         Four genes have been shown to be involved in familial hemiplegic migraine.

 

Triggers

·         Migraines may be induced by triggers, with some reporting it as an influence in a minority of cases and others the majority.

·         Many things have been labeled as triggers, however the strength and significance of these relationships are uncertain.

·         Most people with migraines report to experience triggers.

·         A trigger may be encountered up to 24 hours prior to the onset of symptoms.

 

Physiological aspects

·         Common triggers quoted are stress, hunger, and fatigue (these equally contribute to tension headaches).

·         Psychological stress has been reported as a factor by 50 to 80% of people.

·         Migraines have also been associated with post-traumatic stress disorder and abuse.

·         Migraines are more likely to occur around menstruation.

·         Other hormonal influences, such as menarche, oral contraceptive use, pregnancy, perimenopause, and menopause, also play a role.

·         These hormonal influences seem to play a greater role in migraine without aura.

·         Migraines typically do not occur during the second and third trimesters or following menopause.

 

Dietary aspects

·         Between 12 and 60% of people report foods as triggers.

·         Evidence for such triggers, however, mostly relies on self-reports and is not rigorous enough to prove or disprove any particular triggers.

·         A clear explanation for why food might trigger migraines is also lacking.

·         There does not appear to be evidence for an effect of tyramine on migraine.

·         Likewise, while monosodium glutamate (MSG) is frequently reported, evidence does not consistently support that it is a dietary trigger.

Environmental aspects

·         A review on potential triggers in the indoor and outdoor environment concluded that there is insufficient evidence to confirm environmental factors as causing migraines.

·         They nevertheless suggested that people with migraines take some preventive measures related to indoor air quality and lighting. 

Pain

·         The exact mechanism of the head pain which occurs during a migraine is unknown.

·         Some evidence supports a primary role for central nervous system structures (such as the brainstem and diencephalon) while other data support the role of peripheral activation (such as via the sensory nerves that surround blood vessels of the head and neck).

·         The potential candidate vessels include dural arteries, pial arteries and extracranial arteries such as those of the scalp.

·         The role of vasodilatation of the extracranial arteries, in particular, is believed to be significant.

Classification

ICHD classification and diagnosis of migraine

The International Headache Society most recently updated their classification of headaches in 2004 & in 2016.

·         According to this classification migraine are primary headaches along with tension-type headaches and cluster headaches, among others.

Migraines are divided into seven subclasses (some of which include further subdivisions):

·         Migraine without aura, or "common migraine", involves migraine headaches that are not accompanied by an aura.

·         Migraine with aura, or "classic migraine", usually involves migraine headaches accompanied by an aura. Less commonly, an aura can occur without a headache, or with a non-migraine headache.

·         Two other varieties are familial hemiplegic migraine and sporadic hemiplegic migraine, in which a person has migraines with aura and with accompanying motor weakness. If a close relative has had the same condition, it is called "familial", otherwise it is called "sporadic".

·         Another variety is basilar-type migraine, where a headache and aura are accompanied by difficulty speaking, world spinning, ringing in ears, or a number of other brainstem-related symptoms, but not motor weakness. This type was initially believed to be due to spasms of the basilar artery, the artery that supplies the brainstem. Now that this mechanism is not believed to be primary, the symptomatic term migraine with brainstem aura (MBA) is preferred.

Childhood periodic syndromes that are commonly precursors of migraine include cyclical vomiting (occasional intense periods of vomiting), abdominal migraine (abdominal pain, usually accompanied by nausea), and benign paroxysmal vertigo of childhood (occasional attacks of vertigo).

·         Retinal migraine involves migraine headaches accompanied by visual disturbances or even temporary blindness in one eye.

·         Complications of migraine describe migraine headaches and/or auras that are unusually long or unusually frequent, or associated with a seizure or brain lesion.

·         Probable migraine describes conditions that have some characteristics of migraines, but where there is not enough evidence to diagnose it as a migraine with certainty (in the presence of concurrent medication overuse).

·         Chronic migraine is a complication of migraines, and is a headache that fulfills diagnostic criteria for migraine headache and occurs for a greater time interval. Specifically, greater or equal to 15 days/month for longer than 3 months.

 

·         Abdominal migraine: Some evidence indicates that recurrent episodes of abdominal pain in the absence of a headache may be a type of migraine or are at least a precursor to migraines.

·         These episodes of pain may or may not follow a migraine-like prodrome and typically last minutes to hours.

·         They often occur in those with either a personal or family history of typical migraines.

·         Other syndromes that are believed to be precursors include cyclical vomiting syndrome and benign paroxysmal vertigo of childhood.

 

Differential diagnosis

·         Other conditions that can cause similar symptoms to a migraine headache include temporal arteritis, cluster headaches, acute glaucoma, meningitis and subarachnoid hemorrhage.

·         Temporal arteritis typically occurs in people over 50 years old and presents with tenderness over the temple,

·         cluster headachespresents with one-sided nose stuffiness, tears and severe pain around the orbits,

·         acute glaucoma is associated with vision problems, meningitis with fevers, and

·         subarachnoid hemorrhage with a very fast onset.

·         Tension headaches typically occur on both sides, are not pounding, and are less disabling.

 

·         Those with stable headaches which meet criteria for migraines should not receive neuroimaging to look for other intracranial disease.

·         This requires that other concerning findings such as papilledema (swelling of the optic disc) are not present. People with migraines are not at an increased risk of having another cause for severe headaches.

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