Migraine Headache

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PROF. M. S. ABDULLAH
AGA KHAN HOSPITAL
SEPTEMBER 2018

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Migraine causes severe throbbing
pain or a pulsing sensation, usually
on just one side of the head.
It's often accompanied by nausea,
vomiting, and extreme sensitivity
to light and sound.
Migraine attacks can cause
significant pain for hours to days
and can be so severe that the pain
is disabling.

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Symptoms
Migraines often begins in
childhood, adolescence or
early adulthood. Migraines
may progress through four
stages: prodrome, aura,
headache and post-drome,
though one may not experience
all the stages.

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Prodrome
One or two days before a migraine, you may notice
subtle changes that warn of an upcoming migraine,
including:
Constipation
Mood changes, from depression to euphoria,
Food cravings,
Neck stiffness,
Increased thirst and urination,
Frequent yawning,

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Aura
Aura may occur before or during migraines.
Most people experience migraines without aura.
Auras are symptoms of the nervous system.
They are usually visual disturbances, such as flashes
of light or wavy, zigzag vision.
Sometimes auras can also be touching sensations
(sensory), movement (motor) or speech (verbal)
disturbances.
Muscles may get weak, or you may feel as though
someone is touching you.

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Aura
Each of the aura symptoms usually begins gradually, builds up
over several minutes and lasts for 20 to 60 minutes.
Examples of migraine aura include:
Visual phenomena, such as seeing various shapes, bright spots
or flashes of light, Vision loss,
Pins and needles sensations in an arm or leg,
Weakness or numbness in the face or one side of the body,
Difficulty speaking, Hearing noises or music,
Uncontrollable jerking or other movements
Sometimes, a migraine with aura may be associated with limb
weakness (hemiplegic migraine).

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Attack
A migraine attack usually lasts from four to 72 hours if
untreated.
The frequency with which headaches occur varies from person
to person.
Migraines may be rare, or strike several times a month. During a
migraine, you may experience:
Pain on one side or both sides of your head,
Pain that feels throbbing or pulsing,
Sensitivity to light, sounds, and sometimes smells and touch,
Nausea and vomiting, Blurred vision
Light headedness, sometimes followed by fainting

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Post-drome
The final phase, known as post-drome, occurs after a
migraine attack.
You may feel drained and washed out, while some
people feel elated.
For about 24 hours, you may also experience:
Confusion, Moodiness, Dizziness, Weakness,
Sensitivity to light and sound

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Causes
Though migraine causes aren't understood, genetics
and environmental factors appear to play a role.
Migraines may be caused by changes in the brainstem
and its interactions with the trigeminal nerve, a major
pain pathway.
Imbalances in brain chemicals — including serotonin,
which helps regulate pain in your nervous system —
also may be involved.
Researchers are still studying the role of serotonin in
migraines.

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Causes
Serotonin levels drop during migraine attacks.
This may cause the trigeminal nerve to release
substances called neuropeptides, which travel to the
brain's outer covering (meninges).
The result is migraine pain.
Other neurotransmitters play a role in the pain of
migraine, including calcitonin gene-related peptide
(CGRP).

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Migraine triggers
A number of factors may trigger migraines, including:
Hormonal changes in women.
Fluctuations in estrogen seem to trigger headaches in many
women. Women with a history of migraines often report
headaches immediately before or during their periods, when
they have a major drop in estrogen.
Others have an increased tendency to develop migraines
during pregnancy or menopause.
Hormonal medications, such as oral contraceptives and
hormone replacement therapy, also may worsen migraines.
Some women, however, find their migraines occur less often
when taking these medications.
Foods. Aged cheeses, salty foods and processed foods may
trigger migraines. Skipping meals or fasting also can trigger
attacks.

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Migraine triggers
Food additives. The sweetener aspartame and the preservative
monosodium glutamate (MSG), found in many foods, may trigger migraines.
Drinks. Alcohol, especially wine, and highly caffeinated beverages may
trigger migraines.
Stress. Stress at work or home can cause migraines.
Sensory stimuli. Bright lights and sun glare can induce migraines, as can
loud sounds. Strong smells — including perfume, paint thinner, second hand
smoke and others — can trigger migraines in some people.
Changes in wake-sleep pattern. Missing sleep or getting too much sleep
may trigger migraines in some people, as can jet lag.
Physical factors. Intense physical exertion, including sexual activity, may
provoke migraines.
Changes in the environment. A change of weather or barometric pressure
can prompt a migraine.
Medications. Oral contraceptives and vasodilators, such as nitroglycerin, can
aggravate migraines.

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Risk factors
Several factors make you more prone to having
migraines, including:
Family history. If you have a family member with
migraines, then you have a good chance of developing
them too.
Age. Migraines can begin at any age, though the first
often occurs during adolescence. Migraines tend to peak
during the 30s, and gradually become less severe and
less frequent in the following decades.
Sex. Women are three times more likely to have
migraines. Headaches tend to affect boys more than girls
during childhood, but by the time of puberty and
beyond, more girls are affected.

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Risk factors
Hormonal changes. If you are a woman who has
migraines, you may find that your headaches begin
just before or shortly after onset of menstruation.
They may also change during pregnancy or
menopause. Migraines generally improve after
menopause.
Some women report that migraine attacks begin
during pregnancy, or their attacks worsen. For many,
the attacks improve or don't occur during later stages
in the pregnancy. Migraines often return during the
postpartum period.

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Diagnosis
If you have migraines or a family history of migraines, a
doctor trained in treating headaches (neurologist) will
likely diagnose migraines based on your medical history,
symptoms, and a physical and neurological examination.
the doctor may also recommend more tests to rule out
other possible causes for the pain if the condition is
unusual, complex or suddenly becomes severe.
Blood tests. The doctor may order these to test for blood
vessel problems, infections in the spinal cord or brain,
and toxins in the system.

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Diagnosis
Magnetic resonance imaging (MRI). An MRI uses a
powerful magnetic field and radio waves to produce
detailed images of the brain and blood vessels.
MRI scans help doctors diagnose tumors, strokes,
bleeding in the brain, infections, and other brain and
nervous system (neurological) conditions.
Computerized tomography (CT) scan. A CT scan uses a
series of X-rays to create detailed cross-sectional images
of the brain.
This helps doctors diagnose tumors, infections, brain
damage, bleeding in the brain and other possible medical
problems that may be causing headaches.

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Diagnosis
Spinal tap (lumbar puncture). The doctor may
recommend a spinal tap (lumbar puncture) if he or
she suspects infections, bleeding in the brain or
another underlying condition.
In this procedure, a sample of cerebrospinal fluid is
removed for analysis in a lab.

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Treatment
Migraine treatments can help stop symptoms and
prevent future attacks.
Many medications have been designed to treat
migraines.
Some drugs often used to treat other conditions also
may help relieve or prevent migraines.
Medications used to combat migraines fall into two
broad categories:

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Pain-relieving medications. Also known as
acute or abortive treatment, these types of
drugs are taken during migraine attacks and
are designed to stop symptoms.
Preventive medications.
These types of drugs are taken regularly,
often on a daily basis, to reduce the severity
or frequency of migraines.

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Pain relievers. Aspirin or ibuprofen may help relieve
mild migraines.(Advil, Motrin IB, others)
Acetaminophen also may help relieve mild migraines
in some people. (Tylenol, others),
Drugs marketed specifically for migraines, such as the
combination of acetaminophen, aspirin and caffeine
also may ease moderate migraine pain(Excedrin
Migraine), .
They aren't effective alone for severe migraines.

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Triptans.
These medications are often used in treating migraines.
Triptans make blood vessels constrict and also block pain
pathways in the brain.
Triptans effectively relieve the pain and other symptoms that
are associated with migraines.
Triptan medications include sumatriptan (Imitrex), rizatriptan
(Maxalt), almotriptan (Axert), naratriptan (Amerge),
zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan
(Relpax).
Side effects of triptans include
reactions at the injection site, nausea, dizziness, drowsiness
and muscle weakness. They aren't recommended for people
at risk of strokes and heart attacks.

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Ergots.
Ergotamine and caffeine combination drugs are less effective
than triptans. (Migergot, Cafergot)
Ergots seem most effective in those whose pain lasts for more
than 48 hours.
Ergots are most effective when taken soon after migraine
symptoms start.
Ergotamine may worsen nausea and vomiting related to
migraines, and it may also lead to medication-overuse
headaches. Anti-emetics are needed
Dihydroergotamine (D.H.E. 45, Migranal) is an ergot derivative
that is more effective and has fewer side effects than
ergotamine. It's also less likely to lead to medication-overuse
headaches. It's available as a nasal spray and in injection form.

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Anti-nausea medications.
Medication for nausea is usually combined with other
medications.
Frequently prescribed medications are chlorpromazine,
metoclopramide (Reglan) or prochlorperazine (Compro).
Opioid medications.
Opioid medications containing narcotics, particularly
codeine, are sometimes used to treat migraine pain for
people who can't take triptans or ergots.
Narcotics are habit-forming and are usually used only if
no other treatments provide relief.

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Preventive medications.
These types of drugs are taken regularly, often on a
daily basis, to reduce the severity or frequency of
migraines.
You may be a candidate for preventive therapy if:
You have four or more debilitating attacks a month
Attacks last more than 12 hours
Pain-relieving medications aren't helping

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Preventive migraine medications include:
Cardiovascular drugs.
Beta blockers, propranolol, metoprolol and timolol
calcium channel blockers Verapamil
ACE inhibitor Lisinopril
Antidepressant Amitriptyline
Anti-seizure drugs. valproate and topiramate tegretol
Erenumab given once a month
Botox given once every 3 months

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Ginger powder In 2014, a
study showed ginger root
powder had comparable
benefits with fewer side
effects than a commonly
prescription migraine drug.
Ginger also has anti-
inflammatory properties to
aid in keeping migraines at
bay.

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Recurring migraine headaches
caused by inflammation can be
treated by increasing the
amount of omega-3 fatty acids
in your diet.
Ground flaxseeds and flaxseed
oil are high in omega-3s.
Try adding ground flaxseed to
soup or salad, or use flaxseed
oil as a base for salad dressing.

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Life Style changes
Practice muscle relaxation exercises.
Get enough sleep, but don't oversleep.
Rest and relax.
Keep a headache diary.
Alternative medicine
Non-traditional therapies
Acupuncture.
Biofeedback.
Massage therapy.
Cognitive behavioral therapy.
Herbs, vitamins and minerals.

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THANK YOU