Migraine: A Common Chronic Pain And Distressing Order

Headaches are one of the most common forms of chronic pain (second only to back troubles). Anyone who's suffered the splitting pain of a headache especially a migraine knows how difficult it can be to drive, work, and even carry on a conversation while your head is pounding.

According to Virtual Medical Center , "The World Health Organisation ranks migraine 19th amongst the disability-causing diseases worldwide. It is a common and under diagnosed syndrome which effects up to 12% of the population. Incidence and prevalence of migraine is similar around the world. Onset is typically before age 40 and often occurs during childhood or adolescence.Acute episodes of migraine occur most commonly between 10 and 40 years of age".


Symptoms of Migraine

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

1. The pain can be classified by at least two of the following;

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

2. There is at least one of the following associated symptoms:

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

3. 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 affectone 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.vNoradrenaline 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 theother 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 produced.

What Trigger Migraines

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.

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).

Medication

Just about any over-the-counter (OTC) pain reliever can offer relief for non-migraine headaches, also known as tension headaches, says Jack M. Rozental, MD, PhD, a migraine specialist at Northwestern Memorial Hospital in Chicago. Medications that contain only one drug (acetaminophen, ibuprofen, naproxen, or aspirin) are an effective headache treatment, he says, as are those that include a combination of aspirin, acetaminophen, and caffeine.

For those who suffer from frequent or recurring headaches, doctors sometimes recommend prescription-strength doses of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen. Indomethacin, an NSAID that is available only by prescription, is "usually used for arthritis, but can also be very useful as a headache treatment," Dr. Rozental says."Indomethacin's downside is that it is among the drugs most likely to cause gastric irritation," including stomach ulcers and bleeding. These prescription drugs are sometimes used to treat migraine headaches:

•       Butalbital, abarbiturateoften used in combination with acetaminophen, caffeine, aspirin, and/or codeine.
•        Narcotics, such as oxycodone, hydrocodone, hydromorphone, or codeine.
•         Butorphanol, a narcotic nasal spray.
•         Tramadol.

Unfortunately, the risk with many of these prescription drugs is thatthey can lead to substance abuse and dependence, Rozental says. Butorphanol, in particular, "should be avoided because of its very high propensity to cause dependence after even minimal use," he explains.Frequent use of any pain reliever, including OTC drugs, can also cause what are known as rebound or medication-overuse headaches, says Rozental. To treat this type of headache, all pain-relieving medications must be stopped for at least three months. If you're consistently taking large doses of OTC medications to treat recurrent headaches, talk to your doctor about your symptoms.