Migraine Headache

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Headache is a common problem that accounts for a significant loss of workdays and productivity. Headaches can be caused by a variety of conditions. Migraines headaches specifically will be discussed in this article as they are very prominent and often disabling, with variable success rates for treatment and prevention.

Classification:

Migraines affect 15-20% of the population. They are thought to be an inherited condition and affect women more often than men. 

Attacks start typically between the ages of 15 and 25. There are two basic types of migraines. First, migraine without aura (also called a common migraine) accounts for 80% of cases. Secondly, a migraine with aura is also called a classic migraine. The “aura” varies between patients but is usually manifested by changes in vision such as flashing lights, tunnel vision, or tingling, numbness or other neurologic changes. The aura is usually the same before each attack for the individual migraine patient. The headache itself is described as throbbing, pulsing, and usually one-sided, and it is accompanied by nausea, vomiting, and sensitivity to light and sound. Physical activity makes it worse, concentration is difficult, and the patient usually wants to be in a dark, quiet place. Typically,the attack will last from 4-72 hours.

Cause:

The exact cause of migraines is not known. It is thought to be a dysfunction of nerves and chemicals in the brain called neurotransmitters. Serotonin is a neurotransmitter that is currently implicated in migraine attacks; it is involved in dilating the blood vessels of the brain, which is proposed to be the cause of the pain from migraines. Some triggers of migraines include certain foods (alcohol, aged cheese, chocolate, citrus fruits, monosodium glutamate (MSG), Nutrasweet), stress, and irregular eating and sleeping habits. A subset of women with migraines suffer “menstrual migraines”, in which the rapidly changing levels of hormones trigger migraines on a monthly basis in association with menses.

Treatment:

Treatment varies between each individual. Prevention is the optimal treatment, as some migraine sufferers have a very difficult time aborting the headache once it has started. Simple measures include avoiding foods that trigger an attack and maintaining regular sleep and eating habits. Some patients do well with relaxation techniques and biofeedback, but often medications are needed.

Several classes of medications are used to treat an attack once it has started, with best results occurring if the drugs are used early during in the onset of the headache. Tylenol and anti-inflammatories alone are sometimes effective. Blood vessel constrictors often can abort an attack, including the “triptans"--sumatriptan (Imitrex), rizatriptan (Maxalt), naratriptan (Amerge), and zolmitriptan (Zomig). The combination of ergotamine and caffeine (Cafergot) works similarly. These medications cannot be used in patients with heart disease or severe hypertension (High Blood Pressure) as these conditions can worsen from the vessel constriction. Steroids can help control an attack but may not abort it. Narcotics are an option but are not the first choice in many cases as they can be addicting. Often an anti-nausea medication is used as well to control the nausea that accompanies a migraine.

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For patients with frequent migraines, prophylactic, or long-term preventative medications, may be best. These include the tricyclic antidepressants (amitriptyline, nortriptyline, imipramine, doxepin), a class of anti-depressants known as serotonin reuptake inhibitors that regulate the levels of serotonin in the body, and two classes of medications called beta blockers and calcium channel blockers, which regulate the dilitation and constriction of blood vessels. When these measures fail, a referral to a headache specialist is often necessary.

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