Migraines

Migraines are a complex neurological condition that cause headache and other associated symptoms. They occur in “attacks” that often follow a typical pattern.

There are several types of migraine:

  • Migraine without aura
  • Migraine with aura
  • Silent migraine (migraine with aura but without a headache)
  • Hemiplegic migraine

 

The pathophysiology of migraine has been studied for decades. Various mechanisms and theories have developed. There is no simple explanation for why migraines occur and it may be a combination of structural, functional, chemical, vascular and inflammatory factors.

 

Typical Headache Symptoms

Headaches last between 4 and 72 hours. Typical features are:

  • Moderate to severe intensity
  • Pounding or throbbing in nature
  • Usually unilateral but can be bilateral
  • Discomfort with lights (photophobia)
  • Discomfort with loud noises (phonophobia)
  • With or without aura
  • Nausea and vomiting

Aura

Aura is the term used to describe the visual changes associated with migraines. There can be multiple different types of aura:

  • Sparks in vision
  • Blurring vision
  • Lines across vision
  • Loss of different visual fields

 

Hemiplegic Migraine

Hemiplegic migraines can mimic stroke. It is essential to act fast and exclude a stroke in patients presenting with symptoms of hemiplegic migraine.

Symptoms of a hemiplegic migraine can vary significantly. They can include:

  • Typical migraine symptoms
  • Sudden or gradual onset
  • Hemiplegia (unilateral weakness of the limbs)
  • Ataxia
  • Changes in consciousness

 

Triggers

Migraines can be have specific triggers that are individual to the person. Often it is not possible to identify triggers. Potentially triggers are:

  • Stress
  • Bright lights
  • Strong smells
  • Certain foods (e.g. chocolate, cheese and caffeine)
  • Dehydration
  • Menstruation
  • Abnormal sleep patterns
  • Trauma

 

5 stages

The course of a migraine can be broken down into 5 stages. These stages are not typical of everyone and they will vary between patients. Some patients may only experience one or two of the stages. The prodromal stage can involve several days of subtle symptoms such as yawning, fatigue or mood changes prior to the onset of the migraine.

  • Premonitory or prodromal stage (can begin 3 days before the headache)
  • Aura (lasting up to 60 minutes)
  • Headache stage (lasts 4-72 hours)
  • Resolution stage (the headache can fade away or be relieved completely by vomiting or sleeping)
  • Postdromal or recovery phase

 

Acute Management

Patients often develop their own patterns for helping to relieve their symptoms. Often patients will go to a dark quiet room and sleep. Options for medical management are:

  • Paracetamol
  • Triptans (e.g. sumatriptan 50mg as the migraine starts)
  • NSAIDs (e.g ibuprofen or naproxen)
  • Antiemetics if vomiting occurs (e.g. metoclopramide)

 

Triptans

Triptans are used to abort migraines when they start to develop. They are 5HT receptors agonists (serotonin receptor agonists). They have various mechanisms of action and it is not clear which mechanisms are responsible for their effects on migraines. They act on:

  • Smooth muscle in arteries to cause vasoconstriction
  • Peripheral pain receptors to inhibit activation of pain receptors
  • Reduce neuronal activity in the central nervous system

 

Migraine Prophylaxis

Keeping a headache diary can be helpful in identifying the triggers. Avoiding triggers can reduce the frequency of the migraine. A headache diary is also useful in demonstrating the response to treatment.

Certain medications can be used long term to reduce the frequency and severity of attacks:

  • Propranolol
  • Topiramate (this is teratogenic and can cause a cleft lip/palate so patients should not get pregnant)
  • Amitriptyline

 

Acupuncture is an option recommended by NICE recommend for the treatment of migraines. It is reported to be as effective as prophylactic medications.

Supplementation with vitamin B2 (riboflavin) may reduce frequency and severity.

In migraine specifically triggered around menstruation, prophylaxis with NSAIDs (e.g. mefanamic acid) or triptans (frovatriptan or zolmitriptan) can be used as a preventative measure.

Migraines tend to get better over time and people often go into remission from their symptoms.

 

Last updated April 2019
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