Migraine is characterized by repeated episodes of head pain of moderate to a severe intensity which lasts for hours, sometimes days. Symptoms of migraine headache are not just head pain or nausea and vomiting. A migraine attack can affect your daily life activities. Mostly you will notice that a person suffering from a migraine headache will want to escape into a dark, quiet room to get some rest.
Do you often feel a terrible headache that just doesn’t go away? If the persistent headache comes back again and again quite often, it can be a migraine. Migraine is a common and debilitating neurological condition that is being researched extensively for centuries so that we can find a proper migraine headache treatment. WHO data shows that migraine is the third most common medical condition in the world affecting around 14.7% of the population annually. 92.5% of the ones suffering from migraines experience serious impairments during the attacks and 53.7% require bed rest. Hence, migraine is the 8th leading cause of disability in the world, which makes it an even more debilitating condition than diabetes, osteoarthritis, and alcohol and drug abuse disorders. It is currently the 4th leading cause of patients visiting the emergency department.
Why does migraine occur?
There is probably no person who hasn’t had a headache before. But what is a migraine headache? There are many types of headaches that occur for various reasons. Hence it is of importance to understand the mechanism behind migraine before getting into its diagnosis and the migraine headache treatment. Studies show that migraine has a more neuronal origin, that is it occurs due to abnormal activities of nerves.
The trigeminal system consists of the trigeminal nerve components. As you might already know, there are two types of nerves in our body according to their origin - cranial nerves that arise from the brain and spinal nerves that arise from the spinal cord. The trigeminal nerve is the 5th cranial nerve in our body. The trigeminovascular system consists of the first division of the trigeminal nerve which innervates large intracranial vessels and the dura mater (outermost layer of the meninges that cover the brain). Activation or rather, hyper-stimulation of these nerves lead to headaches. Aura is thought to develop due to depressed activity of nerves which spreads from the back to the front of the brain. The other symptoms such as discomfort on hearing loud noises, seeing bright lights, sudden head movements are due to increased sensitivity of the nerve’s pathway through the brainstem.
History of migraine headache
The word migraine has been derived from the Latin word “hemicrania” - meaning “half skull”. Galenus of Pergamon, a physician of the first century, described severe pain on one side of the head (similar to that felt in migraine) as Hemicrania. He thought the reasons for migraine were damage to the meninges (layers around the brain) and the blood vessels in the head. He also suggested that there might be a connection between the stomach and the head in the development of this condition because of the vomiting that occurred with the pain.
Over the centuries, physicians have tried to understand the reasons for migraine and tried finding an apt headache treatment. At last in the 1930s, Graham and Wolff found that ergotamine could be a migraine headache treatment. Wolff also went on to try and devise experiments to describe the origin of migraine, in the 1950s.
Who gets migraine?
Women have been seen to experience migraine attacks more often than men. This occurs since oestrogen and fluctuations in its levels have a role to play in causing migraine attacks. The age of onset of a migraine is usually in the years of puberty and 90% suffering from migraine are in their 40s. A genetic basis has been found in the occurrence of migraine, hence if you have close family members who suffer from migraine headaches, you have high chances of developing it too. Since it is quite uncertain as to what are causes of migraine, there cannot be a clear answer on what factors lead to it.
Pre & post migraine headache
A migraine attack can be divided into distinct stages based on the symptoms of migraine:-
â— Prodrome stage: It occurs before the onset of most of the migraine attacks and can last for a few hours or days. Symptoms include :
â—‹ Irritability
â—‹ Depression
â—‹ Fatigue
â—‹ Yawning (not at a time that you would usually feel sleepy or not preceded by any heavy work to make you tired)
â—‹ Increased need to urinate
â—‹ Food cravings
â—‹ Difficulty in sleeping
â—‹ Nausea
â—‹ Lack of concentration
â—‹ Muscle stiffness
â— These symptoms can serve as “warning signs” for the development of migraine headache and should be noted down diligently in the migraine diary.
â— Aura stage: This occurs in 25% of cases. It lasts for 5 to 60 minutes. It includes :
â—‹ Visual disturbances
â—‹ Temporary loss or blurriness of vision
â—‹ Tingling sensation or numbing of parts of the body
â— Headache stage: Migraine headache occurs for 4 hours to 3 days. Symptoms include :
â—‹ Headache characteristic of migraine (that shall be described later)
â—‹ Nausea and vomiting
â—‹ Dizziness
â—‹ Fatigue
â—‹ Nasal congestion
â—‹ Anxiety
â—‹ Depression
â—‹ Sensitivity to light, smell and sound
â—‹ Neck and muscle stiffness
â— Postdrome stage: It occurs in almost 80% of cases after the migraine headache has passed away and lasts for 1 to 2 days. The symptoms of this stage are :
â—‹ Lack of concentration
â—‹ Lack of comprehension
â—‹ Depression
â—‹ Fatigue
â—‹ Euphoria
â— Types of migraine -
MIGRAINE WITH AURA - Studies show that 25% of people suffering from migraines experience aura. Aura is a sensation felt due to some problem in the brain. When it is felt right before the headache phase sets in, it is called Migraine Aura.
Visual aura is most commonly experienced in migraine sufferers. It consists of positive visual symptoms like -
â— Shimmering
â— Teichopsia (aka fortification spectra) - a slowly expanding area of loss of vision with a shimmering and jagged border that usually lasts for 20 minutes and then there is a return of normal vision
â— Fragmentation of image as if looking at something through broken glass
â— Scotomas - patches of the area with loss of vision moving around in the field of your vision. This can gradually develop into a loss of vision completely on one side or a tunnel vision and lasts for 60 minutes
MIGRAINE WITHOUT AURA - This is the most common form that is encountered in patients who seek medical treatment for migraine headaches. The symptoms of a migraine without aura lies in a spectrum. However, the main symptoms are a long-lasting headache (4 hours to 3 days) of moderate to severe intensity, throbbing nature, and mostly confined to one side of the head (unilateral) which worsens with head movements or any physical activity, loud noise, or bright light accompanied with nausea or even vomiting (in 30% of sufferers). During the attack, the person will prefer to lie still in a quiet dark room. The sufferer feels exhausted after the attack has passed.
CHRONIC MIGRAINE - Chronic migraine is diagnosed when the individual has been suffering from migraine for more than three months during which he or she develops a headache for at least 15 days every month, out of which the headache suffered in at least 8 days should be due to migraine. This usually occurs when a person suffering from episodic migraine does not seek proper headache treatment.
MENSTRUAL MIGRAINE - The female sex hormones, oestrogen and progesterone, seem to have an effect on the regulation of chemicals in the brain that leads to headaches. Normal or slightly higher levels of oestrogen tend to prevent headache, and dramatic decreases in the levels of oestrogen can precipitate a headache.
ABDOMINAL MIGRAINE - It is mostly seen in children aged 5 to 9 years, but it can also occur in adults. The main symptoms of abdominal migraine are abdominal pain, nausea and vomiting. The abdominal pain linked with migraine is characterised by dull pain of moderate to severe intensity that generally occurs at the middle of the abdomen around the belly button. It lasts for 2 hours to 3 days. There are multiple episodes of pain during that period, but the time between each episode is completely free of any symptoms. Majority of children who suffer from abdominal migraine grow up to develop migraine later in life, even if they get proper migraine headache treatment earlier in life.
HEMIPLEGIC MIGRAINE - This type of migraine causes partial paralysis of half of the body and may be accompanied by coma and headache. This is a rare condition which is inherited by an autosomal dominant pattern, that is if one of your parents or a close relative has this type of migraine, there is a high chance that you may have it too. It usually recovers within 24 hours. However, few patients may be left with complications like episodic impairment of movement (episodic ataxia).
ABDOMINAL MIGRAINE - It is mostly seen in children aged 5 to 9 years, but it can also occur in adults. The main symptoms of abdominal migraine are abdominal pain, nausea, and vomiting. The abdominal pain linked with migraine is characterized by dull pain of moderate to severe intensity that generally occurs at the middle of the abdomen around the belly button. It lasts for 2 hours to 3 days. There are multiple episodes of pain during that period, but the time between each episode is completely free of any symptoms. The majority of children who suffer from abdominal migraines grow up to develop migraines later in life, even if they get proper migraine headache treatment earlier in life.
VESTIBULAR MIGRAINE - This type of migraine may or may not include headaches but is characterized by the following symptoms :
â— Vertigo
â— Imbalance
â— Nausea and vomiting
â— When the headache is present, it is of throbbing nature and is associated with sensitivity to light, sound, and smells.
Vestibular migraine sufferers also complain of car sickness and must have developed migraine headaches at some point in their life.
BASILAR MIGRAINE - Here, migraine is associated with aura-type symptoms arising from the brainstem which precede the attack or occur during it. These include :
â— Perioral paresthesia: Abnormal sensation such as tingling or numbness felt around the mouth area
â— Diplopia is seeing a double image of one single object
â— Unsteadiness
â— Reduced levels of consciousness (rare)
Migraine is diagnosed when you have a headache which when untreated, lasts for 4 hours to 3 days along with at least two of the following symptoms :
â— The pain only on one side of the head which may cover both the sides eventually
â— Throbbing type of pain
â— Moderate to severe intensity
â— Headaches worsen on the fast movement of the head or any physical activity
The diagnosis of migraine is mostly clinical and depends majorly on the symptoms you report. The doctor also conducts a few physical examinations to identify any underlying causes for migraine headaches and finding the right headache treatment for it.
â— Routine measurement of blood pressure and temperature with more emphasis on the head and neck area
â— Testing the cranial nerve responses
â— Fundoscopic examination of the eye
â— Assessment of motor skills and reflexes
â— Psychiatric assessment
Seeing a General Physician (GP)
The diagnosis of migraine is mostly clinical and depends majorly on the symptoms you report. The doctor also conducts few physical examinations to identify any underlying causes for migraine headaches and finding the right headache treatment for them.
â— Routine measurement of blood pressure and temperature with more emphasis on the head and neck area
â— Testing the cranial nerve responses
â— Fundoscopic examination of the eye
â— Assessment of motor skills and reflexes
â— Psychiatric assessment
Brain imaging is hardly ever required during the evaluation of a migraine patient. A thorough neurological examination must be done before brain imaging via CT or MRI is considered. CT or MRI (preferred) of the brain is indicated in the following cases:
â— Abnormalities found in neurological tests
â— Sudden onset (within a few minutes) of what feels like the worst headache ever experienced
â— New onset of headache in someone over 50 years of age
â— Any associated diseases
After consultation with your doctor, it is important that you diligently maintain a migraine diary for at least 4 to 5 weeks.
Migraine diary
The best way to track your migraine symptoms is to maintain a diary. This also helps in giving accurate headache history to your General Physician and in obtaining proper headache treatments. You can either write down the information on paper or download tracker apps on your phone. The following data are important to note down:
â— What was the date and time of your headache?
â— What was the duration and severity of the headache?
â— Did you require bed rest? If not, how uncomfortable was it to continue with your daily activities?
â— Did you face any associated symptoms such as aura, nausea, or vomiting?
â— Did you notice any trigger that might have caused the development of the headache? If yes, then what was the trigger?
â— Were there any relieving factors during the attack?
â— Did the pain reduce within 2 hours?
â— Did you take any headache treatment medicines? If yes, then what medicines did you take?
â— What were the meals you took the day of the migraine attack?
â— Did the pain reduce within 2 hours?
â— Did you take any headache treatment medicines? If yes, then what medicines did you take?
â— What were the meals you took the day of the migraine attack?
â— What stage of the menstrual cycle are you in (if you are a woman)?
As easy as this sounds, maintaining a daily migraine diary seems to be quite uncommon since patients do not understand the value of having all the detailed information presented to their doctor and to themselves. The following are the benefits of having a migraine diary :
â— Identifying potential triggers
â— Understanding their headache type
â— Monitoring their response to the migraine headache treatment It is encouraged for migraine patients to make regular entries in the diary irrespective of whether they experienced a headache or not. If no symptoms are seen, even that should be noted. Setting alarms for making these entries at fixed intervals (at least twice a day) should help maintain regularity.
How to get rid of migraine headache?
A migraine attack progresses through distinct stages. Through awareness and making regular entries in your migraine diary, you will be able to get rid of migraine headaches. Identify the warning signs that come with the pre-headache phase such as yawning, food cravings, and increased need to urinate (the whole list has been already given earlier). Once you face these symptoms, you can practice the following to lower your chances of developing the migraine headache :
â— Take preventive medications
â— Avoid or decrease exposure to triggers like smoking, alcohol, etc.
â— Meditation
â— Relaxing habits
How to cure migraine headaches permanently?
“Is migraine curable?” is a common question asked by patients. A permanent cure for migraine headaches is yet to be found. Treatments for acute attacks of migraine that can help relieve you of symptoms when they occur is as close an answer you can get to the question: How to cure migraine? Migraine suppression treatments can reduce the number of times you experience these attacks. These migraine headache treatments can have optimum results only with full cooperation from the patient since complete adherence to a regular routine along with maintenance of a migraine diary increase the efficiency of the medications.
How to treat migraine headache?
Acute Treatment of migraine
The medicines for acute treatment of migraine attacks must be taken as soon as the headache starts as it gives instant migraine relief
â— Triptans (like Sumatriptan) are specific medications for migraines, especially when analgesics fail to treat the headache and other symptoms. Vomiting is commonly associated with migraine attacks and sometimes it may not allow the sufferer to take oral migraine headache treatments. Subcutaneous injections of Sumatriptan can be used in such cases. However, these medicines should not be used if you have any disease of the blood vessels. The most common side effects faced are dizziness, dryness of mouth, nausea, and headache.
â— NSAIDs can be taken for mild and infrequent migraine attacks. They are available as over-the-counter (OTC) drugs in combination with acetaminophen and caffeine. The most common side effects are bloating burning sensation and discomfort in the upper abdomen and other gastrointestinal problems.
â— Analgesics like Paracetamol or Acetaminophen are never the first choice of drugs to be used as they are not as efficacious as NSAIDs or Combination analgesics.
â— Ergotamine derivatives like Dihydroergotamine may be used but it causes side effects like nausea and vomiting, hence must be taken with antiemetics. They are not to be used if you have any heart disease, high blood pressure, kidney or liver problems or if you have used taken Triptans in the past 24 hours.
â— Antiemetics like metoclopramide are used along with the above medications to prevent vomiting
â— CGRP antagonists like Telcagepant which act directly on the calcitonin gene receptor peptide (that is supposed to be related to the development of migraines) are showing good results in treating acute attacks of migraine.
Choices for acute treatment of migraine differ according to the person’s previous drug responses (if any) along with associated conditions that he/she may be suffering from. One should not expect immediate relief, the migraine medications aim to restore normal functioning within 2 hours.
Preemptive Treatment of Migraine headache
Preemptive treatment of migraine headache means to predict the occurrence of migraine in the near future and administer ways to avoid its development.
Once you have identified the potential triggers with the help of your migraine diary, you can practice avoiding them. Consistency in daily routine is of great importance in preventing migraine attacks since any changes during your weekend outings or travels can tend to stimulate your already sensitive central nervous system. The following lifestyle changes can be made to help prevent migraines:-
Stress: It occurs when a person is scared about their ability to face a challenge. Stress is the most commonly reported trigger of migraine. The headache can develop because of the stress or even when that stress is relieved. You can ask someone to stress less but that hardly helps. What one needs to understand are the consequences of stress - how it can cause progression of episodes of migraine to chronic migraine. It enhances the effect of other triggers like inadequate sleeping habits or irregular eating habits. So how can you try to control your stress? Regular exercise, meditation, and yoga, or indulging in relaxing hobbies such as pottery, gardening, or using stress-relieving coloring books.
Adequate sleep: Patients have to get a full 7 to 9 hours of sleep every night. They have to maintain a fixed time to go to bed and wake up. One must not disrupt this schedule on weekends since that makes it tougher to go back to the normal routine again during the rest of the week. Bed rest during attacks should only last for as long as the head pain occurs. This should not interfere with their normal sleep schedule as frequent daytime resting or sleeping can cause insomnia. If the patient is suffering from any other sleep disorder like sleep apnea, prompt treatment is advised as that can help in improving migraine symptoms. A healthy sleep habit includes keeping electronic devices away from the bed, not touching your phone or laptop for at least 15 minutes before you tuck in bed to sleep, using the bed only to sleep and not to laze around during the day, and definitely keeping food and drinks (except for water) away from the bedroom.
Proper Diet: Many believe that there are particular food items that trigger migraine attacks, however, there is no substantial evidence to prove that. What is more important is to have regular meals at fixed times and not skip meals. One should have three meals daily - breakfast, lunch, and dinner - which should be evenly spaced throughout the days. Alcohol leads to dehydration that can trigger a migraine, hence drinking in moderation should be practiced.
Weight Loss: It is mostly seen in women of reproductive age that obesity is associated with migraine. Studies have shown that weight loss helps in reducing migraines.
Preventive Treatment of Migraine
Migraine suppression treatment is prescribed to the ones who suffer from more than 1-2 attacks per month since such frequent attacks can take a toll on one’s daily life, which makes migraine curable to an extent. The aim is to reduce the frequency and severity of migraine attacks over the course of 3 to 6 months of medications, a reduction that shall last even after the medicines are stopped. Following are the preventive migraine treatment options:
Anticonvulsants like Valproate or Topiramate have proven to be the most efficacious in preventing migraine attacks. Topiramate is especially useful in reducing the effects of chronic migraines. They are not to be used if you have liver problems, kidney stones or are planning to get pregnant. Their common side effects are sleepiness, nausea, and paraesthesia, and they can worsen depression in few patients hence are better avoided in them.
Beta-blockers like Propranolol are quite efficacious. The common side effects include feeling drowsy, sleep disturbances, and weight gain.
Tricyclics like Amitriptyline had been considered as the first-line preventive migraine treatment up until recently due to the high rates at which patients refused to continue this treatment. This was because of its side effects like sedation and weight gain. As you may know, patients suffering from depression can also be treated with tricyclic antidepressants but the dosage prescribed for fighting migraine symptoms, especially sleep disturbances was way less than that used to treat depression.
Triptans like Frovatriptan are used mainly in menstrual migraine for short-term prophylaxis.
Botulinum toxin has been approved by the Food and Drug Administration (FDA) in the United States, Canada, and the United Kingdom to be used in the prevention of chronic migraine disease. However, it is not much commonly used in India.
Calcium antagonists like flunarizine are used in refractory patients. Pizotifen is rarely used anymore.
Medicines - Following are the effective homeopathic medicines for migraine headache treatment:
Belladonna: for headaches with the feeling of head fullness, and sensitivity to noise and light.
Bryonia: for a heavy or "splitting" headache that covers one eye or spreads to the entire head and worsens on moving any part of the body, even the eyeballs. This is usually accompanied by nausea and vomiting, the fullness of the stomach, and thirst.
Gelsemium: for headaches triggered by stress
Glonoinum: for headaches with a sudden onset and aggravated by heat
Ignatia: for migraines that occur in emotionally sensitive people. In such cases, the headache may feel like a nail is being driven into the head, and is associated with muscle and neck stiffness. Sometimes, there may be increased yawning, weeping, or laughing in these cases
Iris versicolor: for intense migraines with the blurring of vision, where the pain extends to the entire area of the face. Such a condition is seen to worsen with rest and gets better on moving. It is mostly associated with vomiting and a burning sensation in the throat and stomach.
Natrum muriaticum: for migraines that worsen emotional stress, exposure to sunlight, eye strain or occur around the time of menstruation. In these cases, the headache tends to feel like "a thousand little hammers were knocking on the brain" and are associated with numbness or tingling feelings in the lips or face before the headache starts., and the eyes are very sensitive to light. The person feels relieved about lying in the dark or sleeping.
Nux vomica: for nausea and digestive troubles associated with migraineSanguinaria: Right-sided migraines with neck and muscle stiffness.
Sepia: Left-sided migraines associated with dizziness and nausea which worsens on missing meals and during menstrual periods or menopause.Silicea (or Silica): for migraines that are triggered by mental stress or occur around the time of the menstrual period, particularly in people who tend to be nervous. Headaches are usually right-sided and worsen from drafts of cold air.
Other remedies include Cimicifuga, Coffea cruda, Cyclamen, Kali phosphoricum, Lachesis, Lycopodium.