Brain Foundation

Migraine -  ‘a common and distressing disorder’

'Migraine is a common and distressing disorder.  It is not likely to take life but can destroy the quality of life at what might have been its most rewarding moments1.'

Studies have shown the incidence of migraine to be 9-10%, about 17% of the female population and 6% of the male population.  So, about 2 million Australians can be expected to suffer from migraine, about 1.5 million women and about 500,000 men.  It is thought that more women suffer migraine than men due to hormonal factors.

'Onset of migraine is from childhood onwards but most commonly in the 20s and 30s and relatively infrequently after the age of 40; therefore, prevalence increases from the first to fourth decades and thereafter declines.  Migraine may nevertheless be a significant health issue among children2.'

Read more about migraine at Virtual Medical Centre

Symptoms

The International Headache Society classifies a headache as a migraine when:

(a) the pain can be classified by at least two of the following;

  • one sided
  • moderate to severe
  • throbbing
  • aggravated by movement


(b) there is at least one of the following associated symptoms:

  • nausea
  • vomiting
  • photophobia (sensitivity to light)
  • phonophobia (sensitivity to noise)


(c) the headache lasts for between 4 and 72 hours.

Other symptoms that may be experienced include

  • osmophobia (sensitivity to smell)
  • aura (visual disturbances such as bright zigzag lines, flashing lights, difficulty in focusing or blind spots lasting 20-45 minutes)
  • difficulty in concentrating, confusion
  • a feeling of being generally extremely unwell
  • problems with articulation or co-ordination
  • diarrhoea
  • stiffness of the neck and shoulders
  • tingling, pins and needles or numbness or even one-sided limb weakness
  • speech disturbance
  • paralysis or loss of consciousness (rare).

Migraine may occur recurrently over many years or even decades. Frequency may vary greatly in the same person over time, from a few a year up to several a week.

 

Stages of Migraine

Migraine can be divided into five distinct phases:

1. Early Warning Symptoms (prodromol)

A significant number of migraineurs experience warning symptoms for up to 24 hours before the attacks start but may not recognise these signs until they know what to look for.  These symptoms include:

  • changes in mood, varying from feeling elated, on top of the world and full of energy, flying through the day’s work and accomplishing twice as much as usual, to feeling depressed and irritable
  • gut symptoms, nausea, changes in appetite (intense hunger or sugar craving: may consume a whole packet of biscuits or chocolates), lack of appetite, constipation, diarrhoea
  • neurological changes, drowsiness, incessant yawning, difficulty finding the right words (dysphasia), dislike of light and sound, difficulty in eye focus
  • changes in behaviour, hyperactive, obsessional, clumsy, lethargic
  • muscular symptoms, general aches and pains
  • fluid balance changes, thirst, passing more fluid, fluid retention.
    All these symptoms arise in the hypothalamus, the deep-seated part of the brain.

2. Aura

Aura accompanies migraine attacks for about 20 – 30% of migraineurs.  The most common aura symptoms are visual disturbances such as bright zigzag lines, flashing lights, difficulty in focusing or blind spots.  Aura affects the visual field of both eyes despite often seeming to affect one only and lasts 5-60 minutes then the vision normally restores itself.  Less commonly aura affects sensation or speech.  When several aura symptoms are present, they usually follow in succession.

3. Headache

Those experiencing classical migraine (migraine with aura) may or may not have a gap of up to an hour between the end of the aura and the onset of the head pain and may feel a bit ‘spaced out’ during the gap.  Regardless of whether one experiences migraine with aura, or common migraine (migraine without aura), the headaches are similar. The headache phase can last up to three days.  It is often throbbing and on one side of the head, but can affect both.  It can be on the same or opposite side to the aura.  Movement makes it worse.  The most common accompanying symptoms in this phase are nausea, vomiting and sensitivity to light, sound and smell.  Eating can help especially starchy foods.  The symptoms can be more distressing than the headache itself.

4. Resolution

The way an attack ends varies greatly.   Sleep is restorative for some.  Being sick can make children feel much better.  For others effective medication can improve attacks.  For a few nothing works except the headache burning itself out.

5. Recovery (postdromol)

A feeling of being drained may exist for about 24 hours, others may feel energetic or even euphoric.

 

What causes migraine?

‘Susceptibility to migraine is normally inherited.  Certain parts of the brain employing monoamines, such as serotonin and noradrenaline, appear to be in a hypersensitive state, reacting promptly and excessively to stimuli such as emotion, bombardment with sensory impulses, or any sudden change in the internal or external environment.  If the brainstem systems controlling the cerebral cortex become active, the brain starts to shut down, a process starting at the back of the brain in the visual cortex and working slowly forward.  The pain nucleus of the trigeminal nerve becomes spontaneously active; pain is felt in the head or upper neck and blood flow in the face and scalp increases reflexly.  Noradrenaline is released from the adrenal gland and causes the platelets to release serotonin.  Serotonin in the circulation is thought to reflect levels of this neurotransmitter in the brain.

The brainstem nuclei of one side have a reciprocal effect on those of the other side; their effects may alternate, causing cortical changes on one side and headache on the other, or causing the headache itself to change from side to side.

Essentially, migraine is caused by the interaction between the brain and the cranial blood vessels.  Treatment can be aimed at constriction of dilated arteries to abort each headache as it comes or at the brain itself in an attempt to prevent the headaches altogether.

This is the present hypothesis for the mechanism by which migrainous symptoms are produced3.

Types of Migraine

Apart from common migraine and migraine with aura, other types of migraine are:

Lower-half Headache or Facial Migraine

The term applies to common migraine that covers one-half of the face involving the nostril, cheek and jaw.

Migraine Aura without Headache

Where the headache of migraine with aura may become less severe over the years or may not occur at all, the attacks are referred to as migraine aura without headache.  It is rare for attacks to have always occurred without a headache and a doctor should be consulted if this develops for the first time when over 50.

Status Migrainosus

This term describes migraine that may last longer than 72 hours.  Symptoms of nausea and light sensitivity resolve after a couple of days but the headache persists.

Abdominal Migraine (recurrent stomach pains in childhood)

Symptoms are periodic abdominal pains (experienced by about 20% of migrainous children compared with about 4% of children who do not suffer from headache).

Rare types of migraine include:

Basilar Artery Migraine (with loss of balance and fainting)

Symptoms include visual disturbances, giddiness, loss of balance, slurred speech followed by aching mainly in the back of the head.  Fainting can occur at the height of the attack.

Hemiplegic Migraine (with weakness on one side of the body)

Symptoms resemble a stroke and may progress until the arm and leg on one side are completely paralysed for a few hours.  Repeated attacks may leave a residual weakness.  Familial hemiplegic migraine occurs where there is a family history of hemiplegic migraine.

Ophthalmoplegic Migraine (with double vision)

Symptom is paralysis of one or more of the muscles moving the eyes resulting in the eyes moving out of alignment and the person seeing double.

Retinal Migraine (with loss of vision in one eye)

Symptom is loss of sight in one eye and normal vision in the other.  The sight clears leaving an ache behind the eye or a generalised headache.

Migrainous Infarction

Symptoms range from permanent blind spots to a full stroke occurring during a typical migraine attack.  An infarct is the death of tissue due to an inadequate blood supply.

Triggers

See also: Management of Headache / Precipitating factors

Triggers are many and varied, not the same for everyone and not necessarily the same for different attacks in the same person.  Identifying triggers may be complicated by the fact that it often takes a combination of triggers to set off a headache.

Dietary Triggers

Common, well-recognised dietary triggers include:

  • missed, delayed or inadequate meals
  • caffeine (coffee and tea) withdrawal
  • certain wines, beers and spirits
  • chocolate, citrus fruits, aged cheeses and cultured products (chocolate and other sugar cravings may be prodomal not triggers)
  • monosodium glutamate (MSG)
  • dehydration.

Environmental Triggers

Environmental triggers include:

  • bright or flickering lights, bright sunlight
  • strong smells, e.g. perfume, gasoline, chemicals, smoke-filled rooms, various food odours
  • travel, travel-related stress, high altitude, flying
  • weather changes, changes in barometric pressure (likewise, decompression after deep-sea diving)
  • loud sounds
  • going to the movies
  • computers (overuse, incorrect use).

Hormonal Triggers

Hormonal fluctuations are implicated as a significant trigger for women as three times as many women suffer from migraine headaches as men, this difference being most apparent during the reproductive years,.  Hormonal triggers may be:

  • Climacteric (final menstrual period)
  • Menstruation (a UK study found 50% of women more likely to have migraine around menstruation)
  • Ovulation
  • Oral contraceptives
  • Pregnancy (may worsen for first few months but in two thirds of women improves in latter part)
  • Hormone replacement therapy (HRT)
  • Menopause.

Physical and Emotional Triggers

Physical and emotional factors include:

  • lack of sleep or oversleeping (even as little as half hour difference in routine, e.g. sleeping in on weekends)
  • illness such as a viral infection or a cold (if taken cold and migraine medication, remember that many cold remedies contain pain-killers)
  • back and neck pain, stiff and painful muscles, especially in scalp, jaw, neck, shoulders, and upper back
  • sudden, excessive or vigorous exercise (regular exercise can however prevent migraine, if migraine is triggered by a blow to the head a doctor should be consulted)
  • emotional triggers such as arguments, excitement, stress and muscle tension
  • relaxation after stress (weekend headache).

Treatment of Migraine

Much can be done about migraine.  Treatment is not just a matter of taking a tablet but a case of each individual developing a migraine management plan that will probably involve lifestyle modifications, medication and complementary therapies.
See: Management of Headache

Medication

Some people can manage their migraines with medications available from a pharmacy.  For many others, these are not sufficiently effective.  If this is the case, or you are unsure about the cause or nature of your headache, or if your headaches change, it is important you consult a doctor.  Studies show that 50% of migraine sufferers have not been diagnosed.  Even if you have previously consulted a doctor and the prescribed treatment has not been successful it is worth going again.  Migraines can be managed, effective migraine management involves a partnership between you and your doctor. Some medications are given once the headache has begun (acute treatment) and others taken daily to reduce the frequency of attacks (preventative treatment).

Acute Treatment

Infrequent, less severe migraine may respond to over-the counter medications such as

  • aspirin (not recommended for young children, some adults respond well to three tablets)
  • paracetamol
  • non-steroidal anti-inflammatory drugs such as ibuprofen (Nurofen, Brufen), naproxen (Naprosyn).
    Medications that may be prescribed for more severe migraine include
  • triptans such as sumatriptan (Imigran), naratriptan (Naramig), zolmitriptan (Zomig) that are based on the serotonin molecule
  • ergotamine compounds (Cafergot) that appear to provide relief by constricting cranial blood vessels
  • stronger non-steroidal anti-inflammatory drugs
  • stronger narcotic-type analgesics.
    Anti-emetic medications often prescribed with other forms of acute therapy to minimise the nausea that often accompanies migraine include
  • metoclopramide (Maxolon), prochlorperazine (Stemetil) or domperidone (Motilium) to increase absorption and reduce nausea.

Preventative Treatment

Prophylactic/preventative medication is taken daily, regardless or whether a headache is present, to reduce the incidence of severe or frequent headaches. These include:

  • beta blockers such as propranolol (Inderal), timolol (Blocadren), atenolol (Tenormin) and metoprolol (Lopresor, Betaloc) that block the beta-receptors on which adrenaline works in the nervous system as well as on blood vessels
  • serotonin antagonists such as methysergide (Deseril),   pizotifen (Sandomigran) and cyproheptadine (Periactin)
  • sodium valproate or valproic acid (eg Epilim), an anti-epileptic drug shown to reduce the intensity of migraine
  • calcium-channel blockers such as verapamil (Isoptin) that stop the constriction of blood vessels by preventing the use of calcium necessary for this reaction
  • antidepressants such as amitriptyline  (eg. Tryptanol) have an action on headache that is independent of their antidepressant action
  • feverfew, a herbal remedy
  • riboflavin 200mgm twice daily has been reported as useful.
    All are effective.  All have side effects and, except feverfew and riboflavin, are prescription drugs.  Many were initially introduced for some other problem and were also observed to reduce headache.

Complementary Therapies

Acupuncture

Stimulating acupoints may ease pain by encouraging production of endorphins (natural painkillers).

Alexander technique

Can help prevent tension headaches by relieving poor posture and pressure that results from it.

Aromatherapy

Combines various scented oils and promotes relaxation and eases tension.

Biofeedback

Can be used to treat tension-type and migraine headaches - patient learns to control blood pressure, heart rate, and spasms in the arteries supplying the brain through a sensory device.

Chiropractic Therapy

Based on the theory that most diseases of the body are a result of a misalignment of the vertebral column with pressure on the adjacent nerves that may affect blood vessel and muscle function. Manual techniques purport to adjust the misalignment.

Homeopathy

Uses active substances found in certain medications highly diluted.

Hydrotherapy

Splashing your face with cold water before lying down for an hour can ease headache. Alternating hot and cold showers dilates then constricts the blood vessels, stimulating circulation. Ice pack on head is another option.

Hypnotherapy

Can help sufferer deal with headache by altering the way the body interprets messages of pain.

Massage

Can reduce muscle tension throughout the body, thereby reducing headache.

Meditation

A recent study on migraine prevention through meditation has had very promising results, all participants reported less severe migraines.

Naturopathy

Uses only natural substances in small amounts and aims to provide a healthier balance of bodily processes.

Osteopathy

Manipulation of the neck or cranial, osteopathy may be used to correct misalignments of the vertebrae that can cause migraines.

Physiotherapy

Treating muscle tension can release pressure that may lead to headache.

Relaxation Techniques

Geared towards reducing pressure in the body and the level of stress chemicals that may worsen headache.

Shiatsu

Combination of massage and pressure can restore the “energy balance” and induce relaxation.

Yoga

Can relieve muscle tension in the back of the neck and correct posture.

Migraine and Other Health Conditions

Studies show that the prevalence of other health conditions, including depression, panic disorder, epilepsy, stroke, anxiety disorders, manic depressive illness, mitral valve prolapse, Raynaud’s syndrome, glaucoma is higher amongst persons with migraine and severe headache than control groups.  Extracts from some of these studies are included below in addition to information about studies indicating a higher prevalence of asthma among migraine sufferers and a link between migraine and multiple sclerosis

Headache and major depression - Is the association specific to migraine?

N. Breslau, L.R. Schultz, W.F. Stewart, R. Lipton, V.C. Lucia, and K.M.A. Welch.

This U.S study found that lifetime prevalence of major depression was approximately three times higher in persons with migraine and in persons with severe headaches compared with controls. Significant bi-directional relationships were observed between major depression and migraine, with migraine predicting first-onset depression and depression predicting first onset migraine in contrast, persons with severe headache had a higher incidence of first-onset major depression (hazard ratio = 3.6) but major depression did not predict a significantly increased incidence of other severe headaches (hazard ratio = 1.6).  The study concludes that the contrasting results regarding the relationship of major depression with migraine versus other severe headaches suggests that different causes may underlie the co-occurrence of major depression in persons with migraine compared with persons with other severe headaches. Neurology 2000; 54: 308-313

Headache Types and Panic Disorder - Directionality and Specificity

N. Breslau, L.R. Schultz, W.F. Stewart, R. Lipton, and K.M.A. Welch.

The U.S study found that lifetime prevalence of panic disorder was significantly higher in persons with migraine and in persons with other severe headaches, compared with controls.  Migraine and other severe headaches were associated with increased risk for the first onset of panic disorder (hazard ratios = 3.55 and 5.75).  Panic disorder was associated with an increased risk for first onset of migraine and for onset of other severe headaches, although the influences in the direction were lower (hazards ratios = 2.10 and 1.85).  The study concludes that comorbidity of panic disorder is not specific to migraine and applies also to other severe headaches. The influence is primarily from headaches to panic disorders, with a weaker influence in the reverse direction. The bi-directional associations, despite the difference in the strength of the associations, suggest that shared environmental or genetic factors might be involved in the comorbidity of panic disorder with migraine and other severe headaches.
Neurology 2001; 56: 350-354


Comorbidity in Migraine – Causes and Effects

R.B. Lipton

This U.S study notes that there is strong evidence that migraine is comorbid with a number of different conditions: epilepsy, stroke, depression, anxiety disorders, and manic depressive illness. There is strong evidence that migraine is comorbid with mitral valve prolapse and Raynaud’s syndrome. Cephalalgia 1998: 18 Suppl 22: 8-14 Oslo Issn 0800-1952

 

Is there an association between migraine headache and open-angle glaucoma?  Findings from the Blue Mountains Eye Study

JJ Wang, P Mitchell and W Smith

In this Australian study, ‘increased odds for OAG (open-angle glaucoma) were found for people giving a history of typical migraine headache and aged 70-79 years after adjusting for variables found associated with glaucoma’.  The study concludes that ‘these data suggest the possibility of an association between history of typical migraine headache and OAG, which could be modified by age’. Ophthalmology, Vol 104, 1714-1719 Copyright © 1997


Migraine and Stroke

The complex relationship between migraine and stroke has been studied intensively.

A recent study, "Duration, frequency, recency, and type of migraine and the risk of ischaemic stroke in women of childbearing age" (M. Donaghy, C.L Chang, N. Poulter, on behalf of the European collaborators of The World Health Organisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception- J Neurol Neurosorg Psychiatry 2002;73:747-750) notes that ‘Migraine is recognised increasingly as a risk factor for ischaemic stroke in women of childbearing age.  Migraine with aura poses a higher risk than migraine without aura.’  The study provides an additional analysis ‘of a previously reported multicentre case-control study of the relation between stroke and migraine in women aged 20-44 years and concludes that ‘the risk seems particularly high in those whose initial migraine type involved aura occurring more than 12 times per year’.

A previous study by Tzourio et al (1995) reported that the risk of stroke was greatly increased for migrainous patients who smoked more than 20 cigarettes a day (odds ratio 10.2) and for those using oral contraceptives (odds ratio 13.9) and that the absolute risk of young women with migraine suffering a stroke was 19 per 100,000 per year4.


Migraine and Asthma

A recent British study, carried out by Professor David Strachan and colleagues at St George’s Hospital Medical School London, compared the prevalence of asthma in nearly 65,000 migraine patients with an equal number of control patients without migraine and found that the relative risk in patients with migraine was 1.59.
Br J Gen Pract 2002; 52:723-728


Migraine and MS

The MS Society of Australia report on their website www.mssociety.com.au : ‘although headache is not a common symptom of MS, some reports suggest that people with MS have an increased incidence of certain types of headache. One report noted that migraine headaches were more than twice a common in a group of MS patients than in a group of people with similar characteristics, but without MS. Another study noted that up to one-third of an MS population studied had a prior diagnosis of migraine. It has been reported that vascular or migraine type headaches may occasionally be the first symptom of MS. One published report that 20% of a sample group of people with MS had a family history of migraine, compared to 10% of controls, suggests that there may be a common predisposing factor to both MS and migraine.
SOURCE: NMSS Information Resource Center and Library. Compendium of Multiple Sclerosis Information (CMSI). ©1997, National Multiple Sclerosis Society. Rev. 10/97.

Your Doctor and Your Migraine

If you are unsure about the cause or nature of your headache, need assistance in managing your migraines or if the pattern of your headaches change, it is important you consult a doctor.  Studies show that 50% of migraine sufferers have not been diagnosed.  Even if you have previously consulted a doctor and the prescribed treatment has not been successful it is worth going again.  Migraines can be managed, effective migraine management involves a partnership between you and your doctor.
See: Management of headache/ Your Doctor and Your Headache

References

  • Migraine and Other Headaches 2000   Professor James Lance Simon and Schuster
  • Headache Disorders and Public Health, Education and Management Implications
  • World Health Organisation, Geneva, WHO/MSD/MBD/00.9, Sept 2000
  • Understanding Migraine and Other Headaches 2002 Dr Anne MacGregor
  • Littlewood et al., 1998 from Mechanism and Management of Headache 6th Ed  James W. Lance and Peter J.Goadsby
  • Headaches Paul Spira 2000 Health Essentials
  • Wolff’s Headache and Other Head Pain 7th Ed Silberstein, Lipton & Dalessio

Prepared by Louise Alexander, PhC, Grad Dip Comm Mngt, Former National Director of the Brain Foundation. Reviewed by Professor James Lance, AO, CBE, MD, Hon DSc, FRCP, FRACP, FAA, Consulting Neurologist, and author, “Migraine and Other Headaches”


1 Migraine and Other Headaches 2000, Professor James Lance

2 Headache Disorders and Public Health, Education and Management Implications, World Health Organisation, Geneva, WHO/MSD/MBD/00.9, Sept 2000

3 Migraine and Other Headaches 2000, Professor James Lance, Simon & Schuster

4 Mechanism and Management of Headache 1998 J.W Lance Butterworth Heinemann

 
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