Migraine

The main symptom of a migraine is an intense headache, typically on one side of the head. In some cases, the pain may occur on both sides and can affect the face or neck. The pain usually presents as a moderate to severe throbbing sensation that worsens with movement, preventing normal activities. Nausea and vomiting may frequently or infrequently accompany migraine headaches.

The symptoms of migraine vary between individuals. A migraine attack can last from hours to days and typically progresses through four stages:

• Prodromal phase: Also known as the premonitory phase, this stage occurs 24 to 48 hours before the onset of a headache. Common symptoms include increased yawning, irritability, neck stiffness, cravings for specific foods, and depression.
• Aura phase: This phase involves symptoms arising from the nervous system, often affecting vision. Symptoms may last from 5 minutes to a few hours and can include hallucinations, tunnel vision, temporary loss of vision, weakness in arms and legs, ringing in the ears, and changes in speech, smell, taste, or touch.
• Headache phase: This phase often begins as a dull pain that escalates to throbbing pain, which can shift from one side of the head to the other. It can last for more than 3 days and may occur frequently.
• Postdromal phase: Also known as the recovery phase, this stage lasts up to a day after the headache. Symptoms may include fatigue, muscle pain or weakness, and lack of appetite.

Is it a migraine or a headache?

Migraine is more than just a headache. Here’s how to differentiate between a headache and a migraine. The most common features that distinguish a migraine from a headache are summarized as POUND:

• P: Pulsating pain
• O: One-day duration of severe pain if left untreated
• U: Unilateral (one-sided) pain
• N: Nausea and vomiting
• D: Disabling intensity

The precise cause of migraine is unknown, but it is believed to occur due to abnormal brain activity temporarily affecting nerve signals, chemicals, and blood vessels in the brain.

It is unclear what leads to this abnormal activity in the brain, but researchers speculate that genetics may increase the likelihood of experiencing migraines due to specific triggers. Additionally, a higher level of the protein calcitonin gene-related peptide (CGRP) in the blood is reported to cause inflammation and pain in the nervous system, leading to migraine attacks.

You can have migraine or experience migraine attacks with or without the following risk factors. However, the more risk factors you have, the greater your chances of having migraine headaches. These risk factors include:

• Female sex: Women are at a higher risk of suffering from migraines compared to men, although the exact cause is not yet known.
• Family history: Migraines tend to run in families. A child with one parent who has migraines has a 50% chance of inheriting it. If both parents have migraines, the chances may rise to 75%. Research indicates that about 90% of migraines can be attributed to a family history of the condition.
• Lifestyle factors: Several lifestyle factors increase the risk of migraines, including stress, fatigue, smoking, lack of exercise or sleep, medication overuse, and caffeine overuse.
• Health conditions: Common health conditions that can increase the risk of migraine headaches include obesity and depression.

Female gender and family history are non-remedial risk factors, meaning they are beyond individual control. However, individuals can seek help for medical conditions and make lifestyle changes to reduce their risk of experiencing migraines.

There's no specific test to diagnose migraines. To determine if you have migraines, your doctor will identify a pattern of recurring headaches along with the associated symptoms. You may need to be patient with your doctor, as it may take some time to confirm the final diagnosis.

Clinical History and Examination

During your first visit, after analyzing your detailed medical history, your doctor may check your vision, coordination, reflexes, and sensations. This will help rule out or confirm other possible underlying causes of your symptoms or conditions causing headaches.

Your doctor may ask if your headaches are:

• On one side of the head
• Pulsating pain
• Severe enough to prevent you from carrying out daily activities
• Made worse by physical activity or moving about
• Accompanied by nausea and vomiting
• Accompanied by sensitivity to light and noise

Note: If you have headaches that are suspicious, your doctor might request a CT or MRI of the brain to rule out other disorders that can cause headaches resembling migraines.

One of the best ways to prevent migraine attacks is by avoiding the triggers. Some suggestions include:

• Have your meals at the same time every day.
• Track the triggers that initiate migraine pain and try to avoid them.
• If weather conditions are unfavorable, stay at home and adjust your schedule accordingly.
• Ensure adequate sleep for at least 7-8 hours in dim or no light.
• Avoid using gadgets before going to sleep.
• Steer clear of bright lights and extreme temperatures.
• Avoid loud music and noisy environments.
• Limit consumption of chocolates, cheese, processed foods, alcohol, and smoking.
• Minimize stress as much as possible.

There are many different medications used to treat and prevent migraines. Natural treatments can also be used as alternatives or to supplement medical treatment. The treatment for migraine is based on the severity of the migraine and the associated symptoms. Non-specific drugs such as analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) are the first choice for mild or moderate migraine. Specific drugs such as ergot derivatives and triptans are recommended for more severe cases, depending on individual requirements. A new class of drugs, calcitonin gene-related protein (CGRP) antagonists and lasmiditan, is used for acute attacks.

1. Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs) are the first choice for migraine treatment. These medications relieve pain by inhibiting the synthesis of prostaglandins, which trigger inflammatory responses. However, some patients may experience gastrointestinal side effects such as dyspepsia, abdominal burning or discomfort, and diarrhea. Common examples of NSAIDs include:

• Aspirin
• Diclofenac
• Ibuprofen
• Naproxen

2. Triptans

This class of drugs is usually advised when other pain relievers, such as NSAIDs, fail to improve symptoms or if the headache is severe. They work by constricting (narrowing) blood vessels in the head, stopping the transmission of pain signals to the brain, and blocking the release of chemicals that cause nausea and other migraine symptoms. Commonly prescribed triptans include:

• Sumatriptan
• Zolmitriptan
• Naratriptan
• Rizatriptan
• Eletriptan
• Almotriptan

3. Ergots

This class of drugs acts as serotonin receptor antagonists. Similar to triptans, they constrict blood vessels in the head, stop the transmission of pain signals to the brain, and block the release of chemicals that cause nausea and other migraine symptoms. They also inhibit the production of pro-inflammatory neuropeptides responsible for migraine pain. Due to vasoconstriction effects, these medications are not advised for individuals with hypertension and heart disease. Examples include:

• Ergotamine
• Caffeine + Ergotamine + Paracetamol + Prochlorperazine

4. Antiemetics

If a migraine is associated with nausea or vomiting, an antiemetic class of drugs is prescribed for effective treatment. It is often prescribed in combination with an NSAID or triptan but can also be used as monotherapy. Common examples of antiemetics include:

• Metoclopramide
• Prochlorperazine
• Metoclopramide + Paracetamol

Patients admitted to an emergency room with severe migraine headaches associated with nausea and vomiting are advised to take sumatriptan or antiemetics/dopamine receptor blockers to manage the condition.

5. CGRP Antagonists

This new class of drug is used to treat and prevent migraine attacks. The medication works by blocking the activity of the protein known as calcitonin gene-related peptide (CGRP), which may cause pain and inflammation that worsen migraine attacks. It is available in the form of an injection. Examples include:

• Erenumab
• Fremanezumab

6. Lasmiditan

This newly approved drug is for the treatment of acute migraine. Lasmiditan acts as a selective serotonin receptor without causing vasoconstriction, unlike triptans. Therefore, this medication can be advised for people with cardiovascular risk factors, heart disease, and those who respond poorly to current migraine treatments. It is available in pill form.

7. Prophylactic Therapy

Certain classes of medicines are used to prevent future migraine attacks. These drugs are given in cases where there are:

• Frequent or long-lasting migraine headaches
• Migraine attacks that cause significant disability or diminished quality of life despite appropriate acute treatment
• Contraindication, failure, or serious adverse effects with therapies used for acute attacks
• Risk of medication-overuse headache
• Menstrual migraine

These drug groups include:

• Beta-blockers such as propranolol, metoprolol, and atenolol
• Antidepressants such as amitriptyline and fluoxetine
• Antiepileptics such as topiramate and sodium valproate
• Calcium channel blockers such as flunarizine and verapamil
• CGRP antagonists like erenumab and fremanezumab (in refractory cases)

It is never advised to self-medicate, as these medicines have a range of harmful side effects. Frequent use of painkillers to relieve migraines could lead to medication-overuse headaches.

1. Watch what you eat

Foods that contain tyramine, a natural amino acid, may trigger your migraine headaches. Some of the foods containing tyramine include aged cheese, nuts, and chicken livers. Below is a list of some examples of foods rich in tyramine that can be consumed with caution or avoided.

• Food groups: Meat, fish, poultry, & eggs
• Use with caution: Sausage, bologna, meats with nitrates or nitrites added.
• Avoid: Aged, dried, fermented, salted, smoked, or pickled products; pepperoni, salami, liverwurst; non-fresh meat or liver; pickled herring.

• Food groups: Dairy
• Use with caution: Yogurt, buttermilk, sour cream.
• Avoid: Aged cheese such as cheddar, Swiss, mozzarella.

2. Build a healthy routine

• Get at least eight hours of sleep daily.
• Exercise regularly.
• Avoid skipping meals and eat small frequent meals throughout the day.
• Stay well hydrated; drink 6-8 glasses of water daily.
• Avoid stress.
• Try muscle relaxation exercises like meditation or yoga.
• Take your medications as advised by your doctor.
• Identify your triggers and try to avoid them.

NOTE: Keep a headache diary to learn about what triggers your migraines and what treatment is most effective.

3. Other home-based solutions

You can try the following options to relieve a migraine headache at home:

• Take some time off: Do not let the fast-paced life take a toll on you. Instead, make sure you take a break and relax right away when you feel a headache coming on.
• Try heat therapy: Place a hot compress, such as a towel soaked in warm water, on your forehead and relax in a dimly lit room.
• Yoga: Yoga asanas that can help relieve tension and ease headaches include seated neck release, viparita karani, adho hastapadasana (standing forward bend), setu bandhasana (bridge pose), shishuasana (child pose), marjariasana (cat stretch), paschimottanasana (two-legged forward bend), adho mukha svanasana (downward facing dog pose), padmasana (lotus pose), and shavasana (corpse pose).
• Massage using essential oils: Gently massage the area where the eyebrows meet and the temples with your knuckles to improve circulation and alleviate headaches. Use essential oils such as peppermint oil, basil oil, and lavender oil.

1. Ayurvedic Remedies

Ayurveda can play a crucial role in managing headaches and improving other symptoms of migraine. You can find all these natural ingredients in your kitchen to help you with migraine. These include:

• Ginger: A well-known remedy for headaches, it reduces inflammation of the blood vessels in the head, thereby relieving headache. Smash ½ an inch of ginger and brew a cup of tea with it. It also aids digestion and reduces the feeling of nausea that occurs during migraines.
• Lemon: Rich in antioxidants, lemon juice soothes irritated sinuses, helping to reduce headaches. Prepare a cup of tea with the juice of a lemon and honey and have it warm. One may also grind the skin of lemons and apply it to the temple for alleviating headaches.
• Pepper: It reduces inflammation and decongests the nose, ultimately helping you breathe freely and get rid of the headache. Try a hot bowl of soup with a dash of ground pepper.
• Cinnamon: Cinnamon reduces the effect of inflammatory markers in blood vessels, thereby decreasing the frequency, severity, and duration of pain attacks. Make a thick paste of cinnamon and water and apply it to the forehead to relieve headache.

Check out some of the common herbs whose benefits have been backed by science for migraine relief. Click here to know more!

2. Acupuncture

Acupuncture is a traditional Chinese medicine therapy that involves inserting thin needles into specific points on the body, known as acupoints, to ease pain. Although the exact mechanism of action is not known, it is believed that this therapy reduces nerve activity to modulate pain response and transmission. Ear acupuncture, a type of acupuncture, is also known to ease migraine pain in people without aura attacks.

3. Neuromodulation Techniques

In this method, electrical stimulation is delivered to targeted sites to alter nerve activity and relieve pain. Single pulse transcranial magnetic stimulation, a noninvasive neuromodulation technique, is the most widely used method to treat migraine pain.

Living with migraine is a daunting task, as not many people realize the extent of pain you endure regularly while maintaining a smiling face. Although it is understandable to feel angry and defeated, training yourself to adopt a positive outlook can help you manage your condition better and improve your quality of life. Moreover, people with migraines often hesitate to come out in the open due to stigma. However, making simple changes in your daily routine can lead to a better and happier life. Here are a few tips that individuals living with migraines can follow to improve their condition and combat migraine attacks.

1. Always be positive
Feeling angry and helpless due to migraines will not help; it may only worsen the condition. Do not let negative feelings harm you. Instead, train your brain to be happy and positive to enhance your well-being.

2. Learn about your condition
Suffering from migraines is not anyone’s fault. Instead of blaming yourself, it is wise to learn and educate yourself about the condition. Consult your doctor about the condition, its medications, triggers, and ways to help yourself or your loved ones combat it.

3. Find the right doctor
Just as obtaining the right medications is crucial for managing a condition, connecting with the right doctor is essential for dealing with migraines. Whether you need to call your doctor during sudden and severe migraine attacks or inquire about medications, your doctor plays a key role in treating your condition and preventing future attacks or complications.

4. Join a support group
The mere idea of sharing your thoughts and talking to someone who understands migraines can provide relief. Joining a support group can be beneficial, as it connects you with others suffering from migraines, allowing you to share concerns or queries with like-minded individuals. Participating in online communities and workshops can help you understand real-life experiences and share your stories.

5. Indulge in self-care
Constantly thinking about migraines can be taxing on your mental health. Instead of burdening yourself with added work at home or in the office, try engaging in various activities to keep yourself occupied. These activities may include listening to music, enjoying time with pets or friends, taking a stroll in a park, or sharing the workload with your partner when stressed. Making these simple adjustments to your daily life can provide significant respite.

It is not justified to frequently change your doctor. While no one can cure migraines, medications can help manage migraine episodes and reduce their frequency.

Regardless of the trigger, it is essential to understand the types of headaches and recognize signs that indicate you should consult a doctor immediately. To learn more about the types of headaches and when to seek medical advice, read the article.

Migraine and comorbidities

1. Migraine and stress: The International Headache Society does not classify stress as a specific type of migraine; however, stress is a known trigger. If you believe stress triggers your headaches, you can try relaxation techniques such as deep breathing, meditation, or yoga to help calm yourself.

2. Migraine and nausea: Nausea is one of the most common symptoms experienced by nearly half of those suffering from migraines. Antiemetic drugs can help manage this symptom, but if you also experience vomiting along with a headache, it is advisable to consult a doctor. Home remedies such as ginger, lemon, and cinnamon may also provide relief.

3. Menstrual-related migraine: More than 50% of women who suffer from migraines experience menstrual-related migraines. As the name suggests, migraines can occur before, during, or after menstruation, often due to sudden hormonal shifts during this time.