Migraine: Phases, Triggers & Treatment Options

Introduction to migraine:

Migraine is remarkably common and complex. Of all the painful states headache is undoubtedly the most frequent and most common disabling condition and reason for seeking medical help. Migraine occurs in episodes causing severe headache, sensitivity to light, noise, smells, nausea or vomiting, dizziness and problem with vision and irritability. It often begins in childhood or young adulthood and recurs with advancing age.

Can my family member also have migraine?

About two-thirds of migraine cases run in families. It is genetic disorder, which means it is of heritable nature, in most instances. The susceptibility to an acute migraine attack depends upon balance between excitation and inhibition at various level of nervous system.

What is the mechanism of a migraine attack?

The phenomenon known as cortical spreading depression is a wave that spreads across part of the Brian known as cerebral cortex causes aura of migraine, alter permeability of barrier called blood brain barrier, activate pair of nerves of brain called trigeminal nerve. There are 12 pairs of nerves which come out of brain. Trigeminal is the fifth pair of nerves. The key role is of CGRP (Calcitonin Gene Related Peptide). CGRP is expressed in trigeminal ganglia and is a potent vasodilator of cerebral and dural vessels.

What are the 4 phases of a migraine attack?

The clinical features of typical migraine attack progresses through four phases.

1. In first phase, prodrome phase, symptoms appear 24 to 48 hours prior to onset of headache. These symptoms include light or sound sensitivity, fatigue, neck pain, irritability or euphoria, food cravings or yawning or changes to bowel function.

2. The second phase, Aura, develops gradually over more than five minutes. These symptoms can be positive or negative. Positive symptoms are bright lines, shapes, white, silver or multicolored lights (visuals), auditory symptoms are noise, music or tinnitus, somatosensory are burning, pain, paresthesia; motor symptoms are jerking or repititive rhythmic movements. Negative symptoms are absence or loss of function e.g. loss of vision, hearing, feeling or ability to move part of body. Auras are mostly visuals.

3. The third phase is headache of throbbing or pulsatile nature. It last from four hours to several days, if not treated. Patient has nausea, sometimes vomiting, photophobia, phonophobia, osmophobia and cutaneous allodynia.

4. The fourth phase is prodrome. When quality of headache resolves, patient feels drained or exhausted and pain when suddenly moving head, in this phase. This phase persists for hours.

What triggers a migraine attack?

Migraines are often worsened by rapid head motion, sneezing, staining at stool and physical exertion. To trigger migraine attacks, evidence based review concludes presence of at least one of the following:

1. Emotional stress
2. Hormones in female
3. Not eating
4. Weather
5. Sleep disturbance
6. Odors
7. Neck pain
8. Light
9. Smoke
10. Sleeping late
11. Food
12. Alcohol
13. Sexual activity

When is CT scan brain or MRI brain needed?

Consideration of neuroimaging (CT Scan brain or MRI brain)  is in following patients.

1. Patients with unexplained abnormal finding on neurological examination.
2. Patients with headaches that do not fulfill definition of migraine or primary headaches.

How to manage migraine attack at home?

• 1. Take painkillers as soon as possible.
• 2. Sleep in dark, quiet room.
• 3. Use ice packs
• 4. Cold coke, as caffeine has proven to treat it.
• 5. Strong coffee or tea as it has caffeine
• 6. Hot shower or hot packs to open the blood vessels
• 7. Drink cold water to cool your system down.
• 8. Apply balm or Vicks on the back of your neck
• 9. Salty food can help balance the chemicals in the brain.
• 10. Eye Mask or blanket is really good for helping calm migraine related anxiety.
• 11. Apply acupressure on some specific points on hands or feet e.g

• a. Base of back of hand between thumb and index finger.
• b. Base of two sides of nose.
• c. Apply pressure between your eyes.
• d. At the base of skull just below hairline on two parallel neck muscle areas.

What’s the Treatment of migraine?

Abortive:

The early use of migraine-specific medications for severe attacks provided the best outcomes.The abortive (symptomatic) therapy of migraine ranges from the use of simple analgesics to CGRP antagonists.

Preventive:

For most patients with episodic migraine who have an indication for preventive therapy, initial treatment is with antidepressants (TCA), SNRI, one of the beta blockers, antiepileptics  or one of the CGRP antagonists. Treatment is tailored with individual patient’s need. Consult your doctor for treatment plan.

Pharmacotherapy and lifestyle measures are the mainstay of migraine prevention.