Migraine - classic; Migraine - with aura
Migraine headaches are repeated or recurrent headaches, possibly caused by changes in the diameter of the blood vessels in the head. Most people with migraines do not have any warning before it occurs. However, in cases of “classic” migraine headache, a visual disturbance called an aura happens before the headache starts.
Classic migraine is different from “common” migraines (which have no warning sign or aura) or “complicated” migraines (which occur with speech, movement, or other problems in the nervous system).
Causes, incidence, and risk factors
Migraine headaches are a common type of chronic headache. They affect about 6 out of 100 people.
- Classic migraine accounts for about one-sixth of all migraines.
- Common migraine and other (rare) forms account for the rest.
The causes of migraine are complex and somewhat controversial. One theory is that the symptoms are due to temporary changes in blood vessels. The blood vessels to the brain may become narrow, resulting in less blood flow to the brain. This could be what causes the visual changes before the headache.
Minutes to hours later, the blood vessels dilate (enlarge), resulting in the severe headache. Classic migraine specifically refers to migraines preceded by visual symptoms.
Migraines occur in women more than men, most often between the ages of 10 and 46 years. In some cases, they appear to run in families.
Attacks of migraine headache may be associated with:
- Allergic reactions
- Bright lights
- Loud noises
- Physical or mental stress
- Changes in sleep patterns
- Smoking or exposure to tobacco smoke
- Missed meals
- Hormonal fluctuations (related to menstrual cycles or use of birth control pills)
- Other conditions
Foods associated with migraine include:
- Foods containing the amino acid tyramine (red wine, aged cheese, smoked fish, chicken livers, figs, some beans)
- Nuts and peanut butter
- Fruits (avocado, banana, citrus fruit)
- Dairy products
- Baked goods
- Meats containing nitrates (bacon, hot dogs, salami, cured meats)
- Foods containing monosodium glutamate (MSG)
- Any processed, fermented, pickled, or marinated foods
True migraine headaches are not a result of underlying brain tumors or other serious medical problems. However, only an experienced physician can determine whether headache symptoms represent migraine or some underlying medical condition that requires further tests. This assessment can only be made after a review of a patient’s history and a thorough neurological examination.
A classic migraine begins with visual disturbances (aura). These warning symptoms may occur anywhere from a few minutes to 24 hours before the headache. The visual changes are common in one or both eyes. They may occur in any combination:
- Seeing zigzag lines
- Seeing flashing lights
- Other visual hallucinations
- Temporary blind spots
- Sensitivity to bright light
- Blurred vision
- Eye pain
Other symptoms that may precede or accompany classic migraine headache include:
- Loss of appetite
- Increased urination
- Increased sweating
- Swelling of the face
The headache itself is often described as a “pounding” feeling that starts on one side of the head and may spread to the other side. For many patients, the headaches start on the same side each time. Many patients describe pain behind the eye or in the back of the head and neck.
The headache typically begins as a dull ache that progressively worsens over several minutes to hours to the point of disabling pain. The headache may last several hours to days, during which patients are sensitive to light or sound. Patients often wish to rest in a quiet, dark room.
To learn what may be triggering your migraine headaches, keep a headache diary. Write down:
- When your headaches occurred
- How severe they were
- Additional symptoms
- What you’ve eaten
- Sleep patterns
- Menstrual cycles
- Any other possible factors
For example, the diary may reveal that your headaches tend to occur more often on days when you awaken earlier than usual. Changing your sleep schedule may then result in fewer migraine attacks.
Some birth control pills and other medications may trigger headaches. Your health care provider should address questions regarding their use.
Even in the absence of a clear factor that triggers migraine attacks, try to keep a regular exercise and sleep schedule. Avoid smoking, caffeine, and alcohol. Some patients have found biofeedback and self-hypnosis to be effective at reducing the frequency of migraine attacks.
Although there is no cure for migraine headaches, numerous medications are available. These medications are used to:
- Prevent migraines from occurring
- Stop the migraine once early symptoms develop
- Treat the symptoms of migraine (e.g., pain, nausea)
All medications have potential side effects and may be incompatible with other medications you are taking. Also, many migraine medications are associated with birth defects and are therefore not safe to use during pregnancy.
Often, a physician will try several classes of medications before one (or a combination) is found to be effective.
Many medications can reduce the frequency of migraines. Generally, these need to be taken daily in order to be effective. These medications are less useful and tolerable to patients with infrequent headaches. Medications in this category include:
- Beta-blockers (e.g., propanolol)
- Anti-depressants (e.g., amitriptyline)
- Anti-convulsants (e.g., valproic acid)
- Calcium-channel blockers (e.g., verapamil)
- Serotonin re-uptake inhibitors
STOPPING AN ATTACK
Other medications are taken when there is the first sign of an impending migraine attack. In the case of classic migraine, this is typically when visual disturbances are first noted. These medications can effectively stop the migraine in its tracks, preventing the progression to other migraine symptoms or reducing the severity of the attack.
Many of these medications cause constriction of blood vessels and cannot be given to patients at risk of heart attack or other conditions. These medications include:
- Ergots (e.g., DHE-45)
- Serotonin agonists / triptans (e.g., sumatriptan)
These medications come in various preparations to enable administration via different routes. For example, patients who experience vomiting and cannot keep pills down may benefit from a nasal spray or injectable dose.
Call for an appointment with your health care provider if taking an ergotamine-containing medication and you are likely to become pregnant (these medications can have serious side effects to a developing fetus).
Other medications are primarily given to treat the symptoms of migraine. Used alone or in combinations, these drugs can minimize pain, nausea, or emotional distress caused by the migraine. Some of these medications may also have some effect on the underlying process in addition to providing symptomatic relief. Medications in this category include:
- Anti-emetics (e.g., prochlorperazine)
- Sedatives (e.g., butalbital)
- Anti-inflammatories (e.g., ibuprofen)
- Narcotic analgesics (e.g., meperidine)
For additional resources, see migraine support group.
Migraine headaches usually do not represent a significant threat to your health. However, in rare circumstances, people with migraine may be at risk of serious complications. A severe migraine may result in a stroke, possibly due to prolonged constriction of blood vessels. Some people may have side effects of medications. A physician should choose the appropriate medications based on symptoms and other conditions.
Experienced physicians can identify patients who may be at increased risk from these complications and can provide treatment that reduces such risk.
The large number of people affected by migraine has led to extensive research into finding effective treatment. In the future, expect that new medications will continue to be developed.
Calling your health care provider
If a person has any of the following, call for an evaluation by a physician immediately:
- Speech, vision, balance, movement, sensation, and other neurological problems, particularly if the person has NOT had these symptoms with previous headaches
- Loss of consciousness
- A change in headache pattern
- The worst headache in one’s life
- Headaches that are more severe when lying down
- A headache that starts extremely abruptly
Such headaches may be the result of stroke, intracranial hemorrhage, aneurysm, or other serious condition and require the immediate attention of a physician.
Depending on the history of the headache, a CT scan or MRI may be done to rule out any of the above conditions.
Also contact your healthcare provider if:
- Previously effective treatments are no longer helpful.
- Side effects of medications occur, including irregular heartbeat, changes in skin color (pale or blue), extreme sleepiness, persistent cough, depression, fatigue, nausea, vomiting, diarrhea, constipation, stomach pain or cramps, dry mouth, extreme thirst, among others.
People at high risk of migraines should avoid any factors that seemed to trigger a previous migraine.
Most patients with migraine can identify certain foods that are closely associated with their migraine headaches. To find out which foods are responsible, avoid all of the above-mentioned foods and then gradually work each food back into the diet. An accurate headache diary helps determine which foods may be responsible.
Many people with migraine become familiar with their warning symptoms prior to a headache and may be able to take medication to lessen the oncoming headache.
by Sharon M. Smith, M.D.
All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.