Introduction

Migraine is one of the causes of recurrent, episodic headache. About 1 in 4 women, and 1 in 12 men, develop migraine at some point in their life. It usually starts in childhood or adolescence, and peaks in adolescence. Generally migraine becomes less common after 45-50 years old, though some may persist throughout life. The actual cause of migraine is still unknown. However, one is more likely to develop migraine if his/her immediate family members also have migraine.

Migraine can be generally classified into 2 main types :

1. Migraine without aura: patient has headache without aura. This is 5 times more common than migraine with aura.
2. Migraine with aura: headache is preceded by aura.

Symptoms

A. Headache

Migraine headache is usually one-sided and often described as ‘throbbing’ or ‘pulsating’. The headache may spread to involve both sides.Typically, it slowly gets worse, then gradually eases off, lasting 4 to 72 hours. Migraine headache can be moderate to severe. Patients may complain that they could not resume their activity or work when the attack comes. The attack may come infrequently, eg once in few months, or sometimes more frequently, eg few times a week.

Other than that, patient may feel nauseous, with or without vomiting. During the attack, most patients could not tolerate bright lights or loud noises, and prefer to lie in a dark room until the headache subsides. Head movement may worsen headache.

B. Aura

Aura refers to warning signs before the headache. Usually it lasts 1- 15 minutes. Examples of aura:

• Visual aura: eg temporary loss of part of vision, flashes of lights eg zig-zag lines that slowly spread before disappearing
• Numbness and ‘pins and needles’ sensation in the lips, face and hands
• Speech problem.
• Others: odd smell/sensation, slight confusion in thinking

Before each attack, patient may have vague changes in mood and appetite. This feeling may begin hours or even days before the actual headache. This is then followed by the aura( absent in migraine without aura), then the headache. Finally the headache gradually fades. During this time patient may feel tired, irritable, depressed, and may have difficulty concentrating.

C. Triggering factors :

Migraine may occur more frequently in the presence of triggering factors :

• Diet:cheese, chocolate, red wines, citrus fruits, caffeine, and foods containing tyramine.
• Environmental:Smoking and smoky rooms, glaring light like bright screens or flickering TV sets, loud noises, strong smells eg perfume.
• Psychological:Depression, anxiety, anger, tiredness, stress, etc. Some attacks occur not during stress but when patient relaxes, leading to so-called ‘weekend migraine’.
• Medicines:Hormone replacement therapy (HRT), some sleeping tablets, and oral contraceptive pill.
• Others:Menses,different sleep patterns, menopause.

However these triggering factors may not apply to all patients, eg some may be able to take cheese or chocolate without increase in the frequency of attack.

Less common types of migraine

a. Menstrual migraine

Migraine attack occurs only around periods, and not at other times.(catamenial migraine)

b. Abdominal migraine

This mainly occurs in children where there are attacks of abdominal pain which last several hours but without headache.

c. Ocular migraine

It causes temporary loss of all or part of the vision in one eye, or sometimes abnormality in eye movement.

d. Hemiplegic migraine

Headache is associated with weakness of one side of the body. It can be confused with a stroke.

e. Basilar-type migraine

Symptoms include headache at the back of the head, and strange aura symptoms such as temporary blindness, double vision, vertigo, tinnitus, slurred speech, dizziness.

Diagnosis

A diagnosis of migraine is made from typical symptoms, after excluding other causes of headache from physical examination. There is no test to confirm migraine. Sometimes patient can have other type of headache superimposed on the migraine headache. Doctors will have to ask all the symptoms in detail to reach at the correct diagnosis. In case of uncertainty, investigations like blood tests or brain scan are done to rule out other causes of headache.

Treatment

Treatment of migraine can be divided into acute and preventive treatment. Patients are advised to consult their doctors before starting treatment.

a. Acute treatment:

This is for immediate relieve of headache. Painkillers should be taken as soon as possible after symptoms begin, to either reduce the severity or stop the headache completely. Examples of painkillers are paracetamol(Panadol), mefenamic acid(ponstan), ibuprofen, diclofenac(voltaren), naproxen(synflex) etc.

Treatment can be repeated hours later if no relief. However these should not be taken on regular basis because painkiller overuse can worsen headache paradoxically. Patients should also be aware of the side effects of the painkillers eg gastric problem, allergic reaction before taking them.

For nausea and vomiting, patient can take antiemetic (anti sickness medicine), preferrably in soluble form for better absorption. Examples include metoclopramide (maxolon), prochlorperazine( stemetil).

Alternatively triptan medicine (eg sumatriptan) can be taken if painkillers do not help. It is specific for migraine headache & it often reduces or aborts a migraine attack. patient should take the first dose early when the headache is just beginning to develop for best effect.

Ergot alkaloids like Cafegot is also used in severe migraine headache, but it should be avoided in elderly, pregnancy or those with heart disease.

b. Preventive treatment

Preventive treatment help to reduce the severity & frequency of migraine attack. It is considered when the headache is too frequent or severe, and strongly interferes with patient’s activity or work. It should be taken everyday, with or without headache occuring. Treatment can be discontinued after 3 to 6 months once symptoms are controlled.

Examples of preventive treatment are: Pizotifen (sandomigran), flunarizine(sibelium), Propranolol, sodium valproic(epilim) etc. The choice of medicine depends on patient’s tolerance and their individual side effects on the patient.

c. Non-pharmacological measures

Apart from taking medications, patients are also advised to take non-pharmacological measures to reduce migraine attack, eg relaxation training, stress management, avoidance of triggering factors eg bright light, certain food, stress and sleep deprivation.

Complications

Rarely, in complicated migraine, patient may have stroke related to the migraine attack. Some patient may developed severe, continuous attack , so called “status migrainousus”, whereby stronger painkillers are needed.

Conclusion

Frequent or severe migrainous headache may interfere with daily activities. Patient are encouraged to seek medical treatment for better symptom control and better quality of life.