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Overview

A migraine is a throbbing or pulsating headache that is often unilateral (one sided) and associated with nausea; vomiting; sensitivity to light, sound, and smells; sleep disruption; and depression. Attacks are often recurrent and tend to become less severe as the migraine sufferer ages.

Types
Migraines are classified according to the symptoms they produce. The two most common types are migraine with aura and migraine without aura. Less common types include the following:

• Basilar artery migraine
• Carotidynia
• Headache-free migraine
• Ophthalmoplegic migraine
• Status migraine

Incidence and Prevalence
Migraines afflict about 24 million people in the United States. They may occur at any age, but usually begin between the ages of 10 and 40 and diminish after age 50. Some people experience several migraines a month, while others have only a few migraines throughout their lifetime. Approximately 75% of migraine sufferers are women.

Causes

The cause of migraine is unknown. The condition may result from a series of reactions in the central nervous system caused by changes in the body or in the environment. There is often a family history of the disorder, suggesting that migraine sufferers may inherit sensitivity to triggers (page jump to section below) that produce inflammation in the blood vessels and nerves around the brain, causing pain.

Triggers
A trigger is any stimulus that initiates a process or reaction. Commonly identified migraine triggers include the following:

• Alcohol (e.g., red wine)
• Environmental factors (e.g., weather, altitude, time zone changes)
• Foods that contain caffeine (e.g., coffee, chocolate), monosodium glutamate (MSG; found in Chinese food), and nitrates (e.g., processed foods, hot dogs)
• Glare
• Hormonal changes in women
• Hunger
• Lack of sleep
• Medications (over-the-counter and prescription)
• Perfume
• Stress

Signs and Symptoms

Migraine pain is often described as throbbing or pulsating pain that is intensified by routine physical activity, coughing, straining, or lowering the head. The headache is often so severe that it interferes with daily activity and may awaken the person. The attack is debilitating, and migraine sufferers are often left feeling tired and weak once the headache has passed.

A migraine typically begins in a specific area on one side of the head, then spreads and builds in intensity over 1 to 2 hours and then gradually subsides. It can last up to 24 hours, and in some cases, several days.

There may be accompanying symptoms such as nausea, vomiting, sensitivity to light (photophobia), or sensitivity to sound (phonophobia). Hands and feet may feel cold and sweaty and unusual odors may be intolerable.

Migraine with aura is characterized by a neurological phenomenon (aura) that is experienced 10 to 30 minutes before the headache. Most auras are visual and are described as bright shimmering lights around objects or at the edges of the field of vision (called scintillating scotomas) or zigzag lines, wavy images, or hallucinations. Others experience temporary vision loss.

Nonvisual auras include motor weakness, speech or language abnormalities, dizziness, vertigo, and tingling or numbness (parasthesia) of the face, tongue, or extremities.

Migraine without aura is the most prevalent type and may occur on one or both sides (bilateral) of the head. Tiredness or mood changes may be experienced the day before the headache. Nausea, vomiting, and sensitivity to light (photophobia) often accompany migraine without aura.

Basilar artery migraine involves a disturbance of the basilar artery in the brainstem. Symptoms include severe headache, vertigo, double vision, slurred speech, and poor muscle coordination. This type occurs primarily in young people.

Carotidynia, also called lower-half headache or facial migraine, produces deep, dull, aching, and sometimes piercing pain in the jaw or neck. There is usually tenderness and swelling over the carotid artery in the neck. Episodes can occur several times weekly and last a few minutes to hours. This type occurs more commonly in older people.

Headache-free migraine is characterized by the presence of aura without headache. This occurs in patients with a history of migraine with aura.

Ophthalmoplegic migraine begins with a headache felt in the eye and is accompanied by vomiting. As the headache progresses, the eyelid droops (ptosis) and nerves responsible for eye movement become paralyzed. Ptosis may persist for days or weeks.

Status migraine is a rare type involving intense pain that usually lasts longer than 72 hours. The patient may require hospitalization.

Treatment

The physician analyzes the patient’s migraine history to devise an appropriate treatment program. The goals of treatment are to prevent or reduce the number of migraines (called prophylactic treatment) and to alleviate symptoms and shorten the duration of the migraine (called abortive treatment).

Prophylactic Treatment
Prophylactic (preventative) medication may be prescribed for patients who have frequent headaches (3 or more a month) that do not respond to abortive treatment. Using one medication (monotherapy) is tried first, but a combination of medicines may be necessary. Many of these medications have adverse side effects. If migraines become controlled, the dosage is often reduced or the drug discontinued.

Beta blockers (e.g., propranolol [Inderal®], atenolol [Tenormin®]) are the preferred medications. These drugs produce an effect on heart rate. They should not be taken by patients with asthma and should be used with caution in patients with diabetes.

Side effects include gastrointestinal upset, insomnia, low blood pressure (hypotension), slowed heart rate (bradycardia), and sexual dysfunction. Some beta blockers pass into breast milk and may cause problems in nursing infants

Antiseizure drugs such as valproic acid (Depakote®), topiramate (Topomax®), and gabapentin (Neurontin®) may be effective in the treatment of migraine.

Side effects include nausea, gastrointestinal upset, sedation, liver damage, and tremors.

Calcium channel blockers (e.g., verapamil, amlodipine [Norvasc®]) inhibit artery dilation and block the release of serotonin. They should not be taken by patients with heart failure or heart block.

Side effects include constipation, flushing, low blood pressure, rash, and nausea.

Tricyclic antidepressants (TCAs; e.g., amitryptaline [Elavil®], nortryptaline [Pamelor®], desipramine [Norpramin®]) block serotonin reabsorption and take 2–3 weeks be effective.

Side effects include the following:

• Constipation
• Dry mouth
• Low blood pressure (hypotension)
• Increased heart rate (tachycardia)
• Urinary retention
• Sexual dysfunction
• Weight gain

High doses of TCAs have been implicated in seizures, stroke, and heart attack. Abrupt discontinuation of these medications may cause headache, nausea, and malaise, and may intensify side effects.

Selective serotonin reuptake inhibitors (SSRIs; e.g., paroxetine [Paxil®], fluoxetine [Prozac®], sertraline [Zoloft®] are usually better tolerated than TCAs, but may not be as effective.

Side effects include nausea, insomnia, sexual dysfunction, and loss of appetite.

Methysergide maleate (e.g., Deseril®, Sansert®) may be prescribed for patients with frequent, severe migraines.

Side effects include insomnia, drowsiness, lightheadedness, and hair loss. This drug should not be used by patients with coronary artery disease and must be discontinued for 3–4 weeks after 4–6 months of use because it can cause retroperitoneal fibrosis, a condition in which the blood vessels in the abdomen thicken, which reduces blood flow to organs.

Abortive Treatment
Mild, infrequent migraines may be relieved using over-the-counter medication. Severe headaches with accompanying symptoms may require prescription medication.

During a migraine, people often prefer to rest or sleep alone in a dark, quiet room. Applying cold packs to the head or pressing on the bulging artery in front of the ear on the painful side of the head may provide temporary pain relief.

Analgesics (e.g., aspirin, ibuprofen, acetaminophen) provide symptomatic relief from headache pain and should be taken at the first sign of a migraine. They are most effective for infrequent migraines (less than 3 a month) and breakthrough headaches (i.e., headaches that occur despite using prophylactic medications).

Frequent use of analgesics (i.e., more than 4 times a week) can cause rebound headaches and may interfere with prophylactic treatment. Acetaminophen is sometimes combined with other drugs to form an analgesic compound (e.g., Midrin®).

Side effects caused by aspirin and ibuprofen (e.g., Advil®, Motrin®) include gastrointestinal upset and bleeding. These drugs should be taken with food and used with caution. Ibuprofen is available in suppository form, which can be useful if the migraine is accompanied by severe nausea and vomiting.

Serotonin receptors (e.g., Imitrex®, Amerge®, Axert#&174) are fast-acting, usually well- tolerated medications commonly used to treat migraines. They are available in oral, injectable, and nasal spray forms and can be taken any time during the headache.

Side effects include flushing, discomfort, tingling, and nausea.

Ergots (e.g., Cafergot®, Mioranal®) may be administered orally or as a suppository and is often combined with antinausea drugs, such as prochlorperazine (Compazine®). This medication should be taken at the first sign of a migraine and may not be effective if the headache has moved into the throbbing stage.

Side effects include gastrointestinal upset, dizziness, stroke, and high blood pressure (hypertension). Ergots should not be taken by patients with heart, vascular, liver, or kidney disease.

Prevention

Avoiding triggers, managing stress, and taking prophylactic medications can help prevent migraines. Keeping a migraine journal can help identify triggers and gauge the effectiveness of preventive measures. Patients should monitor the following:

• Activities
• Emotional factors (e.g. stressful situations)
• Environmental factors (e.g., weather, altitude changes)
• Foods and beverages
• Medications (over-the-counter and prescription)
• Migraine characteristics (e.g., severity, length)
• Physical factors (e.g., illness, fatigue)
• Sleep patterns

Stress management techniques (e.g., biofeedback, hypnosis) and stress-reducing activities (e.g., meditation, yoga, exercise) may help prevent migraines.

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