Neurological Disorders: Migraine Headache

What is migraine-headache?

Migraine headache is one of the commonest types of primary headaches (means no secondary causes like tumors etc are identifiable). This neurological disorder is characterized by recurrent episodes of severe headache, either one sided or diffuse. Women are affected more than men.

Causes of Migraine Headache

The exact mechanism that triggers & maintains migraine is still not completely resolved, however various hypotheses including, neuro-chemical like serotonin, substance P, vascular & neural theories have been postulated.

Migraine Headache may be triggered by various factors including certain food stuff, preservatives, stress, sleep deprivation etc.

What are the different types of Migraine-Headache?

Classified based on the usual types seen in the clinical practice;

• Classical
• Common
• Complicated
• Retinal
• Basilar
• Abdominal
• Probable
• Hemiplegic
• Migraine equivalents etc.

The details are given later.

How does patient present?

• Headache
• Prodromal symptoms
• Aura symptoms
• Nausea and vomiting
• Photophobia (light bothering)
• Phonophobia (sound bothering)
• Vertigo (spinning sensation) or dizziness
• Malaise (sick) feeling
• Generalized weakness etc.

Migraine headache is characterized by severe and recurrent episodes of headache usually lasting between 4 and 72 hours (3 days). In about 50% of patients, protean vague symptoms like mood changes, irritability etc occurs prior to the onset of headache and called as prodromal symptoms.

Migraine aura is typically seen in classical migraine patients and it differs from the prodromal symptoms by its occurrence just before the headache & the experience of well defined symptoms like visual phenomena e.g. zigzag bright lines, scintillating light patterns etc.

Classical migraine:

In this type the headache is typically unilateral and throbbing in nature and frequently associated with aura.

Common migraine:

Here the headache may occur on both sides and in a diffused manner.

In both types the severity varies but generally on a scale of 1 to 10, majority of the sufferers’ claim 7 to 10. Nausea and vomiting are frequently seen. Light and sound may bother them. Dizziness, weakness, malaise may accompany the headache too.

Complicated migraine:

This presents with headache as above and a prominent neurological deficit like a stroke for example (paralysis of a limb).

Retinal migraine:

This is characterized by headache and recurrent episodes of temporarily decreased vision or blindness in one eye.

Basilar migraine:

This subtype usually occurs in younger people especially young women or children and headache is accompanied with varieties of symptoms like double vision, speech difficulties, dizziness, swallowing problems, spinning sensation in the head etc.

Abdominal migraine:

This is typically seen during childhood although very rarely can affect the adults too. Severe recurrent episodes of abdominal pain with or without vomiting are the usual presentation. Of course the abdominal investigations like ultrasound, CT/MRI, endoscopy etc should come normal, means there should not be another identified cause for patient’s belly symptoms.

Probable migraine:

This term is used when patient’s symptoms are suggestive but not confirmatory for a migraine episode.

Hemiplegic migraine:

In this type, patients during their headache experience foal neurological deficits in the form of paralysis of limbs (hemiplegia) on one side of the body. If there is a family history it is called as familial hemiplegic migraine, if no family history then sporadic hemiplegic migraine.

Migraine equivalents:

This term is used when a patient experiences a symptom or group of symptoms that are typical for migraine, however without a prominent headache.

They occur episodically and symptoms like visual auras, sensory/motor complaints, confusion, dizziness or vertigo etc are usually the experienced by the patient.

Diagnosis

The diagnosis of migraine headache is essentially a clinical one. Some times investigations like a CT or MRI of brain, certain blood tests, CSF (cerebrospinal fluid) analysis, angiogram etc may be ordered if the clinical picture is not typical. In migraine these investigations are expected to come normal unless patient has more than one health condition.

Treatment

The treatment is done usually at these four levels;

• Migraine trigger factors
• Acute migraine
• Status migranosus
• Chronic migraine (preventive)

If patient can identify any migraine precipitating factors like stress, sleep or food deprivation, certain food item like cheese, chocolate etc then they are to be avoided as much as possible.

For the acute severe migraine attack the following medications may be tried;

• Triptan group of drugs like sumatriptan
• Ergot group of drugs like ergotamine
• NSAIDs like naproxen

They are generally available as oral preparations and some of them as nasal sprays, injections, suppositories etc. Patients who have nausea and/or vomiting are treated with medications like promethazine, procholorperazine etc.

Some patients have responded to haloperidol slow intravenous infusion when other agents didn’t help much.

Status migranosus are severe recurrent or almost non stopping migraine-episodes that do not respond much to the usual agents like triptan, ergots etc.

These patients are usually treated with a course of steroids (e.g. prednisolone). Intravenous ergotamine is some time tried in a hospital setting, and these patients require medications to prevent vomiting as it is a frequent side effect of intravenous ergotamine.

If the patient is experiencing frequent episodes the preventive treatments may be required.

The following agents are usually tried;

• Beta blockers like prpranolol
• Anti convulsants like sodium valpoate, topiramate
• Calcium channel blockers like verapamil etc

A Neurologist is frequently involved in the care of these patients.

Migraine Headache to Neurology Articles

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