Migraine

Migraine is one of the neurological syndromes characterized by altered bodily perceptions, serious headaches, and nausea. Physiologically, this migraine headache is a neurological state which is more common to women than to men. The word migraine was actually borrowed from Old French word migraigne (it was originally \”megrim\”, but respelled in 1777 on a contemporary French model).

A migraine headache is a form of vascular headache caused by vasodilatation which means enlargement of blood vessels which causes the discharge of chemicals from nerve fibers that coil around the large arteries of the brain. Growth of these blood vessels stretches the nerves that coil around them and causes the nerves to release chemicals and these chemicals cause inflammation, pain, and further enlargement of the artery. The increasing enlargement of the arteries increases the pain.

Migraine attacks actually stimulate the sympathetic nervous system in the body. The sympathetic nervous system is frequently considered as the part of the nervous system controlling primitive responses to stress and pain- the so-called \”fight or flight\” response, and this activation lead to many of the symptoms related to migraine attacks; for instance, the increased sympathetic nervous activity in the intestine causes nausea, vomiting, and diarrhea.

Sympathetic activity also delays emptying of the stomach into the small intestine and thereby obstructs oral medications to enter the intestine and being absorbed.

The impaired absorption of oral medications often results in the ineffectiveness of medications prescribed to treat migraine headaches.

The increased sympathetic activity also decelerates the blood circulation that leads to paleness of the skin as well as cold hands and feet.

The increased sympathetic activity also causes the sensitivity to light and sound sensitivity along with blurred vision.

Migraine afflicts 28 million Americans. It is found that females suffer more frequently (17%) than males (6%). Missed work and lost productivity from migraine create havoc on public. However, migraine still remains in most of the cases underdiagnosed and under treated as it is found that less than half of individuals with migraine are diagnosed by their doctors.

Migraine Headaches- Causes

The causes of migraine headaches need more research as it is still not clear to the doctors. In the 1940s, it was assumed that a migraine begins with a spasm, or partial closing, of the arteries leading to the main part of the brain known as cerebrum. The first spasm reduces blood supply to the part of the brain, which causes the aura such as lights, haze, zig-zag lines, or other symptoms, that some people come across. These very arteries then become too relaxed and increases blood flow causing pain.

About 30 years later, the chemicals dopamine and serotonin were found to be responsible for migraine headaches. These chemicals are also known as neurotransmitters. Dopamine and serotonin are generally found in the brain, but they can persuade blood vessels to act in unusual ways if they are present in abnormal amount or if the blood vessels are extraordinarily sensitive to them.

Together, these 2 theories have come to be famous as the neurovascular theory of migraine, and it is now assumed that both theories provide insight into the reasons behind the headache.

Diverse triggers are thought to initiate migraine headaches in people prone to developing them. Different people may have different approaches.

Smoking has been acknowledged as a trigger for many people.

Certain foods, especially chocolate, cheese, nuts, alcohol, and Mono Sodium Glutamate (MSG), a flavor enhancer used in many foods, including Chinese dishes, may cause migraine headaches.

Missing a meal or altering sleep patterns may also cause a headache.

Stress and tension are other risk factors. People often have migraines during increased emotional or physical stress.

Contraceptives (birth control pills) are a common trigger. Women may experience migraines at the end of their pill cycle as the estrogen component of the pill comes to an end. This is also called an estrogen-withdrawal headache.

Migraines may occur more frequently in persons with the following diseases:

Epilepsy

Familial dyslipoproteinemias (abnormal cholesterol levels)

Hereditary hemorrhagic telangiectasia

Tourette syndrome

Hereditary essential tremor

Hereditary cerebral amyloid angiopathy

Ischemic stroke: Migraine with aura is a risk factor (odds ratio, 6:1).

Depression and anxiety

Migraine Headache- Symptoms

Migraine is a chronic condition with frequent attacks. Most (but not all) migraine attacks are related to headaches.

Migraine headaches usually are coupled with an intense, throbbing or pounding pain that involves one temple. Sometimes the pain is felt in the forehead, around the eye, or sometimes at the back of the head.

The pain usually is unilateral as it occurs on one side of the head, although about a third of the time the pain is bilateral which means that it happens on both sides of the head.

The unilateral headaches usually change sides from one attack to the next. But you must know it that unilateral headaches occurring always on the same side indicates the doctor to consider a secondary headache, for instance, one caused by a brain tumor.

A migraine headache usually is increased by daily activities including walking upstairs.

Nausea, vomiting, diarrhea, facial pallor, cold hands, cold feet, and sensitivity to light and sound are commonly associated with migraine headaches. Due to this sensitivity to light and sound, migraine sufferers generally choose to lie in a quiet, dark room during an attack. A typical attack persists between 4 and 72 hours.

An estimated 40%-60% of migraine attacks are indicated by premonitory (warning) symptoms lasting hours to days. The symptoms may include the following:

Sleepiness
Irritability
Fatigue
Depression or euphoria
Yawning
Cravings for sweet or salty foods.

Patients and their family members should know that when these warning symptoms occur it may be the migraine attack beginning.

Migraine aura

About 20% of migraine headaches are connected with an aura. Usually, the aura is followed by the headache. Although occasionally, it may occur simultaneously with the headache. The most common auras involve:

Migraine with aura (classic migraine) generally has several early visual symptoms, such as photopsia (flashes of light) and fortification spectra (wavy linear patterns in the visual fields), or migrating scotoma (patches of blurred or absent vision).
The headache is usually characterized by throbbing or pulsing. Migraines are generally unilateral (affecting one side), but the side affected in each period may vary. But unilaterality is not a requirement for migraine diagnosis.

A less common aura is characterized by pins-and-needles sensations in the hand and the arm on one side of the body or pins-and-needles sensations around the mouth and the nose on that particular side.

Other auras may involve auditory (hearing) hallucinations and abnormal tastes and smells. The headache usually remains for 6-24 hours. Migraineurs generally like to lie quietly in a dark room.

Sometimes, a history of certain triggers can be detected. Common associations in migraine include:

Head injury
Physical exertion
Fatigue
Drugs (nitroglycerine[Nitrostat], Histamine, Reserpine[Serpasil], Hydralazine [Apresoline], Ranitidine [Zantac], estrogen)
Stress.

For approximately 24 hours after a migraine attack, the migraineur may feel lack of energy and may also experience a little headache coupled with sensitivity to light and sound. Unfortunately, some sufferers may face recurrences of the headache during this period.

Migraine Headaches, Variants

Migraine devoid of aura (common migraine) is a throbbing headache without any prior visual symptoms.

Vertebrobasilar migraines are characterized by dysfunction of the brainstem (the lower part of the brain, responsible for automatic activities like consciousness and balance).

The symptoms of vertebrobasilar migraines include:

Fainting as an aura
Vertigo (dizziness in which the environment appears spinning)
Double vision
Confusion
Speech disturbances
Tingling of extremities
Clumsiness.

Hemiplegic migraines are characterized by:

Paralysis or weakness of one side of the body
Mimicking a stroke.

The paralysis or weakness is usually transitory, but sometimes it can remain for days.

Retinal or ocular migraines are rare attacks. This is characterized by repeated incidents of scotomata (blind spots) or blindness on one side which lasts less than an hour and can be accompanied by headache. Irreversible vision loss also can be a complication of this unusual form of migraine.

Abdominal migraine suggests periodic abdominal pain (especially in children). This type is not accompanied by headache.

Status migrainosus is the term that describes migraine attacks lasting for days. These attacks may cause complications, like dehydration.

How is a migraine headache diagnosed?

Migraine headaches are usually diagnosed when the symptoms stated earlier are present. Migraine is generally common in childhood to early adulthood. If migraines first occur in an individual beyond the age of fifty, advancing age is more likely to cause other types of headaches. A family history of migraine, suggests a genetic inclination to migraine sufferers. Therefore, the examination of individuals with migraine attacks is normal.

Patients having the first headache ever, worst headache ever, a significant change in the characteristics of headache or in association with the headache with nervous system symptoms such as visual or hearing or sensory loss, may need additional tests such as blood testing, brain scanning (either CT or MRI), and a spinal tap to exclude diseases other than migraine.

Non-medication therapies for migraine

Treatment also includes therapies that may or may not engage medications.

Using ice, biofeedback, and relaxation techniques may be useful in barring an attack once it has started.

Sleep may be the suitable medicine if it is possible.

Preventing migraine takes motivation for the patient to make some life changes. Patients are informed about these things as to triggering factors that can be avoided.

These triggers include:

Smoking
Avoiding certain foods especially those high in tyramine such as sharp cheeses or those containing sulphites (wines) or nitrates (nuts, pressed meats).

Normally, maintaining a healthy life-style with proper nutrition, an adequate intake of fluids, sufficient sleep and exercise may curtail the amount of suffering. Acupuncture has been suggested to be a helpful therapy.

Many people are able to control migraines or tension headaches following stress-busting strategies. Although you can\’t have power over the stressful events that come your way, you can change your response to those events. You may need to experiment with techniques including meditation, massage, and acupuncture to find which is suitable for you.

Moderate exercise is an effective stress reliever. Walking is a great option because it delivers an extra protection against tension headaches. When you walk, the swinging motion of your arms tends to relax your neck’s and shoulders’ muscles. Breaking up those knots reduces the very root of tension headaches.

Following balanced diet throughout the day will help balance your blood sugar causing no more hunger headaches. Try to have meals and snacks that contain a protein along with a complex carbohydrate, such as peanut butter on whole-grain bread or chicken breast with brown rice and must take enough fluids as dehydration is another common headache trigger.

Physical therapy includes exercise and education to reduce pain and improve range of motion. For people who suffer from tension headaches, physical therapy can be helpful to strengthen the neck muscles and establish new habits that lead to better posture.

Patients with serious migraine headaches and also having a history of neurological symptoms related to their attacks are the most suitable candidates for preventive therapy. For these patients, even a single previous complicated migraine headache qualifies them for long-term preventive therapy.

The choice of preventive medication is applicable to the individuals having comorbidities (concurrent medical conditions) such as depression, weight gain issues, exercise tolerance, asthma, and pregnancy plans. All medications have side effects; therefore, the choice of medication is essential.

Such preventive drugs include beta-blockers, tricyclic antidepressants, some anticonvulsants, calcium channel blockers, cyproheptadine (Prediction), and NSAIDs such as naproxen (Naprosyn). Unlike the specific headache-relieving drugs (abortive drugs), most of these were formulized to combat other conditions and have been inadvertently found to be effective in headache prevention. The following drugs also have preventive effects but they also include more side effects:

Methysergide maleate (Sansert) – This drug has many side effects.

Lithium (Eskalith, Lithobid) – This drug has many side effects.

Indomethacin (Indocin) – This drug can cause psychosis in some people with cluster headaches.

Steroids: Prednisone (Deltasone, Meticorten) works really well for some people and should be tried if other therapies fall short.

How long a person should continue a preventive therapy plan depends on the function of his or her response to the drug being consumed. If headaches stop absolutely, it is sensible enough to gradually decrease the dosage as long as headaches do not recur.

Medication for migraine

Individuals having rare mild migraine headaches that do not hinder daily activities usually medicate themselves with over-the-counter (OTC or non-prescription) pain relievers (analgesics). Many OTC analgesics are available but these analgesics are safe and effective only for short-term relief of headache (as well as muscle aches, pains, menstrual cramps, and fever) on using according to the instructions on their labels.

There are two major classes of OTC analgesics:

Acetaminophen (Tylenol)
Non-steroidal anti-inflammatory drugs (NSAIDs)

Acetaminophen:

Acetaminophen lessens pain and fever by acting on pain centers in the brain.
Acetaminophen is well bearable and is generally considered easier on the stomach than NSAIDs. However, acetaminophen can result in severe liver damage if it is taken on high (toxic) doses or used on a regular basis for a long time period. In case of the individuals consuming moderate or large amounts of alcohol on regular basis, acetaminophen can cause serious damage to the liver even in lower doses that generally are not toxic. Acetaminophen can also damage the kidneys if taken in large doses. Therefore, acetaminophen should not be consumed more frequently or in higher doses than recommended on the package label.

NSAIDS

The two types of NSAIDs include:

Aspirin
Non-aspirin

Aspirin, Aleve, Motrin, and Advil all are NSAIDs and are equally effective in relieving pain and fever.

Aspirin, acetaminophen, and caffeine also are accessible combined in OTC analgesics for the treatment of headaches as well as migraine. Some combination analgesics are: Pain-aid, Excedrin, Fioricet and Fiorinal.

Choosing an effective analgesic or analgesic combination is often a trial and error method because individuals react differently to different analgesics. In general, a person should use the analgesic that has been found fruitful in the past. This will enhance the probability that an analgesic will be useful and diminish the risk of side effects.

Migraine Headache in Children

Migraine headaches are the most familiar severe and recurrent headache pattern experienced by children. These often debilitating experiences are significant for their sudden commencement and accompanying symptoms of nausea, abdominal pain, vomiting, and relief by sleep. Doctors focus on excluding other severe diseases or conditions when they first examine migraineurs. Treatment includes finding and avoiding trigger factors in the environment, giving instant pain relief, and taking preventive drugs.

Uneasiness in the stomach or vomiting is common. Many children prefer to avoid bright lights, loud noises, or strong odors. These may intensify their headache. While various medications may be prescribed to treat a migraine headache, the severe headache is often completely neutralized by deep sleep.

The symptoms of migraines hinder the normal activities in about 65%-80% of children. A study over 970,000 self-reported migraineurs aged 6-18 years reveals that 329,000 school days were lost per month.

Frequency

Studies reveal that migraine headaches occur in 5%-10% of school going children in the United States. This percentage gradually increases through adolescence and raises at about 44 years of age.

Gender

The report indicates that the age of onset of migraine headaches is earlier in boys than in girls. While from infancy to 7 years of age, boys are affected equally or slightly more than girls the prevalence of migraines seems to increase during the adolescence and young adult years. By this time, 20%-30% of young women and 10%-20% of young men suffer from migraines. After menarche (the time when the first menstrual period occurs), a females become more prone to migraine pains. This keeps increasing until middle age. But the rate of migraines seems to decline in both sexes by 50 years of age.

Age

Most migraineurs starts experiencing attacks before 20 years of age. About 20% of children have their first attack before their fifth birthday. Preschool children experiencing a migraine attack usually appear sick and have abdominal pain, vomiting, and a strong need to sleep. They may express pain by petulance, crying, rocking, or seeking a dark room in order to sleep.

Migraineurs aged 5-10 years of age may experience:

Headache
Nausea
Abdominal cramping
Vomiting
Photophobia (sensitivity to light)
Phonophobia (sensitivity to sound)
Osmophobia (sensitivity to smells)
A need to sleep

They usually fall asleep within an hour when the attack begins.
The most common related symptoms include:

Paleness with dark circles under the eyes
Tearing
Swollen nasal passages
Thirst, swelling
Excessive sweating
Increased urination

Diarrhea

Older children may experience headache on one side of their skull. But the headache site and intensity often vary during or between attacks.

Research has revealed that many \”sinus headaches\” are really of migrainous origin. As children age, headache intensity and extent increases, and migraines begin to occur at more regular intervals. Older children also complain a pulsating or throbbing characteristic to their headaches. Headaches often shift to the one-sided temple location in most adult migraineurs. Childhood migraines often come to an end for a few years after puberty.

Migraine Headache in Children: Causes

The exact cause(s) of migraine headaches is yet to be known. Some migraines are may be due a temporary deficiency of the brain chemical called serotonin. Many of the drugs found successful in treating migraines target this chemical. Some migraineurs are quite aware of the fact that their headaches are caused by something they eat, drink, or a particular activity as most people know what triggers the migraine.

The most common triggers include:

Alcohol, chocolate, cheese, nuts, shellfish, Chinese food (commonly containing MSG – mono sodium glutamate), sugar, and caffeine.

Migraines most likely have quite a few trigger factors and various internal causes. Although many migraine disorders do not grow until middle age, early detection of migraine risk factors may help a child adopt a healthy lifestyle.

Diet

About 20%-50% of migraineurs are sensitive to foods. These dietary triggers are thought to bring a change that causes a migraine attack. Helping children learn to know and avoid these triggers is helpful but it often seems difficult to make them understand. The following are some common dietary triggers:

Tyramine: Individuals with low amount of a substance called phenol sulfotransferase P are believed to be sensitive to dietary monoamines (a type of molecule) for example tyramine and phenylethylamine. Cultured dairy products such as, aged cheese, sour cream, buttermilk and also chocolate, and citrus fruits are believed to cause vasodilation (widening of the blood vessels) in some people. Some migraines may also be triggered by artificial sweeteners.

Beverages: Alcoholic beverages (especially red wine) and surfeit of or withdrawal from caffeinated drinks such as coffee, tea, cocoa, or colas may trigger a migraine headache. Migraineurs need to limit caffeinated sources to no more than two cups per day in order to prevent caffeine-withdrawal headaches. Caffeine can be found in chocolate containing foods and candies; therefore, it is essential for the children with migraines to avoid these foods.

Nitrates and nitrites: These vasodilating agents are seen in preserved meats. Instances of foods containing these chemicals are: lunch meats, processed meats, smoked fish, sausage, pork and beans with bacon, sausage, salami, pastrami, liverwurst, hotdogs, ham, corned beef, corn dogs, beef jerky, bratwurst, and bacon.

Monosodium glutamate (MSG): MSG enhances flavor and acts as a vasodilator found in many processed foods. Therefore it is necessary to check Food labels. MSG sources include Accent seasoning, bacon bits, baking mixtures, basted turkey, bouillon cubes, chips (potato, corn), croutons, dry-roasted peanuts, breaded foods, frozen dinners, gelatins, certain Asian foods and soy sauce, pot pies, relishes, salad dressing, soups, and yeast extract.

Citrus fruits, avocados, bananas, raisins, and plums can also be the triggers. Although few individuals are sensitive to fruit, children with migraines should still eat a well-rounded, natural diet including fruits and vegetables and avoid processed foods. A headache diary (a pattern often emerges after 6-8 weeks) may be useful. Try to avoid creating an unnaturally limited diet that decelerates a child\’s growth and development.

Drugs

Both OTC and prescription medications can trigger or deteriorate migraine headaches. Drugs like Cimetidine (Tagamet), estrogen (Premarin), histamine, hydralazine (Apresoline), nifedipine (Procardia), nitroglycerin (Nitro-bid), ranitidine (Zantac), and reserpine (Serpasil) can intensify migraine frequency.

Excessive use of OTC pain medications and analgesics may be responsible for occasional migraine attacks and converts it to analgesic-abuse headaches or drug-induced headaches that do not respond to treatment. Children who have migraines should avoid frequent or extensive use of NSAIDs, acetaminophen, triptans, or ergotamines. Migraineurs who have been treated for a long time with amphetamines (Biphetamine), phenothiazine (a type of antihistamine), or propranolol (Inderal) should avoid sudden withdrawal from these medications. This may cause migraine headaches.

Activity

In children who have an inborn propensity to migraine headaches, attacks can arise as a result of psychological (emotional), physiological (internal body processes), or environmental triggers. Remember, Physical exertion and travel or motion can also be the triggers.

Psychological triggers include stress, anxiety, worry, depression, and sadness. Migraine headaches are not an imagined or psychological illness. It’s the Stress that makes a causal tendency for migraine more difficult to manage. The occurrence of migraines can be limited but not eliminated completely by maintaining a healthy lifestyle.

Physiological triggers: These include fever or illness, lack of food, rest, or sleep. Children with migraines should follow a strict a routine with regular meal times and enough sleep.

Environmental triggers: These include fluorescent light, bright light, flickering light, fatigue, barometric pressure changes, high altitude, strong odors, computer screens, or rapid temperature changes. Some migraineurs complain that complex visual patterns like stripes, checks, or zigzag lines cause their migraines.

Physical exertion: Some strenuous activity can trigger childhood migraine. Some migraineurs report that they often get a headache after participating in sports or being extremely active. Minor head trauma for instance, being hit in the head with a ball, falling on one\’s head may also cause a migraine attack.

Travel or motion: This may lead to migraine, particularly in young children.

[Suggestion: If headaches cannot be controlled within 6 months, you should take your child to a pediatric neurologist (a person specializing in the treatment of brain/nerve disorders). Children, who suddenly develop new neurological problems such as weakness, thinking difficulties, or seizures, are also instructed to see a pediatric neurologist.]

Prevention and Therapy

The primary aims of preventive therapy are to check migraine attacks and reduce the frequency and severity of attacks. Most of the preventive migraine medications have strong side effects. Therefore, only children with at least 1-2 attacks per week should receive them. Parents and caregivers should have realistic outlook. While medications reduce the impact of migraines, they do not get eradicate underlying causes. Half of all patients have a 50% reduction in migraines (at most).

When to Seek Medical Care

Parents should take children with severe headaches to a physician who will ensure that no life-threatening underlying condition is to blame. He or she will also offer a diagnosis and support that no severe underlying illness is detected, and a preparation for effective pain treatment.

The doctor should describe the disease to the child and the parents or caregivers. The treatment of children having mild, occasional migraine attacks mainly include rest, trigger avoidance, and stress reduction.

The doctor should also reassure parents that the headache is not due to a brain tumor or other fatal condition. It is useful to maintain regularity- a regular bedtime, strict meal schedules, and not overloading the child with too many activities are important. Helping the child know migraine triggers is also helpful but often difficult. Ridding migraine triggers decreases the frequency of headaches in some children but does not completely stop it.

A headache diary can be used to record triggers and nature of attacks. Triggering factors that occur up to 12 hours prior to an attack should be down. Other important factors include:

Date and time the attack began

Type and location of headache pain

Symptoms before the headache

All food and drink consumed prior to the attack

Bedtime, wake time, and quality of sleep prior to the attack

Menstrual periods or female hormones (if applicable)

Activities before the headache began

Medications taken and their side effects

Unfortunately, even it is sometimes become not possible for the most careful person to identify specific migraine triggers.

Immediate treatment

Some children find ice or pressure on the affected artery useful to decrease pain for a while. Nonsteroidal antiinflammatory drugs (NSAIDs) are effective if consumed at a high but proper dose during the aura or in the early headache phase. Common over-the-counter (OTC) NSAIDs include ibuprofen (Advil, Children\’s Advil/Motrin, etc.) and naproxen (Aleve, Naprosyn, Anaprox, Naprelan). Acetaminophen (Tylenol and others) may also limit pain. Aspirin should not be suggested to children or adolescents.

Digestion temporarily decelerates or stops during migraine attacks, delaying absorption of oral medications. Some times, carbonated beverages may develop absorption. Other treatment methods, such as self-relaxation, biofeedback, and self-hypnosis, may be suitable alternatives to drug therapies in childhood migraine, especially in adolescents. Response rates in children are higher than in adults and show continued success over time.

In spite of the development of many effective anti-migraine medications, sleep is considered to be the most powerful and best treatment because sleep restores normal brain function, relieves pain, and resolves many related migraine symptoms.

Things you should keep in mind:

Causes of migraine	Things to follow
Effect of dopamine and serotonin	Avoid smoking
Smoking	Avoid stress
Chocolate	Avoid foods high in tyramine, sulphites, nitrates
Alcohol	Avoid wines
Caffeine	Maintain healthy diet
Shellfish	Sleep sufficiently
Chinese food	Increase your intake of fluids
Missing meal	Exercise regularly
Unhealthy diet (cheese, nuts)	Meditation
Mono Sodium Glutamate	Massage/ acupuncture
Stress and tension	Choose right medication
Strenuous activity	Eat plenty of fresh fruit and vegetables
Depression	Maintain a strict routine
Anxiety	Avoid aspirin
Altering sleep	Don’t overburden yourself
Contraceptives	Maintain a headache diary
Hereditary diseases	Hereditary diseases
Epilepsy	Don’t strain your eyes before computer screen
Abnormal cholesterol level	Avoid loud sound
Drugs	Avoid strong odors
Head injury	Seek doctor’s advice