Migraine Headache

This is the second most common headache and occurs with an average frequency of about 12% in the general population. Women outnumber men in the U.S. by a factor of 3 to 1 with migraines. There is a genetic factor as migraine sufferers' family members are getting migraines about 3-fold more often than the general public.

Symptoms

Migraines present in 85% without an aura (formerly called "common migraines") and in 15% with an aura (formerly called "classic migraines"). An aura consists of changed behaviors such as pacing, yawning, craving for certain foods, lethargy, depression or mild euphoria. These symptoms are separate from the migraine aura, which consists of neurological symptoms such as visual symptoms that come on 1 or 2 hours before the migraine headache starts and disappear about 1 hour after the start of the migraine.

These migraine aura symtoms are quite varied and can include numbness of the skin in a hand or a foot on the side where the migraine is and around the mouth area. Spotty eye field defects can also occur immediately prior to the onset of the headache and there may be deficits in language expression and pronunciation. Other such migraine aura symptoms can consist of double vision, ringing in the ears, balance problems, gait problems and decreased levels of consciousness.

The actual migraine headache is on one side of the head, can last 4 hours to 3 days, is throbbing in nature, moderately to severe in intensity and is made worse by physical activity, light or noise. The patient is complaining of nausea and might be vomiting with a severe migraine. In a small percentage of patients a more severe form of complicated migraine (or "migraine with prolonged aura") can develop where the patient has prolonged symptoms of a migraine aura for more than 1 hour, but usually less than 1 week. These patients should be investigated thoroughly by a neurologist as a small percentage of these patients can develop persistent neurological symptoms including a "migrainous infarction" (=a stroke like clinical picture) (Ref. 1, p. 2067).

Treatment

Medication that is used is quite different between attacks as compared to during an attack. During a migraine attack non steroidal anti-inflammatory drugs (=NSAIDs) and dihydroergotamine or sumatriptan, which stimulate serotonin receptors, are used. Drug dependency issues on narcotics has to be discussed frankly with the patient because of the danger of rebound migraines that are triggered by the contiued use of narcotics. Sumatriptan can be given intranasally, but overuse and dependency on this medication also must be monitored by the physician and in males there is a higher risk for heart attacks as a side-effect of the medication. Prochlorperazine (brandname: Stemetil) can be given intravenously in the Emergency Room as a drip and can abort a migraine.

Between migraine attacks there is a number of preventatives that are effective. They consist of beta-blockers such as propranolol, metoprolol, timolol and others; NSAIDs such as ASA, naproxen or ketoprofen; calcium channel blockers such as verapamil or flunarizine; antidepressants such as amitriptyline.

Gabapentin is the latest medication that has been found useful in several smaller studies. Gabapentin(brand name: Neurontin) releases GABA in some parts of the brain and inhibits the NMDA pain receptors. Dr. Stephen Clarke, Clinical Assistant Professor in the Div. of Neurology of the University of BC/Vancouver/Canada, reviewed the use of gabapentin at a conference in Vancouver/BC in November 2004 (Ref. 10).

Other medication for headache prevention are the anticonvulsant gabapentin; the MAO inhibitor phenelzine and the serotonin stimulating drugs methysergide and cyproheptatine. Unfortunately many of these medications do not work 100% and there is a lack of good randomized studies to prove effectiveness. It is important to include in the regimen of anti-migraine measures non drug regimens such as avoidance of triggering factors like certain foods (chocolate, red wine, certain cheeses and strong smells) or bright lights and noises. Consistent sleeping patterns and meal times need to be established. Counseling when emotional factors play a role, relaxation techniques like yoga, self hypnosis and biofeedback methods are all helpful as well. The more complex cases should be referred to a neurologist or even a multidisciplinary headache clinic.

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Neurological Disease

Common Causes of Headaches

Disclaimer

This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor. However, the responsibility of treatment stays in the hands of your doctor and you.

References

1. Goldman: Cecil Textbook of Medicine, 21st ed.,2000, W. B. Saunders Company

2. B. Sears: "The top 100 zone foods". Regan Books, Harper Collins, 2001.

3. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 176.

4. Noble: Textbook of Primary Care Medicine, 3rd ed.,2001, Mosby, Inc.

5. Goroll: Primary Care Medicine, 4th ed.,2000, Lippincott Williams & Wilkins

6.Rosen: Emergency Medicine: Concepts and Clinical Practice, 4th ed., 1998, Mosby-Year Book, Inc.

7. Ruddy: Kelley's Textbook of Rheumatology, 6th ed.,2001, W. B. Saunders Company

10. The 50th Annual St. Paul's Hospital Continuing Medical Education Conference for Primary Physicians, Nov. 16 - 19, 2004

Last Modified: Dec. 24, 2007