What Is Migraine?

A migraine is a type of headache that usually happens in episodes or "attacks." Attacks may last anywhere from four hours to as long as 72 hours. Long considered "just another type of headache," migraine is now recognized as a distinct neurologic disorder.

The pain of a migraine headache is generally moderate to severe and can disrupt normal activities. It may feel like it is throbbing or pulsating and may be located on one side of the head. The pain may be accompanied by nausea, vomiting, or sensitivity to light or sound.

Migraine is more common in women than men and is thought to affect nearly 18.6% of women and 6.5% of men. Studies have shown that up to 59% of women and 70% of men with migraine have never been diagnosed by a health care professional. Many people have pain and other symptoms so severe that they only want to lie down in a dark room and go to sleep. This, obviously, is very disruptive to their lives. However, migraine can be treated with medication. Today, there are a number of drugs available to either help prevent migraines or treat them after they begin.

What Causes Migraine?

No one knows exactly why migraines occur. We do know that the tendency to develop migraines can be inherited. Studies have shown that if one parent has migraines, there is a 40% chance that the child will have migraines. If both parents have migraines, there is a 75% chance that their children will have migraines.

New research is shedding light on the pathogenesis of migraine and accordingly on how we treat it. Migraine is now seen as part of a continuum with migraine at one end and common daily headache at the other. In fact common daily headache may be caused by rebound from the medication used to treat migraine.

Inflammation appears to play a large part in the etiology, with ill defined triggers causing inflammation in the trigeminal afferent fibres. Impulses are then transmitted to the sensory nucleus of the trigeminal nerve where 5HT receptors are involved in the release of substance P, bradykinins, etc. These inflammatory mediators in turn cause vasodilation, sensitization, hyperalgesia and nociceptor enhancement.

These findings would suggest a role for anti-inflammatories in the management of migraine.Once the diagnosis is made - even migraine sufferers can have tumours and subdurals - there is a myriad of treatments available. Although every ER seems to have its' favourite routine, it is better to tailor the treatment to the individual patient.

Common Migraine Triggers

Falling estrogen levels that occur just before menstruation can precipitate a migraine headache in many women. Many factors or triggers may start a migraine. In people who are sensitive to these triggers, avoiding them can go a long way to reducing migraine related disability.

It is important for you to know which triggers may cause your migraines. One way to do this is to track triggers – such as what you've had to eat or drink – around the time of each migraine. A handy way to do this is with the interactive Migraine Diary on this site.

On the Diary, mark off in the "Possible Triggers" area your recent activities, diet, stresses, and medications, all of which might help you determine what brings on your migraine. You can identify triggers to be avoided, plus take the completed Diary pages with you when you visit your health care professional and discuss the results.

What Are the Symptoms of Migraine?

Initially, it can be hard to tell whether a headache is a migraine rather than an "ordinary" headache. Characteristics of migraine attacks that can help differentiate them from other types of headaches include:

• Moderate to severe pain
• Nausea
• Sensitivity to light and noise (and sometimes smell)
• Throbbing, pulsating at site of pain
• Pain, mainly one-sided
• Pain made worse with activity
• Vomiting

Some people experience aura 10 to 30 minutes before they have a migraine headache. Aura can include visual changes such as bright flashing lights; flickering, colored zigzag lines; blind spots; or loss of vision off to one side. Aura also can include a tingling sensation or numbness in the arms or legs, or dizziness. The cause of aura is still unknown.

To be sure that your symptoms are related to a migraine headache rather than another physical problem, see your health care professional or doctor. After reviewing your symptoms and performing and examination, he or she may confirm the diagnosis of migraine or order further testing to rule out other causes.

How Are Migraines Treated?

Thanks to ongoing research, health care professionals know more about migraine and have more medications available to treat or prevent it. For sufferers who have very frequent migraine attacks, health care professionals often prescribe medication to help prevent them. These medicines are taken daily to help reduce the frequency and severity of migraine attacks.

Migraine can interrupt normal routines, interfering with work, family or recreational activities. Looking at all your options and talking with your health care professional can help you get the best results in managing your migraines.

Since inflammation is felt to play such a large role it would make sense that NSAIDS should be tried first. In fact they work about 50-60% of the time. It is necessary to use doses higher than we ordinarily use. There are the problems usually associated with NSAIDS - GI upset, aggravation of asthma etc., but in their favour it can be said that they are cheap (except for Ketorolac), easy to use and non-sedating.

These medications are used routinely in the ER and each hospital has its' favourite drug. They work about 60-80% of the time and are more effective if given IV. Generally it is better to give them as an IV push (3 - 4 minutes) as opposed to over 20-30 minutes.

It should be noted that these drugs have side effects that we in the ER don't often recognize, because the akinesia that patients suffer compels them to leave the ER as soon as the medication is finished. They also suffer dystonias and a dysphoria the can last for 24 hours. Benadryl or Cogentin can help with the dystonia.

The advantages of drugs in this group include their antiemetic effect, their efficacy, their effective behavioural control and the fact that they can be used as a single agent.

Their disadvantages are that they are sedating, can cause hypotension and dystonia and are contraindicated in patients with renal disease or those on MAO inhibitors.

These drugs are often used in combination with Dexamethasone 10 mg IV. Adding this anti-inflammatory agent makes sense and seems to enhance the effectiveness of the treatment. Dexamethasone can also be given orally 4-8 mg repeated after one hour.

These agents act centrally on the serotonin receptors to block the release of inflammatory mediators. Presently available are dihydroergotamine (DHE) and sumatriptan (Imitrex).

DHE has been around for 50 years. It is useful in "hard to treat" migraine and is 70-80% effective. It is cheap and has a low incidence of rebound because of its' relatively long half-life. Recently it has been released for intranasal administration. The dose is 1 mg IM or SC at the first sign of the headache. An additional 1 mg can be given after 30-60 minutes. The maximum dose in 24 hours is 3 mg. DHE can be given by slow IV administration, 1 mg followed by a second 1mg 60 minutes later if necessary. Maximum IV dose is 2 mg per attack.

It is contraindicated in pregnancy, CAD/PVD, uncontrolled hypertension and renal or hepatic failure. It cannot be used in patients on Macrolides or Beta-blockers. Also it cannot be used for 24 hours after prophylactic ergotamine or for 6 hours after Sumatriptan.

Sumatriptan has been studied extensively and is 70-80% effective. Unfortunately it has a short half-life and so has a high rate of recurrence (40-60%). It is available orally, subcutaneously and intra-nasally.

Side effects include chest heaviness (4%) of which 0.1% is thought to be ischemic. There have been case reports of Ventricular fibrillation, MI and Cardiac Arrest. It is considered contraindicated for patients with ASHD or risk factors for ASHD. Other contraindications include uncontrolled hypertension, pregnancy, PVD, hemiplegic migraine and use of Lithium, MAO inhibitors and possibly SSRIs.

Some ERs have a No Narcotics policy with respect to migraine. However, there is a group of patients for whom other medications don't work, and for this group narcotics should not be withheld. They work 60-70% of the time and they're safe in pregnancy, but rebound incidence is high.

There is of course a potential for abuse. Also they are sedating and can cause hypotension. They are contraindicated in COPD, hepatic insufficiency and in patients on MAO inhibitors.

Remember that although migraine is common, most migraine sufferers don't come to the ER. Moreover, although rebound is common, most patients don't return for further treatment. So try not to treat these patients like criminals when they present to your ER.

Intuitive Pharmacol™

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Migraine causes and treatment - The latest secrets.