Migraine Headache

Some people call any bad headache a “migraine,” but that’s not the case.  Migraine is a very specific type of headache, & is helped by its own special class of medicine.  Nobody really knows what causes it, though there are several theories.  It often runs in families.

Above all, migraines are cyclical headaches.  They come, go, and recur.  An attack typically lasts more than four, & less than 72, hours.  Of course, there are also what are called “Atypical Migraines,” which act differently (last longer, symptoms are variable, etc.), but are relieved by regular migraine treatment.

The International Headache Society (IHS) diagnoses Migraines if:

  • Two of the following four characteristics: 1) pulsating, 2) unilateral (one side of head only), 3) moderate or severe intensity, 4) exacerbated by normal activity; and also
  • At least one of the following two characteristics: 1) nausea / vomiting, or 2) photophobia plus phonophobia [both light & sounds make the discomfort much worse].

Up to 60% of migraine sufferers get a prodrome 1-2 days before the headache, consisting of mood changes, perhaps increased yawning.ย  Up to 25% have an aura, various visual or other strange sensations, lasting 5-60 minutes immediately before the headache starts.

Many people with migraines can identify triggers.  Some of the most common ones are stress, menstrual periods (before, during, or after), hunger, weather, poor sleep, odors, lights, alcohol, smoke, and others.  Birth control pills that contain estrogen can bring out migraine, but a woman with migraines can still take them if she’s <35, the estrogen dose  is low, & her migraines don’t get worse.

Head CT scans & MRIs arenโ€™t necessary unless an examiner finds actual abnormalities on physical exam (possible with a simple migraine, but quite unusual).  The IHS requires five episodes before a migraine diagnosis can be made, but this is mainly for research purposes.  If a patient has had at least 2 episodes (proving recurrence), a โ€œtreatment trialโ€ may help.

โ€œTreatment Trialโ€ is really a diagnostic trial, of therapy.  If a medicine helps, thatโ€™s probably what you have.  But of course, placebo helps too, so clinicians who order treatment trials should maintain a certain degree of healthy intellectual skepticism.

For migraines, there are 3 possible treatments:

  • โ€œAbortive therapy,โ€ taken at the immediate onset of headache (or during the aura, if present), to stop it then-and-there.  We call these medications โ€œtriptans;โ€ the first such was sumatriptan, & all subsequent generic names have the same root.
  • Prophylaxis, taken every day, to prevent a migraine from occurring.  This is useful for people with very frequent attacks.  Some of the possibilities include โ€œCalcium Channel Blockersโ€ [verapamil, & others], โ€œBeta-Blockersโ€ [propranolol, & others], or โ€œTricyclic Antidepressantsโ€ (nortryptilene, & others).
  • Simple Pain Medicine, like acetaminophen or NSAID medications.  If these work well, they may be all a patient needs.  They can also be taken along with the two strategies above.

Treatment Trials should aim for maximum dose of medication, building up to it as tolerated.  If you just try a low dose, and it doesnโ€™t work, youโ€™ll never know if more actually might have helped.

Whether or not migraines can cause a Stroke is still debatable.  If so, the risk is very low.

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