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Dr. SHASHI BHUSHAN KUMAR

MBBS,MD(PSYCHIATRY) - AIIMS

Consultant Neuropsychiatrist & Deaddiction Specialist

MIGRAINE

What is Migraine?

Migraine is a condition that causes episodes ('attacks') of headaches. Other symptoms such as feeling sick (nausea) or vomiting are also common. Between Migraine attacks, the symptoms go completely. There are two main types of Migraine:

➙ Migraine without aura - sometimes called Common Migraine.

➙ Migraine with aura - sometimes called Classic Migraine.

Who gets Migraine ?

Migraine is common. About 1 in 4 women, and about 1 in 12 men, develop Migraine at some point in their life. It most commonly first starts in childhood or as a young adult. Some people have frequent attacks - sometimes several a week. Others have attacks only now and then. Some people may go for years between attacks. In some cases, the Migraine attacks stop in later adult life. However, in some cases the attacks persist throughout life.

WHAT ARE THE SYMPTOMS OF A MIGRAINE ATTACK ?

Migraine without aura


This is the most common type of Migraine. Symptoms include the following.

The headache is usually on one side of the head, typically at the front or side. Sometimes it is on both sides of the head. Sometimes it starts on one side, and then spreads all over the head. The pain is moderate or severe and is often described as 'throbbing' or 'pulsating'. Movements of the head may make it worse. It often begins in the morning, but may begin at any time of day or night. Typically, it gradually gets worse and peaks after 2-12 hours, and then gradually eases off. However, it can last from 4 to 72 hours.

Other symptoms that are common include: feeling sick (nausea), vomiting, you may not like bright lights or loud noises, and you may just want to lie in a dark room.

Other symptoms that sometimes occur include: being off food, blurred vision, poor concentration, stuffy nose, hunger, diarrhea, abdominal pain, passing lots of urine, going pale, sweating, scalp tenderness, and sensations of heat or cold.

Migraine with aura

About 1 in 4 people with Migraine have Migraine with aura. The symptoms are the same as those described above (Migraine without aura), but also include an aura (warning sign) before the headache begins.

➙ Visual aura is the most common type of aura. Examples of visual aura are: a temporary loss of part of vision, flashes of light, objects may seem to rotate, shake, or 'boil'.

➙ Numbness and 'pins and needles' are the second most common type of aura. Numbness usually starts in the hand, travels up the arm, and then involves the face, lips, and tongue. The leg is sometimes involved.

➙ Problems with speech are the third most common type of aura.

➙ Other types of aura include: an odd smell, food cravings, a feeling of well-being, and other odd sensations.

One of the above auras may develop, or several may occur one after each other. Each aura usually lasts just a few minutes before going, but can last up to 60 minutes. The headache usually develops within 60 minutes of the end of the aura, but it may develop while the aura is still present. Sometimes, just the aura occurs and no headache follows. Most people who have Migraine with aura also have episodes of Migraine without aura.

Phases of a Migraine attack


A Migraine attack can be divided into four phases:

➙ A 'premonitory' phase occurs in up to half of people with Migraine. You may feel irritable, depressed, tired, have food cravings, or 'just know' that a Migraine is going to occur. You may have these feelings for hours or even days before the onset of the headache.

➙ The aura phase (if it occurs).

➙ The headache phase.

➙ The resolution phase when the headache gradually fades. During this time you may feel tired, irritable, depressed, and may have difficulty concentrating.

Do I need any tests ?

Usually not. There is no test to confirm Migraine. A doctor can be confident that you have Migraine if you have the typical symptoms. However, some people with Migraine have non-typical headaches. Sometimes tests are done to rule out other causes of headaches. Remember, if you have Migraine, you do not have symptoms between attacks. A headache that does not go, or other symptoms that do not go, are not due to Migraine.

Tension Headaches are sometimes confused with Migraine. These are the common headaches that most people have from time too time. Note: if you have Migraine, you can also have Tension Headaches at different times to Migraine attacks.

What causes Migraine ?

The cause is not clear. One theory is that blood vessels in parts of the brain go into spasm (become narrower) which may account for the aura. The blood vessels may then dilate (open wide) soon after, which may account for the headache. The blood vessels then gradually return to normal. This is not the whole story, and it is now thought that some chemicals in the brain increase in activity in addition to any blood vessel changes. It is not clear why people with Migraine should develop these changes. However, something may 'trigger' a change in your brain to set off a Migraine attack.

Migraine is not a strictly inherited condition. However, it often occurs in several members of the same family. So, there may be some genetic factor involved which makes you more prone to developing Migraine.

What are triggers ?

Most Migraine attacks occur for no apparent reason. However, something may trigger Migraine attacks in some people. Triggers can be all sorts of things. For example:

➙ Diet. Dieting too fast, irregular meals, cheese, chocolate, red wines, citrus fruits, and foods containing Tyramine (a food additive).

➙ Environmental. Smoking and smoky rooms, glaring light, VDU screens or flickering TV sets, loud noises, strong smells.

➙ Psychological. Depression, anxiety, anger, tiredness, etc.

➙ Medicines. For example, Hormone Replacement Therapy (HRT), some sleeping tablets, and the Oral Contraceptive Pill (OCP).

➙ Other. Periods (menstruation), shift work, different sleep patterns, the menopause.

It may help to keep a migraine diary. Note down when and where each Migraine attack started, what you were doing, and what you had eaten that day. A pattern may emerge, and it may be possible to avoid one or more things that may trigger your Migraine attacks.

What are the treatment options for Migraine ?

➙ A. PAINKILLERS

Paracetamol or aspirin work well for many Migraine attacks. (Children under 16 should not take Aspirin.) Take a dose as early as possible after symptoms begin. If you take painkillers early enough, they often reduce the severity of the headache, or stop it completely. A lot of people do not take a painkiller until a headache becomes really bad. This is often too late for the painkiller to work well. The only solution may then be to find a quiet, dark room to 'sleep it off'.

Take the full dose of painkiller. For an adult this means 900 mg Aspirin (usually three tablets) or 1000 mg of Paracetamol (usually two 500 mg tablets). Repeat the dose in four hours if necessary. Soluble tablets are probably best as they are absorbed more quickly than solid tablets.

➙ B. ANTI-INFLAMMATORY PAINKILLERS

Anti-inflammatory painkillers probably work better than Paracetamol or Aspirin to ease a Migraine. (Although, strictly speaking Aspirin is an anti-inflammatory painkiller.) They include Ibuprofen which you can buy at pharmacies or get on prescription. Other types such as Diclofenac, Naproxen, or Tolfenamic Acid need a prescription.

➙ C. DEALING WITH NAUSEA AND SICKNESS

Migraine attacks may cause nausea (feeling sick) or vomiting. The nausea causes poor absorption of tablets into your body. If you take painkillers, they may remain in your stomach and not work well if you feel sick. You may even vomit the tablets back. Tips that may help include:

Use soluble (dissolvable) painkillers. These are absorbed more quickly from your stomach and are likely to work better.

You can take an anti-sickness medicine with painkillers. A doctor may prescribe one. Like painkillers, they work best if you take them as soon as possible after symptoms begin.

An anti-sickness medicine is available as a suppository if you feel very sick or vomit during Migraine attacks. A painkiller suppository is also available.

➙ D. COMBINATIONS OF MEDICINES

Some tablets contain both a painkiller and an anti-sickness medicine. For example, Vasograin, and Domcet. They may be convenient. However, the dose of each constituent may not suit everyone, or be strong enough. You may prefer to take painkillers and anti-sickness medicines separately so that you can control the dose of each.

➙ E. TRIPTAN MEDICINES

A triptan is an alternative if painkillers do not help. These include: Almotriptan, Eletriptan, Frovatriptan, Naratriptan, Rizatriptan, Sumatriptan, and Zolmitriptan. They are not painkillers. They work by interfering with a brain chemical called 5HT. An alteration in this chemical is thought to be involved in Migraine. Some triptans work in some people and not in others. Therefore, if one triptan does not work, a different one may well do so. Most people who have Migraine can usually find a triptan that works well for most Migraines, and where side-effects are not too troublesome. Do not take a triptan too early in an attack of Migraine. (This is unlike painkillers described above which should be taken as early as possible.) You should take the first dose when the headache (pain) is just beginning to develop, but not before this stage. (For example, do not take it during the premonitory or aura phase until the headache begins.)

➙ Preventing Migraine attacks :-

A medicine to prevent Migraine attacks is an option if you have frequent or severe attacks. It may not stop all attacks, but the number and severity are often reduced. Medicines to prevent Migraine are not painkillers, and are different to those used to treat each Migraine attack. A doctor can advise on the various medicines available

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