Common and Classical Migraine

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Overview

Migraine is a collection of symptoms that usually includes headache as the prominent complaint. Sometimes called "sick headache," "weekend headache," and other names, it is very common and most people know someone who has suffered from migraines or has migraines themselves. The headache is usually severe, on one side of the head, and, in about 1 out of 5 people, it is accompanied by other symptoms. Migraine headaches are typically divided into those with or without a warning (aura).

Interestingly, migraine symptoms can occur without a headache. In many instances, it affects many members of the same family. In fact, the inheritance of migraine is an area of exciting research as its cause.

Migraine is what is called a diagnosis of exclusion. In other words, everything else has to be ruled out prior to the diagnosis of migraine.

Immediately seek medical attention if you or someone you are caring for experiences any of the following:

  • Stiff neck and a high fever associated with headache
  • Sudden onset of a severe headache
  • Loss of motor function, the ability to think clearly, or convulsions associated with headache
  • Head injury
  • Increased intensity and/or frequency of headaches

Who's at risk?

  • Migraines affect up to 17% of women and 6% of men.
  • There is often a strong family history.
  • Children may get migraines, but the peak age of onset is about age 30.
  • Episodes often occur throughout a person's life, but it is not uncommon for migraine attacks to stop in late adulthood.
  • There is a type of migraine that starts after age 50, with no previous episodes.
  • For many women, migraines occur in a monthly pattern related to the menstrual cycle.
  • The most common type of migraine is without aura, or warning.

Signs and Symptoms

Headache is the most common complaint, and it usually occurs on one side of the head. The pain is described as severe, sharp, and often throbbing.

There may be a warning that the headache is about to start, beginning hours to minutes before the pain. The most common warning includes changes in vision, described as flashing lights or shimmering. It is difficult to see through these visual changes, which often start 10–15 minutes before the head pain, and can travel and expand in the visual fields as this stage progresses. These vision changes usually stop when the headache starts. Some people notice a change in personality before the headache starts. They may be distractible, irritable, or otherwise feel like they are "not themselves" for several hours ahead of time.

During the headache there may be nausea and even vomiting. There is often hypersensitivity to light and sound. There can be weakness in an arm or leg, or loss of sensation or other symptoms that can be confused with a stroke (so-called a "complicated migraine"). The migraine can last for several hours. Sleep often breaks the cycle, and the headache is gone on awakening. After the attack, many people feel drained, have a mild headache, and describe this stage as a "migraine hangover."

Self-Care Guidelines

During the attack:

  • Acetaminophen, ibuprofen, and other over-the-counter pain remedies can be helpful to stop the migraine once it starts.
  • Some migraines respond well to caffeine, so a couple cups of coffee may help stop an attack in some people. Note that some over-the-counter headache remedies also have caffeine in them (eg, Excedrin® Migraine).
  • Rest, quiet, and protection from light and noise are helpful for some people.

To prevent an attack:

  • Avoiding certain foods can help. Both caffeine and caffeine withdrawal can be problems for people who get migraines. In addition, many foods, including those listed below, could be eliminated as an experiment.
    • Red wine
    • Cheese
    • Nuts
    • Foods with nitrates or nitrites (ie, preserved meats)
    • Artificial sweeteners
  • Keep a headache diary – Compare the foods you have eaten with the days that you have a migraine.
  • Practice relaxation techniques – There is some evidence that learning how to trigger a relaxation response can help to reduce headache frequency.

When to Seek Medical Care

  • If it is the first time you have ever had this type of headache.
  • When you experience sudden onset of a severe headache over several minutes.
  • If you are disoriented, confused, lose consciousness, or have a seizure.
  • If the severe headache occurs during intense effort (eg, lifting something heavy, bearing down during a bowel movement, or during sexual intercourse).
  • If this is a new or progressive headache and you are over 50 years old.
  • If you have a new headache associated with some other infection.
  • If the headache persists more than several days.
  • If the nausea and vomiting are preventing proper fluid intake.

Treatments Your Physician May Prescribe

There are 2 classes of treatments that are typically used in migraines:

  • Abortive treatment – to stop the headache once it has started.
  • Preventative, or prophylactic, treatment – to prevent headaches from occurring in the first place.

Abortive treatment:
Any treatment that is prescribed to try to stop the headache once it has started is called an abortive therapy. Medicines related to aspirin (do NOT give aspirin to any child aged 18 years or younger) and ibuprofen can be effective, but probably the most commonly used type of abortive treatment is called the "triptans." These include sumatriptan (Imitrex) and similar medicines. In most cases, abortive treatments should be taken as soon after the headache begins as possible in order to be effective. Obviously, for extremely brief headaches abortive treatments are not very effective. The other problem is that any treatment that can be used to stop a headache can also create a cycle of return of the headache, or rebound, once the medicine has worn off.

Prophylactic treatments:
Prophylactic, or preventative, treatments are used every day to try to stop the headache from starting in the first place. Certain kinds of blood pressure medications were found to be very effective in this way and are still used regularly. In addition, many antidepressants and anticonvulsants can also act to prevent headaches. These are medicines that must be taken every day, whether a headache occurs or not.