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 that migraine affects over 3 million Australians. It is thought that more women suffer migraine than men due to hormonal factors.
Migraine can begin from childhood but often it appears in a patient in their 20s or 30s. It is relatively ‘infrequent 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.’
The International Headache Society classifies a headache as a migraine when:
(a) the pain can be classified by at least two of the following;
(b) there is at least one of the following associated symptoms:
(c) the headache lasts for between 4 and 72 hours.
Other symptoms that may be experienced include
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.
Migraine can be divided into five distinct phases:
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:
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.
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.
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.
A feeling of being drained may exist for about 24 hours, others may feel energetic or even euphoric.
‘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.
Apart from common migraine and migraine with aura, other types of migraine are:
The term applies to common migraine that covers one-half of the face involving the nostril, cheek and jaw.
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.
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.
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:
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.
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.
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.
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.
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 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.
Common, well-recognised dietary triggers include:
Environmental triggers include:
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:
Physical and emotional factors include:
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
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).
Infrequent, less severe migraine may respond to over-the counter medications such as
Prophylactic/preventive medication is taken daily, monthly or at regular intervals, regardless of whether a headache is present, to reduce the incidence of severe or frequent headaches. These include:
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
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
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
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
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
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.
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
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.
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
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