Understanding Migraines
What is a Migraine?
Migraines are not merely severe headaches; they are a complex neurological disorder impacting multiple regions of the brain. According to a World Health Organization (WHO) survey, severe migraines rank among the most disabling chronic disorders, comparable to conditions such as quadriplegia, psychosis, and dementia.
A migraine typically manifests as mild to severe head pain lasting between 4 to 72 hours. The pain is often unilateral, located on one side of the head, and is described as throbbing. Accompanying symptoms frequently include nausea, vomiting, and heightened sensitivity to light, sound, and movement. Various factors can trigger migraine attacks, including inadequate sleep, missed meals, stress, alcohol consumption, specific foods, flickering lights, noise, and certain scents.
The Phases of a Migraine
Research indicates that the origin of migraines is in the central regions of the brain, with initial symptoms such as irritability, depression, neck stiffness, food cravings, and fatigue occurring prior to the headache phase, known as the prodromal phase. Following this, some patients may experience auras, which are temporary neurological phenomena that typically affect vision. Patients may see spots, flickers, or zigzag lines, and may also experience sensory disruptions like pins and needles, numbness, or difficulty articulating words. It is important to understand that not all individuals with migraines experience auras.
The mechanisms linking the prodromal and aura phases to the headache phase remain unclear. One hypothesis suggests that these brain events cause the dilation of blood vessels surrounding the brain, activating pain-sensing nerves that generate the pain sensation.
The Role of Estrogen in Migraines
Estrogen is a significant migraine trigger, influencing the frequency and severity of attacks during menstruation, pregnancy, menopause, hormone replacement therapy, and the use of oral contraceptives. Migraine attacks are often linked to drops in estrogen levels, particularly during the luteal phase of the menstrual cycle, with many women reporting migraines two days before and three days after their period begins.
Migraine Treatments
Non-Pharmacological Treatments
Non-pharmacological approaches focus on changing behaviors to avoid triggers and incorporating relaxation techniques into daily routines. Recommended strategies include maintaining a balanced diet, avoiding missed meals, staying hydrated, limiting caffeine intake, exercising regularly, ensuring adequate sleep, and employing cognitive behavioral therapy and stress management techniques.
Pharmacological Treatments
While many individuals self-medicate for migraines, established treatments should be discussed with healthcare providers. Medications for acute migraine attacks can be categorized as specific or non-specific treatments. Non-specific treatments include analgesics such as aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs, and opiates, which are used to alleviate general pain. Specific migraine treatments include ergotamine, dihydroergotamine, and triptans (including sumatriptan, zolmitriptan, and others) that target neurovascular headaches.
Preventative Medications
For some patients, acute migraine treatments may be ineffective, necessitating the use of preventative medications that are taken daily, even in the absence of symptoms. These aim to reduce the frequency and severity of migraine attacks. Common preventative medications include β-blockers (such as propranolol and metoprolol), botulinum toxin type A, angiotensin-converting enzyme (ACE) inhibitors, tricyclic antidepressants, calcium channel blockers, and antiepileptic drugs.
For women with hormonally-associated migraines, oral contraceptives can provide a continuous supply of estrogen, thereby reducing attack frequency. Additionally, certain vitamins and minerals, such as magnesium and riboflavin (vitamin B2), are considered ‘probably effective’ for migraine prevention by the American Academy of Neurology.
Recent advancements have introduced antibodies that target the calcitonin gene-related peptide (CGRP) and its receptor, proteins involved in migraine pain pathways. The first of these treatments, Erenumab, received FDA approval in 2018, although its high cost and injection method present challenges for patients.
Migraine Management
Migraines can be debilitating, and while there is no definitive cure, various pharmaceutical and non-pharmaceutical options exist to help improve the quality of life for those affected. Finding the most suitable treatment is a vital discussion to have with a primary care provider or specialist.
References
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Novartis and Amgen announce FDA approval of Aimovig (Tm) (erenumab), a novel treatment developed specifically for Migraine Prevention. Novartis. May 18, 2018. https://www.novartis.com/news/media-releases/novartis-and-amgen-announce-fda-approval-aimovigtm-erenumab-novel-treatment-developed-specifically-migraine-prevention.