Migraine

Key Features of Migraine Headaches

Development of aura which may occur over several minutes and lasts less than 1 hour.
Symptoms typical of this phase may include:
- Visual disturbances: such as flashing lights, spots, shimmering or zigzag lights, which can vary in intensity.
- Neurologic changes: might include numbness or tingling in lips and tongue, acute confusion, difficulty in finding words (aphasia), vertigo, unilateral weakness, and drowsiness.

This phase features a headache that accompanies nausea and vomiting.
Characteristics of the headache include:
- It is usually unilateral, situated predominantly in the frontotemporal regions, and described as a throbbing pain often worse behind one eye or ear.
- Onset of headache typically occurs within one hour of aura symptoms.

Pain intensity may shift from a throbbing sensation to a dull ache.
Headaches during this phase, along with associated nausea and vomiting, can last anywhere from 4 to 72 hours.
In older patients, there may be presentations of aura without the headache pain, often referred to as visual migraine.

This type of migraine begins without any preceding aura before the headache onset.
Characteristics include:
- Unilateral pulsating pain that is aggravated by routine physical activities.
- Common symptoms include nausea, vomiting, photophobia (sensitivity to light), and phonophobia (sensitivity to sound).
Duration of these migraines is typically between 4 to 72 hours, often triggered by factors such as stress, hormonal changes, or occurring in the early morning hours.

Status migrainosus: defined as a headache that lasts longer than 72 hours.
Migrainous infarction: this occurs when neurologic symptoms persist and are not fully reversible within 7 days, and evidence of ischemic infarction is visible on neuroimaging studies.
Unclassified migraines: refers to headaches that do not meet the specific criteria for classification as a traditional migraine.

Migraine headaches are among the most common types of headaches, with significant ramifications on individuals' quality of life.
Common features include:
- Recurrent and episodic head pain, usually unilateral.
- Pain is typically described as throbbing and can last from 4 to 72 hours.
Symptoms are often accompanied by nausea and sensitivity to light and sound.
Genetic predisposition plays a role in migraine susceptibility; they tend to run in families, affecting a higher percentage of women who also have a greater likelihood of experiencing major depressive disorders.
Risk Factors: those who suffer from migraines may face an increased risk of developing conditions like stroke and epilepsy.
Pathogenesis: the exact mechanisms of migraines are not completely understood yet, but it is believed that they involve neuronal hyperexcitability, changes in vascular dynamics, and can be triggered by environmental factors such as caffeine and certain food items.

Trigger stimuli activate hyperexcitable neurons, leading to migraine-related pain through a cascade involving vascular changes and the activation of nociceptors.
Pain arises from the activation of pain-sensing cells in blood vessels, with a notable contribution from the trigeminal nerve pathway activation, along with the release of substances such as glutamate, which enhance the experience of pain.

Diagnosing migraines involves thorough evaluations based on the patient’s medical history, in addition to physical, neurologic, and psychological assessments.
Symptoms during migraine episodes are typically consistent, which aids in diagnosis.
Neuroimaging techniques such as MRI may be warranted for certain patient profiles or if atypical symptoms arise.
Special attention should be given to educate women over 50 years old regarding the cardiovascular risks that may accompany migraines.

Effective pain management is fundamental, encompassing both abortive and preventive therapy strategies.
Patient Education: It's critical to ensure that patients understand their collaborative care plans and treatment options.

The goal is to alleviate pain during the aura phase or soon after headache onset. Common medications prescribed include:
- For mild migraines: analgesics such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen.
- For severe migraines: triptans, ditans, and ergotamine derivatives may be utilized.
Caution is advised regarding the potential for rebound headaches with chronic medication use.
Triptans: Particularly effective in relieving headaches and related symptoms through the process of vasoconstriction.

Common triptans include sumatriptan and eletriptan; these should be administered at the onset of a migraine attack.
Not recommended for individuals with ischemic heart disease or a history of coronary artery disease.
Patient Education: Patients must report any experiences of chest pain or discomfort while using triptans. Additionally, caution should be observed to avoid combining triptans with SSRIs or St. John’s wort.

Ditans: Such as lasmiditan; considered safer due to the absence of vasoconstricting effects.
CGRP-R Antagonists: For example, ubrogepant serves as an oral option for acute migraine treatment.
Ergotamine preparations: Effective for intervention at headache onset; however, these should not be taken concurrently with triptans.

Preventive therapy is indicated for patients experiencing frequent migraines (more than twice weekly) or those that severely impact their daily functioning.
Common preventive medications include:
- NSAIDs, beta-blockers (e.g., propranolol and timolol), calcium channel blockers (e.g., verapamil), and antiepileptic drugs (e.g., topiramate, nortriptyline).

Educate patients to monitor their pulse while on beta-blockers.
Exercise caution with topiramate due to a noted association with suicides at high doses.

Chronic migraine is characterized by having more than 15 headache days per month.
OnabotulinumtoxinA is approved for chronic migraine treatment; CGRP-R antagonists are also employed for prevention.
Keeping a headache diary can be useful to record episode characteristics and responses to treatments.

Encourage the identification and avoidance of environmental and lifestyle factors that trigger migraine episodes, such as certain foods.
Lifestyle Strategies: These can include resting in darkened rooms or applying cool cloths to the head.
Medical Marijuana: Emerging evidence suggests it may reduce migraine episodes, especially products rich in CBD.
External Devices: Devices such as Cefaly are used for trigeminal nerve stimulation and prevention of migraines.
Complementary Treatments: Strategies like exercise, biofeedback, and nutritional supplements such as B12, magnesium, and specific herbs can provide additional support. Education about any potential interactions before using alternative therapies is also crucial.