“Migraine” derives from the Latin word hemicrania (or heMICRANia), meaning “half the skull.” As early as the second millennium B.C., migraine headaches have been categorized as different from other types of headaches by their peculiar qualities:
- Typically unilateral, although a third can involve both sides of the head.
- Preceded by the migraine aura in a fourth of patients—a visual, olfactory (smell), or other sensory illusion that precedes or accompanies a migraine, but may occur even without a subsequent headache.
- Throbbing, increased with movement or exertion
- Pain builds up over a few hours.
- Lasts from a few hours to three days
- Associated with nausea and vomiting
- Hypersensitivity to bright lights and sound
Statistics on Migraine
According to the Migraine Research Foundation , migraines affect a billion people worldwide as the 3rd most prevalent human disease. Most common between the ages of 25-55, children can also get them. They typically recur once or twice monthly, but some people suffer with them daily (chronic daily migraine). They can be so incapacitating that most people are unable to function (especially in employment) during an attack, resulting in over $30 billion dollars lost in productivity annually; add to this the cost of treating them, and the true financial impact on a family can be an increase in their healthcare costs by 70%.
After puberty, the demographics are such that more women get them (3 to 1 prevalence); before puberty, more boys; this leads to a suspicion of a hormonal influence on them, since the shift in proportions begins in adolescence and often menopause causes migraines to fade.
The aura and the fact that it originates in the brain have led some to believe it might be a type of epilepsy.
Could the migraine headache be a type of epilepsy?
Epilepsy and migraine headache are two different diseases. Because they both have things in common (aura or focal neurological symptoms, for instance) and can occur together, they can even be misdiagnosed as each other. Further confusing things is that people with migraines are more likely to have epilepsy and epileptic patients commonly have migraines (twice as likely). Additionally, the same things can trigger both1 and often they each benefit from the same medications, such as anticonvulsants (anti-seizure medications).
Although they are two different diseases, neither of them can be said to be completely independent of the other. Although no one will say they are different types of the same disease (or completely different diseases), researchers feel that both epilepsy and migraine headaches, although different, are part of a “network of intersecting disorders2. Not quite a straight answer, but the most current one.
What are they, exactly? What causes migraines?
One thing is certain: it is a disorder of recurrent attacks. There are four main phases3:
- Prodrome. Three-fourths of patients have changes in their affect—depression, euphoria, irritability, food cravings, constipation, stiff neck, etc.
- Aura. One-fourth experience a spontaneous activity of nerve cells (neurons), resulting in bright lights (“scintillating scotomata”), sounds (ringing, music), sensory changes (feelings of burning, pain, tingling), or even involuntary movements (jerking or repetitive movements). Some have auras without headaches.
- Headache. Often one-sided, but not always. Nausea can accompany the pain. It can last from hours to days.
- Postdrome. This is usually a feeling of exhaustion.
The theory that migraines were caused by a vascular abnormality of dilated blood vessels in the brain has been debunked. Today, it is believed to be caused by a phenomenon called “cortical spreading depression.4” This is described as a self-propagating wave of both grey (neurons) and white (glia) matter in the cerebral cortex that not only results in the aura, but also affects a major nerve—the trigeminal, as well as alters the barrier between the brain and the blood stream, called the “blood-brain barrier” (BBB).
The trigeminal nerve is the 5th Cranial Nerve, and controls sensations and muscles of the face. It has three divisions, the ophthalmic, the maxillary, and the mandibular. The trigeminal involvement causes inflammation to spread along the meninges (thin, pain-sensitive covering over the brain) which results in the headache itself.
The barrier that protects the brain, the BBB can allow leakage of inflammatory substances as part of the process.
How are migraines diagnosed?
According to the Headache Classification Committee of the International Headache Society (HIS)5, to qualify as a migraine headache, there must be at least 5 attacks with
- Headache lasting 4-72 hours
- Unilateral, pulsating, painful, aggravated by physical activity
- Nausea or photophobia (light sensitivity)
If the headache is preceded by an aura, this list to declare it a migraine becomes shorter, all based on the nature or the aura itself.
What are different types of migraines?
- Hemiplegic migraine: has motor weakness.
- Retinal migraine: when the aura involves visual phenomena.
- Chronic migraine: so designated when occurring 15 or more times a month. Devastating and disabling, chronic migraine can revert to much less frequent (episodic) in over half the patients over time. Chronic migraines are associated with psychiatric disorders, sleep disorders, and a variety of pain syndromes (gastrointestinal and other).
- Vestibular migraine: accompanied by vertigo.
- Menstrual migraine: when a migraine is associated with a menstrual period. (An “estrogen-associated” migraine can occur at other times of the month.)
- Abdominal migraine: this is usually a gynecologic diagnosis of exclusion, after ruling out causes by any of the pelvic or abdominal organs. All pain is perceived in the brain, and if the “cortical spreading” described above involves that part of the brain receiving input from the abdomen, it may present as abdominal pain in the complete absence of anything actually going wrong there.
Are there any tests to diagnose migraines?
Tests are usually not necessary, as a migraine is usually based on the symptom cluster as reported by the patient. However, neuroimaging (CT) should be considered when there is an unexplained neurological finding, if the criteria for a migraine are not fulfilled, or if a headache is severe and sudden.
How are migraines treated?
Because migraines occur in the brain, behavioral and biofeedback can be used to help address or avoid the known triggers.
The drugs to treat migraines are separated into a first, second, and third choice:
- First choice includes propranolol (beta-blocker), amitriptyline (Elavil—antidepressant), and topiramate (Topamax) and valproate (Depakene)—anti-seizure meds.
- Second choice: for those who don’t respond adequately to the first-choice medications, there are other beta blockers—atenolol (Tenormin), nadolol, metoprolol (Lopresor), timolol; botulinum toxin A; neuromodulators—gabapentin (Neurontin), verapamil); and other antidepressants—other tricyclic ones like nortriptyline (Aventyl) and protriptylne.
- If these don’t work well either, there are also third choice drugs: the herb feverfew; tizanidine (Zanaflex); memantine (Namenda); pregabalin (Lyrica); cyproheptadine; and zonisamide.
How long will treatment for migraines go on?
Treatment will last as long as there are migraines.
Another way to ask this is, “How long are migraines going to wreck my life?” This may be a dramatic way to ask, but it is not melodramatic, because migraines do indeed impact one’s quality of life very negatively.
Most people who begin migraines in the twenties or later will see them reduced in pain intensity, duration, and frequency beginning in their fifties, with some reporting actual resolution of them altogether.
Migraine headaches are devastating, incapacitating, and—for anyone who has plans—very unfair. Thankfully, most respond to the standard approaches, but there are always a few for whom nothing at all will work. Such a condition is not a terminal disease, but it just as surely can kill aspirations, vocations, and quality of life. As time goes on, research will one day offer help for these few stubborn cases, but if the research doesn’t, the time will.
- Davies PTG, Panayiotopoulos CP. Migraine triggered seizures and epilepsy triggered headache and migraine attacks: a need for re-assessment. Journal of Headache Pain. 2011; 12(3): 287–288.
- Cutrer FM. Pathophysiology of migraine. Semin Neurol 2006; 26:171.
- The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33:629.
- Lidiane Lima Florencio, Anamaria Siriani de Oliveira, Gabriela Ferreira Carvalho, Fabiola Dach, Marcelo Eduardo Bigal, César Fernández-de-las-Peñas, Débora Bevilaqua-Grossi. Association Between Severity of Temporomandibular Disorders and the Frequency of Headache Attacks in Women With Migraine: A Cross-Sectional Study. Journal of Manipulative and Physiological Therapeutics, 2017; 40 (4): 250 DOI: 10.1016/j.jmpt.2017.02.006.
- Wake Forest Baptist Medical Center. "Effective help is available for migraine sufferers." ScienceDaily. ScienceDaily, 22 September 2017.
- http://www.webmd.com/migraines-headaches/guide/migraine-term-definitions#. (“10 Terms Every Migraine Sufferer Should Know.”)
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