How Migraines are Diagnosed and Treated
By Dr. Arieh Kuritzky – Chief Neurologist
When people go to see a doctor,
headaches are one of the most common complaints. Approximately 80% of
the population experiences a headache at least once a year. Headaches
can be split into two categories: Primary and Secondary.
Primary headaches are the kind of
headaches whose primary cause is unclear. In this group you will find
Migraines, Cluster Headaches, Tension-Type Headache and other more rare
types.
The Secondary group includes
headaches with a known cause that have an effective treatment helping to
alleviate the pain. This group includes Sinus-Related Headaches,
Meningitis, headaches caused by damage to the jaw joints, Intracranial
Bleeding or pressure and headaches related to different parts of the
face: eyes, teeth, muscles and the nerves of the skull.
This review deals with the Primary Headache known as a "Migraine".
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What is a Migraine?
Migraines have been part of humanity
since antiquity. The name comes from the ancient Greek word
“Hemicrania”, meaning “half a head”.
Migraines are characterized by bouts
of headaches, mainly on one side of the head, which can last anywhere
from 4 to 72 hours and are accompanied by nausea, vomiting, and
increased sensitivity to light and noise. Clinical diagnosis is done by a
physician, based on the symptoms the patient complains about.
Currently, there is no known testing method to conclusively confirm
migraines.
Since 1988, migraines are diagnosed according to the criteria set by the International Headache Society. (HIS)
The Official Criteria for Diagnosis of Migraines:
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Two Major Types of Migraines:
We differentiate between two types of migraine: With or without an aura.
The aura is a temporary perceptual
disturbance which typically appears some time prior to the beginning of
the headache. It usually lasts for about 20-30 minutes and often
includes symptoms like blurred vision, partial blindness, visual
hallucinations (bright lights or zigzagging lines), “holes” in the field
of vision and in some cases – complete blindness. In more rare
situations, auras manifest as a feeling of weakness, as well as pins and
needles felt in half of the body - and even severe dizziness.
About 15% of all migraines are
accompanied by auras. Two thirds of people experience migraines without
an aura and the rest experience it intermittently.
The headache lasts between 3 hours
and 72 hours and is accompanied by symptoms like nausea, vomiting,
photophobia, phonophobia, sweating, diarrhea, paleness and in severe
cases – a fugue state.
Recently, attempts have been made to
simplify diagnosis by a family doctor by interviewing many people who
suffer from migraines and finding the most common complaints shared by
them all. It has been proven that a migraine can be positively diagnosed
if the patient has 2 out of 3 of the following symptoms:
Nausea, Photophobia, and Diminished Capacity.
In the US and Europe, around 16% of
the general population suffers from migraines. The phenomena is more
prevalent in women, standing at 20-23%, where only 10-12% of men suffer
from it. The frequency amongst prepubescent children stands equally at
4%, but rises more rapidly in women and peaks at the age of 40. Attack
frequency is around 1.5 per month, and about 10% experience an attack
once a week.
The quality of life
for a person suffering from frequent migraines is low, and considered as
one of the most debilitating diseases there are. The disease harms the
sufferer’s health, their family ties, their social functions and their
ability to study and work. This quality is similar to that of people
suffering from clinical depression and worse than of people who have
diabetes, high blood-pressure or just experienced a heart-attack.
Genetics
Migraines are known to be hereditary. Specifically, in one type of rare migraine, the hereditary cause was found in the 19th
chromosome of the area that regulates the absorption of calcium ions
into the cells, a function the cell requires to preform normally and
transfer signals to other cells. The genetic defect blocks the channels
the calcium is absorbed through, which leads to cell functions being
disturbed. The problem is that the gene responsible for the common
migraine has not yet been identified. At this time, a vast research is
being conducted in order to find the relevant genetic defect.
How Migraines Happen
Migraines are probably a disease in
the brain and not in a cardiovascular one as previously though. Auras
are probably caused by diminished functions of a certain part of the
cortex, which progresses in a steady pace and is accompanied by a
decrease of blood flow to those parts. The headache begins when
blood-flow decreases and therefor is not related to the expansion of
blood-vessels as previously thought.
The changes in the cortex seem to
affect the brain-stem, which causes the expansion and inflammation of
the intracranial blood vessels (most likely the cause of the pain). The
brain stem is the cause of the other symptoms, like nausea.
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Treatment
Treatment can be divided into
medicinal and behavioral. Behavioral treatment focuses on changing
certain habits and avoiding things that exacerbate migraines. It appears
that the brain of a patient suffering from migraines is affected by
extreme situations, and thus, they need to make sure they get regular
and sufficient sleep and food and avoid stress. In other words, people
who suffer from migraines must avoid states of extreme hunger, stress or
fatigue. In addition, some foods may also lead to migraines, so it is
important to recognize them and avoid them completely, though there is
no specific food that causes migraines, making recognizing these foods
an individual’s responsibility. A person suffering from migraines needs
to monitor their daily routine and pinpoint the things that exacerbate
or trigger migraine attacks in the first place. Since these triggers can
change from time to time, it can be very frustrating as this behavior
cannot guarantee cessation of migraines.
Medicinal Treatment:
Treating a severe attack:
This treatment can be divided into specific treatment by specialized
migraine medicine called “Triptans”, and non-specific treatment by
general painkillers like paracetamol, Aspirin, etc. Specialized
treatment in only effective for migraines and is not effective for other
kinds of headaches, while non-specific medicine is meant for general
use.
Triptans are a relatively new kind of
medicine, which works on the serotonin receptors in your brain. These
receptors are located on the blood vessels in the brain, mainly in the
cerebral cortex and the nerve-endings related to these blood vessels.
The drug’s effect on the receptors prevents the expansion of these blood
vessels and the inflammation that is typical to migraines.
Side-effects of triptans include
weakness, a feeling of pressure and discomfort in the chest which are
not heart-related, aren’t dangerous and usually pass quickly. Reaction
to these drugs is very individual and cannot be predicted, so it might
be necessary to try different variations until one finds the kind that
is most effective for them, with minimal side-effects.
These drugs are safe and effective, and often significantly increase a patient’s quality of life.
In recent studies, the use of
triptans early on during the onset of a migraine effectively stopped the
progression of the attack and often prevent a recurring attack.
Preventative Treatment:
Meant to reduce the frequency, intensity and duration of a migraine.
Such treatment should be undertaken when a patient has at-least 3-4
attacks every month, which debilitate the patient, disturbing their
daily routine, and in cases where severe symptoms occur or when treating
attacks that are in progress fails.
Preventative drugs include beta-blockers, antidepressants, epilepsy medicine, calcium channel blockers and anti-inflammatories.
It’s recommended to start with a low
dosage and gradually increase it. 6 to 8 weeks should be provided to
establish the efficacy of the treatment and it should be undertaken for
at-least 6 months. If an attack occurs during the course of the
preventative treatment, a patient may use drugs like triptans in
conjunction.
Choosing the type of preventative
treatment depends on a patient’s state of health, occurring side-effects
and counter indications. In fertile women, pregnancy must be avoided
for the duration of the treatment.
The most effective
migraine-preventing drugs are beta-blockers (such as Nadalol,
Metaprolol, Propranolol and others). These drugs cannot be used on
patients suffering from asthma, insulin-dependent-diabetes and
congestive heart failure. People who participate in competitive sports
may experience a decrease in physical fitness.
In recent years, epilepsy medicine
has also been used for preventative treatment. The leading kinds are
sodium valproate and topiramate. Their efficacy is similar to that of
beta-blockers. Both kinds are quite tolerable, making their use popular.
Depending on a patient’s state of health, antidepressants, calcium
channel blockers or anti-inflammatory drugs may be used in addition.
Daily Chronic Headache:
Recently, there is more evidence showing that migraines are a
progressive disease that can transform into daily chronic headaches.
This transformation is linked in 70% of cases to over-use of
painkillers, but it can also be spontaneous without an indicating cause.
Sometimes, the pain starts out as a
daily occurrence and the causing mechanism is unclear. It is theorized
that it may be the result of new patterns that form in the central
nervous system. The pain threshold is reduced to a minimum triggering
the pain for external and internal stimuli that normally wouldn’t
trigger a headache or migraine.
This information radically changes
the way neurologists consider preventative treatment. Early intervention
may prevent the progression of the disease into a daily state, as well
as the creation of irreversible changes in the brain and increased
resistance to any form of treatment.
Through this review, we can see that
today, more than ever before, we have a lot of information, with more
becoming available all the time, as to what causes migraines, how they
form and the tools in which to deal with it. Treatment today includes
both the use of specialized drugs that are effective in over 80% of
cases in conjuncture with effective, preventative treatment.
In conclusion, the days where
doctors say they have "no way of treating migraines" are over. Instead,
modern medicine now has a lot to offer in most cases and it is highly
recommended that you talk to your family doctor and ask for an effective
treatment for migraines.
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vendredi 31 octobre 2014
How Migraines are Diagnosed and Treated
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