Six million migraine attacks occur per year in South Africa.
From 10% to 30% of migraines occur with an aura.
Migraines are more common in adult women than in men.
What are migraines?
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This is the most common type of vascular headache. Migraine headaches can be divided into two main types:
Migraine with aura (classic migraine)
Migraine without aura (common migraine)
From 10% to 30% of migraines occur with an aura, which is a collection of symptoms that usually occurs 15 to 30 minutes before a migraine headache begins. The most common symptoms are visual disturbances, such as flashing lights, distortion in the size or shape of objects (zigzagging), or blind or dark spots in your field of vision. An aura may also include symptoms affecting your nervous system, such as numbness or tingling in your face or arm, strange smells or sounds, or weakness on one side of your body.
Migraines are more common in adult women than in men, often occurring just before or during menstrual periods and usually waning after menopause. A migraine sufferer usually has his or her first attack between the ages of 19 and 30 years.
A migraine may occur several times a week or might only happen once every few years.
What are the causes?
The exact causes of migraines are not clear.
Changes in blood flow are one cause on which researchers and scientists agree.
Family history may play a role in about 75% of cases there is a clear family connection; a migraine sufferer might have an inherited abnormality of the blood vessels. In fact, a family history of migraine is often the most telling clue to its diagnosis.
A correlation between changes in oestrogen levels and migraine suggests that hormones may also play a role.
Recent investigations have linked migraine to fluctuations in a brain transmitter, called serotonin and 5HT. Other research suggests that many migraine sufferers have lower then usual amounts of endorphin the bodys natural painkiller.
Migraine triggers
The key to migraine prevention is migraine prediction. Past experience can teach you what triggers your migraine. Common triggers are:
Weather fluctuations particularly from dry to humid conditions and bright overcast days
Changes in temperature such as when taking a hot bath
Certain drugs (such as the, caffeine and alcohol particularly beer and red wine
Certain foods, in a few people especially preservatives in cured meat, biltong, chocolate, citrus fruits and aged cheeses. Not eating regular meals, skipping meals, or fasting may also trigger migraine headaches in some people.
Stress, though migraine headaches often start during the "let-down" period after a stressful time, such as a weekend or vacation. Curiously, migraines tend to disappear temporarily in times of extreme stress or physical duress (wartime, life-threatening illnesses)
Irregular sleeping habits (sleeping too much or too little) such as "sleeping in" over weekends
Allergies
Glaring or flickering lights (water reflections, television, rave parties)
Smoking cigarettes
What are the symptoms?
The pain of a migraine is felt as an intense, throbbing pain in the forehead, temple, ear, jaw or even around the eye. It usually starts on one side of the head, but eventually spreads to the other side. It is sometimes preceded by an aura. The migraine is often accompanied by other symptoms such as nausea, vomiting and visual disturbances. Each instance lasts two to 72 hours averaging 12 to 18 hours and may be incapacitating enough to disrupt daily activities.
During a migraine attack the body might swell with retained fluid, and appetite wanes. Sufferers feel wretched and often have a strong aversion to noise, light and certain smells.
The end of an attack is marked by a rewarming of the limbs and the return of appetite. There are seldom any after-effects.
Course
During the initial stage of a migraine, the nervous system reacts to a trigger, and causes a spasm in the arteries at the base of the brain, which are rich in nerves. The spasm constricts several arteries which supply blood to the brain and reduces its blood flow. Serotonin, which constricts arteries, is released and further reduces the blood flow to the brain. A reflex vasodilatation sometimes follows this process.
How is a diagnosis made?
The history and physical exam are all that is needed to diagnose migraine headaches. Additional tests are only needed to help diagnose other conditions which may cause similar symptoms. See Diagnosis under Headaches.
Treatment
Medication
Medicine can be used either to relieve symptoms or prevent attacks. Different drugs are used in each approach, but none cure the underlying disorder.
Medication to treat an attack
Medication to prevent an attack
Medication to treat an attack
In most people, migraine headaches can be relieved by a mild painkiller - for example, paracetamol, aspirin or naproxen (NSAID) - if taken in high enough doses and if taken early enough at the time of an attack. Stronger analgesics, containing codeine, are often necessary. If nausea or vomiting accompany the migraine, tablets may not be absorbed sufficiently from the gut. Effervescent tablets or suppositories are then often more effective.
Anti-nausea medication can help to reduce accompanying nausea and vomiting.
Ergot alkaloids (made from a fungus that grows on grain), such as Cafergot or Migril, might help many if taken early enough, but are not effective once the headache is established. In excess, especially with poor timing, these medications may exacerbate rather than alleviate a headache. Ergotamine has a number of side-effects. Care should be taken not to exceed the recommended dose.
Sumatriptan (Imigran) is an effective remedy that works on the serotonin and 5-HT neurotransmitter systems, thought to be involved in migraine. The medication is available on prescription and can be used at any stage of a migraine bringing rapid relief in about half an hour in approximately 80% of patients. It is available in tablet form, by injection (often given by patients themselves), or of recent, in a nasal spray preparation. However, it is expensive and may have adverse effects in those with cardiovascular problems.
Similar-acting drugs which have recently become available, are: Naratriptan (Naramig) Zolmitriptan (Zomig) Rizatriptan (Mexalt)
A new Rapidisc preparation has recently become available in South Africa. The Rapidisc is placed on the tongue and dissolves rapidly.
Narcotics, such as pethidine injections, should be avoided because of the high potential of addiction.
Medication to prevent an attack
If attacks occur more often than three times a month, drugs to prevent attacks should be prescribed. Various prophylactic treatments are available. No one treatment has an advantage over another and its often a case of trial and error to find a drug which is most effective in a particular patient. Drugs to prevent migraine include:
beta-blockers, such as propranolol (i.e. Inderal) which will reduce blood vessel dilatation;
pizotifen (Sandomigran) unfortunately often associated with weight gain;
anti-depressants, such as amitriptyline;
clonidine which inhibits blood vessel contraction and dilatation;
flunarizine (Sibelium) methysergide;
cyproheptadine (Periactin).
Prophylaxis is usually given for up to six months. Treatment is then stopped. In many cases, the attacks do not re-occur, and if they do, it is often with a reduced frequency and severity.
Identifying triggers
Eliminating the foods that could trigger a migraine attack can help a small percentage of migraine sufferers. An anti-migraine diet is structured by means of elimination of known triggers specific to an individual. It is a good idea to keep a migraine diary which will provide useful information regarding the pattern of your headaches.
Other
Relaxation training (where you learn to relax mind and body), can be combined with biofeedback, a technique which can teach people better control over indicators of bodily functions such as blood pressure, heart rate, temperature, muscle tension and brainwaves.
General stress-reducing techniques include: yoga, jacuzzi baths, enjoyable exercise (good choices being swimming and brisk walks), listening to soft music or whatever else helps you to unwind.
Researchers have found that migraine sufferers mentally trained to raise the temperature of their hands developed fewer and less severe headaches.
Applying cold packs can give temporary relief. Pressing on the bulging artery in the temple area can also provide relief.
Caffeine can help to offset an attack - provided it is taken as soon as a migraine attack is expected.
Reviewed by Dr Andrew Rose-Innes, MD, Department of Neurology, Yale University School of Medicine, New Haven.
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