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Living with Migraine

Population based studies show that approximately 5% of men and 15-17% of women suffer from migraine headaches. Over 80% of these individuals suffer some degree of headache related disability. There is a high chance that your headaches may be Migraine.

A migraine headache can cause intense throbbing or a pulsing sensation in one area of the head and is commonly accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can cause significant pain for hours to days and be so severe that all you can think about is finding a dark, quiet place to lie down.

Even though these headaches are so common, migraine is still under-recognised and mis-treated, perhaps in part because there are no biological markers or specific tests.

Some migraines are preceded or accompanied by sensory warning symptoms (aura), such as flashes of light, blind spots, or tingling in your arm or leg.

Migraine headaches often begin in childhood, adolescence or early adulthood. Migraines may progress through four stages, including prodrome, aura, headache and post-drome, though you may not experience all the stages.

Migraine without aura is the commonest subtype of migraine. It has a higher average attack frequency and is usually more disabling than Migraine with aura.


What is Aura?

Aura is basically symptoms that may occur before or during migraine headaches. Auras are symptoms that are usually visual disturbances, such as flashes of light. Sometimes auras can also be touching sensations (sensory), movement (motor) or speech (verbal) disturbances. Most people experience migraine headaches without aura. 

Each of these symptoms usually begins gradually, builds up over several minutes, and then commonly lasts for 20 to 60 minutes. 

          Examples of aura include:

               • Visual phenomena, such as seeing various shapes, bright spots or flashes of light

               • Pins and needles sensations in an arm or leg

               • Speech or language problems (aphasia)

          Less commonly, an aura may be associated with limb weakness (hemiplegic migraine).


Is your headache Migraine? 

International headache society(IHS) criteria for diagnosing Migraine without aura.

      A.        At least 5 attacks fulfilling criteria B-D

      B.        Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

      C.        Headache has at least two of the following characteristics:

                    1.   Unilateral location

                    2.   Pulsating quality (Throbbing or varying with heartbeat)

                    3.   Moderate or severe pain intensity- Severity that limits daily activity

                    4. Aggravation by or causing avoidance of routine physical activity (eg. walking or climbing stairs)

      D.    During headache at least one of the following:

                    1.   Nausea and/or vomiting

                    2. Photophobia (Fear of light) and Phonophobia (Fear of sound)

      E.    Not attributed to another disorder

Criteria for diagnosing migraine with aura: These diagnostic criteria are the same as those for migraine without aura, bit they include symptoms of aura as described previously.  

Migraine without aura often has a strict menstrual relationship. Very frequent migraine attacks are now distinguished as Chronic migraine provided that there is no medication overuse.

Migraine without aura is the disease most prone to accelerate with frequent use of symptomatic medication, resulting in a new headache which is described as Medication-overuse headache.


‘Red flags’, that your headaches may not be Migraine.

  •     The first or worst headache of the patient’s life, particularly if the onset was rapid.
  •     A change in the frequency, severity or clinical features of the attack from what the patient has commonly experienced.
  •    The new onset of headache in middle-age or later >40 years. 
  •    The occurrence of a new or progressive headache that persists for days.
  •    The precipitation of head pain by coughing, sneezing or bending down.
  •    The presence of systemic symptoms such as muscle pain, fever, malaise, weight loss, scalp tenderness or jaw claudication.
  •    The presence of focal neurological symptoms, of any abnormalities found on neurological examination, or of confusion, seizures or any impairment in the level of consciousness. 


Investigations: Diagnosis is basically clinical. CT or MRI is required only if red flags as mentioned above are present. 


How severe is your headache?

    Mild attacks: You can continue his or her usual activities with only minimal disruption

    Moderate attacks: Your activities are moderately impaired

    Severe attacks: You are unable to continue your normal activities and can function in any capacity only with severe discomfort and impaired efficiency

    Ultra-severe cases: Headache is prolonged for more than 72 hours with inability to function in any useful capacity. 

How to stay free from Headaches?

One of the most important things in managing your headaches, is to identify the trigger factors and avoiding them. Start with a headache diary to help you keep a track of events before and after headaches. A sample of the headache diary is given below.


Headache diary

Date

Time

(Onset/Relief)

Duration 

Intensity

Scale 0-10

10 Most severe

TriggersMedication & Dose

Relief

Complete/Partial








Preventing attacks

    Trying to identify migraine triggers may help predict an attack and enable you to take preventative action. Some triggers are unavoidable like pregnancy.    

     The following common triggers for migraine have been identified: 

      • Anxiety and emotion: stress can lead to a migraine attack causing the muscles to tense up. 

      • Change in habits or routine can include change in sleeping patterns or routines

      • Food: Regular small meals may help in preventing attacks. If an attack follows up to six hours after eating a particular food try excluding it to see if it is the cause. 

      • Bright lights and noise can cause stress and should be avoided if possible. These are the commonest triggers.

      • Strenuous exercise can be the cause of a migraine attack.


How to manage your headaches?

If you have a mild attack, then you can take over the counter analgesic and rest, and you should be fine. If you have recurrent moderate to severe headaches, then you should see a neurologist. 

Moderately severe attacks can be managed with medications such as belonging to NSAID’s, Sumatriptan, and Ergotamine. Sumatrpitan is among the commonest drug used for migrainous headaches worldwide, either as a single drug or in combinations. Reported side effects of Sumatriptan include sensations of heaviness or tightness in the chest, chest pain, pain in the throat, tingling in the head or limbs, nausea and, in the case of subcutaneous injection, local tingling at the injection site. These side effects are usually self-limiting, but in some patients they may preclude the use of this medication. Patients with cardiac risk factors, cardiac disease or uncontrolled hypertension must not take Sumatriptan.

Very severe attacks may need visit to emergency medical center. 


Do you need prophylaxis?

The principle underlying a prophylactic treatment regimen is to use the least amount of the medication with the fewest side effects to gain control of the symptoms until the preventive treatment can be permanently stopped. The use of prophylactic treatment is indicated if (a) the migraine attacks are severe enough to impair the patient’s quality of life or (b) the patient has 3 or more severe migraine attacks per month that fail to respond adequately to abortive or symptomatic therapy. 

Common medications used for headache prevention are Metoprolol, Propanolol, Flunarizine, Valproate, and Topiramate. Different individuals may have different response to medication.


Important points to remember

   • Management of migraine is a team approach, the patient being the most important member of the team.

    • Patient should understand the diagnosis and nature of migraine.

    • Patient should understand helpful “non pill” therapy, such as the avoidance of triggers and the use of ice, which may be used along with their medication. 

    • Patient should understand the nature of the medication prescribed, as well as its possible side effects, interactions with other medications and any contraindications (e.g., pregnancy). 

    •   The patient should keep a diary in order to record medications used, dosages, responses to and evaluation of treatment, including side effects, and over-the- counter or other medications being used. The patient should share this information with the physician. 

   •  The prophylactic medications should not be expected to work immediately; some take 1–2 months to work, especially calcium-channel blockers. 

   • The patient should be prepared to expect some side effects, to take medication daily and to recognise that the physician may have to change the medication. 

   • The patient should expect some migraine attacks, although they will probably be less severe or less frequent than previously experienced. 

   • Prophylactic medications are designed to be used for a number of months and then discontinued. For the few patients with difficult headache problems, however, longer term use  may be necessary. 

   • The patient should not use headache medications other than those prescribed, including over-the- counter headache medications; excessive use of other analgesics and over- the-counter medications may reduce the effectiveness of the prophylactic medications. 

   • The patient should report if they become pregnant or are contemplating pregnancy.