Migraine is a primary headache disorder. In other words, a headache that is not the result of any insult on the brain such as stroke, bleed, inflammation, or tumor. Migraine can start as early as childhood, with peak incidence in the third decade of life followed by steady decline through the sixth decade. Though not fatal, migraine headaches are the second most common worldwide cause of disability calling for treatment of this disorder. Migraine headaches affect 15% of the general population and females nearly three times as much as males. Migraine are often familial, especially when involving the males of the family.
Diagnosis of migraines:
Migraine is a clinical diagnosis. However, a Neurologist may at times use an MRI picture of the brain to exclude secondary causes if atypical features are associated with the patient’s headache. Any patient suffering from five or more lifetime headaches fulfilling the criteria below is diagnosed with migraine headaches. Migraine headaches last at least four hours (up to 72 hours) and are moderate to severe in intensity, one sided in onset, and typically worse with movement. Migraine patients typically prefer to take a nap in a dark quiet room during their headache attacks. Their headaches can be associated with nausea/vomiting and or sensitivity to light AND sound.
Migraine classification and progression:
Migraines are classified based on the type and frequency. The majority of patients have migraines without a warning sign or aura referred to as migraine without aura. However, up to 20% of patients have migraine with aura. The aura can last up to an hour and occurs within an hour of headache onset. The most common aura is visual accounting for 90% of all auras. Patient can experience a central darkening of vision with shimmering lights in the periphery referred to as a scintillating scotoma. However, the aura can be a sensory disturbance, trouble with language, or paralysis. Additionally, patient may have a visual aura that is followed by a second aura type such as tingling.
Another important reason to treat patients suffering with migraines apart form disability is stroke risk. Patients suffering from migraine without aura are 2.2 times more likely to have a stroke and 2.7 times if they have migraine with aura. When the migraine aura is coupled with estrogen containing contraception use, the risk of stroke becomes 6.1 times that of patients who do not suffer with headaches. This risk is further compounded up to 39 times when further combined with cigarette smoking.
Another classification of migraines is based on headache frequency. A patient suffering from 15 or more headache days monthly, where 8 of those headaches are migraines, for three or more consecutive months is said to have chronic migraine. A frequency below that is referred to as episodic migraine. This classification allows for better treatment selection as patients with chronic migraines become candidate for injectable treatments such as Botox injections.
There are four phases in each single migraine attack only during one of which a headache occurs. Not every patient experiences all four phases, however, often times, patients are simply unaware of the presence of these symptoms. Due to these four phases, headache attacks can sometimes last a whole week and feel “never ending”.
The migraine can start with the prodromal phase which can last up to 24 hours and during which the patient can experience fatigue, irritability, depressed mood, trouble concentrating, memory difficulties, excessive thirst, frequent urination, excessive yawning, insatiable hunger, neck stiffness, nausea, poor sleep, and sensitivity to light and sound. After this phase, some patients will proceed to have their aura and others go directly go into the headache phase which can last 72 hours as described above. The period between the end of the headache and return to normal is referred to as the postdrome phase which can last up to 25 hours. During the postdrome phase, patients can experience symptoms similar to the prodrome but most commonly fatigue, difficulty concentrating, and neck stiffness.
Treatment of migraine headaches:
The treatment of migraine headaches is more often aimed at reducing disability such as missed school days or days at work. However, headache freedom is not uncommonly a secondary goal even if not always possible. The first line treatment of migraines is therapeutic lifestyle changes and trigger avoidance. Common triggers include sleep deprivation, oversleeping, exposure to bright lights, periods of fasting, stress, stress letdown, dehydration, changes in daily routine, and tyramine containing foods such as aged cheese and wine to name a few. Lifestyle changes include ensuring adequate sleep (8 hours nightly), ample hydration, regular meals, stress and trigger avoidance, blue light blocking glasses (FL-41 lenses), and regular exercise to name a few.
In addition to lifestyle changes, Neurologists employ a wide armamentarium of old and new medications. There are two types of medications prescribed. Abortive therapies are used when a headache attack occurs with the hopes to end it. Preventative or prophylactic therapies are used on a regular basis irrespective of headache presence with the hopes to reduce the frequency, severity, and duration of headaches.
Examples of over the counter abortive therapies include Tylenol (Acetaminophen), Advil (Ibuprofen), Motrin (Ibuprofen), Aleve (Naproxen), Excedrin migraine, and BC powder. Examples of prescribed abortive therapies include Cambia (Ketorolac), Triptans (such as Sumatriptan or Imitrex), Ubrelvy (Ubrogepant), Nurtec (Rimegepant), and Reyvow (Lasmiditan).
Examples of over the counter preventative therapies include Magnesium, Vitamin B2 (Riboflavin), Feverfew, Butterbur, and CoQ10. Prescribed migraine preventatives are available in oral, injectable, and infused formulations. The orals include things like the blood pressure medications Propranolol and Verapamil, antidepressants such as Amitriptyline (Elavil) and Venlafaxine (Effexor), and antiseizure medications such as Topiramate (Topamax), Valproic acid (Depakote), Gabapentin (Neurontin), and Pregabalin (Lyrica). Injectables medications include Botox (Onabotulinum A), Aimovig (Erenumab), Emgality (Galganezumab), Ajovy (Fremanezumab), and occipital nerve block (Triamcinolone/Bupivicaine). There is a single infused medication called Eptinezumab (Vyepti).
In addition to medications, lifestyle changes, and trigger avoidance, Neurologists may employ Cognitive Behavioral Therapy (CBT), a form of psychotherapy that treats depression, anxiety, and certain neurological disorders such as migraines and ADHD. Lastly, the addition of nerve stimulators is now possible using one of several FDA approved devices such as Cefaly (Trigeminal nerve stimulator), GammaCore (Vagus nerve stimulator), Nerivio Migra (remote electrical neuromodulation), and single pulse transcranial magnetic stimulation sTMS. If you suffer from frequent and disabling headaches please make an appointment at the Neurology clinic to get your life back.
Oliver Achi, MD, Medical Director, Neurology Services
Iberia Medical Center
2312 East Main Street
New Iberia, LA 70560