Migraine BasicsLast Updated:
Several readers have already asked enough great questions about migraine to fill a month’s worth of blogging, so I thought I would jump right in with some of the basics. One of the biggest hurdles to good migraine treatment is getting an accurate diagnosis. As common as migraine is, you would assume that any primary care doctor could diagnose and treat it. While that may be the case for someone with mild, infrequent attacks, it isn’t always true.
Getting a diagnosis
During medical school, doctors receive about four hours of instruction on headache disorders. That’s it — just one afternoon to learn everything there is to know about over 200 different headache disorders. No one can become an expert under those circumstances. There are doctors who specialize in headache medicine — usually neurologists who have completed advanced training and are board certified Headache Specialists. Others began specializing long before this training existed, so lack of board certification doesn’t necessarily mean they are not competent. However, there are many doctors, dentists, chiropractors, and other health care providers who claim to treat headaches but do not have up to date training.
Finding the right doctor
The best way to find a qualified headache specialist is to check the United Council for Neurologic Specialities list of Headache Medicine diplomates. These headache specialists all use the same criteria when diagnosing a patient who complains of headache. Their source is the International Classification of Headache Disorders, 3rd Edition (beta). This guide is available for public download to anyone with an internet connection.
Migraine’s shared symptoms
While time and space constraints will not permit me to list and explain every single headache disorder, I would like to give you a glimpse into the common symptoms of all forms of migraine. Most people think that migraine involves a bad headache. It is also common knowledge that people with migraine may vomit and crave quiet darkness. Some have even heard of auras, but few really know what this is. All of these symptoms are true, sometimes, for some people.
All migraine diagnoses have one thing in common.
Migraine is a genetic, neurological disease. Yes, it’s a disease, not a headache. It’s a little like epilepsy. Someone with epilepsy won’t have seizures all the time. Between seizures, that person still has epilepsy and must take medication and maintain a healthy lifestyle to reduce the risk of more seizures. Sometimes medicine stops the seizures completely, but sometimes no medicine helps at all. As with epilepsy, migraine has triggers that set off attacks. What most people think of when they hear the word “migraine” are actually attacks, or flare-ups. A 2014 study demonstrated that the brains of migraine patients are hypersensitive to stimuli even between attacks. When exposed to a sufficient number of triggers, an attack will begin. Good migraine treatment seeks to reduce a persons reactivity to triggers and help them avoid known triggers whenever possible (more on triggers tomorrow).
Attacks occur in four phases
Because the entire nervous system is involved in a migraine attack, symptoms affect the whole body. Patients have difficulty concentrating or communicating. Their reaction times are slowed. Digestion slows down (or stops altogether) and can set of nausea and vomiting. Patients may yawn uncontrollably, feel depressed, irritable, or energetic, or experience tinnitus. Light and sound become painful. This “prodrome” can go on for up to two days before the headache phase begins.
You may have heard about aura and seen photographs of wavy lines across a person’s visual field. While likely the most famous aspect of migraine, aura only occurs in less than 25% of all migraine patients. Even among patients diagnosed with migraine with aura, very few ever get the stereotypical aura. More often, they will experience blind spots or flashing or twinkling lights. They may experience odd sensations such as tingling or hear noises or smell odors that don’t exist. For patients with hemiplegic migraine, the symptoms can even mimic a stroke. People can garble their words and experience one-sided paralysis or weakness. In rare cases, patients feel as though parts of their body are much larger or smaller than reality. This is called Alice in Wonderland Syndrome. Yes, Lewis Carroll had migraine and it is speculated that much of his experience with this disease is reflected in his written work.
Once the headache begins (if it even starts at all) the pain can be very mild and respond to over-the-counter pain relievers such as aspirin, naproxen, or a caffeine-containing combination like Excedrin. For most patients the pain is severe enough that prescription medicines are required though.
The first-line treatment for an acute migraine attack is a class of drugs known as triptans. There are several different medicines in this class and multiple delivery methods. The chosen triptan is based on a number of factors including the presence of nausea and vomiting, average duration of attacks, the presence of menstrually-related attacks, affordability, and insurance coverage.
Triptans available by prescription in the US:
- Imitrex (sumatriptan)
- Sumavel Dose Pro (sumatriptan by auto-injector)
- Maxalt (rizatriptan)†
- Maxalt MLT orally-disintegrating tablets†
- Relpax (eletriptan)
- Axert (almotriptan)*
- Zomig (zolmatriptan)*
- Zomig Nasal Spray
- Zomig ZMT orally-disintegrating tablets*
- Amerge (naratriptan)
- Frova (frovatriptan)
†FDA-approved for children as young as 6 years old
*FDA-approved for adolescents 12-17
Unfortunately, not everyone with migraine can tolerate triptans. For some people, triptans are contraindicated due to other medical conditions. These patients must rely on older, less effective medicines such as DHE, barbituates, and opioids. These older medicines also carry greater risks.
The headache phase typically lasts 4 to 72 hours. Any attack lasting more than 72 hours is considered an emergency and should be checked out by a doctor right away to rule out more serious problems and provide stronger medicines to help break the cycle of pain.
Once the headache subsides, patients still have to contend with several hours of sensitivity to light, sound, and odors, plus fatigue and difficulty concentrating or communicating. It’s called “postdrome” and feels a lot like a hangover.
All phases not required
Even if one or more of these phases is not present, a person may still have migraine. Whatever is going on in the brains of migraine patients produces strange symptoms that can make a person feel as if they are going crazy. If your friend has migraine and describes symptoms that sound unbelievable, trust them. They are not making it up or trying to avoid responsibilities. Frankly, it’s a wonder they can function at all.
How to help
When a friend or loved one experiences a migraine attack, here are a few simple steps to help them.
- Be quiet. Whisper if you must.
- Turn off as many lights as possible.
- Offer to help find their medicine, a glass of water, an ice pack, or anything else they might need.
- Give them space, but stay close by in case you are needed.
- Be patient. An attack can last for days.
- Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd edition (beta version).” Cephalalgia. July 2013 vol. 33 no. 9 629-808 10.1177/0333102413485658.
- Robert, Teri, Anatomy of Migraine, Health Central, August 1 2014, retrieved online at http://www.healthcentral.com/migraine/understanding-migraine-29375-5.html
- Schwedt, Todd J, Zuniga, Leslie and Chong, Catherine D, Low heat pain thresholds in migraineurs between attacks, Cephalalgia 0333102414550417, first published on September 22, 2014 doi:10.1177/0333102414550417
- Schwedt, Todd J, Krauss, Melissa J, Frey, Karen, and Gereau IV, Robert W, Episodic and chronic migraineurs are hypersensitive to thermal stimuli between migraine attacks, Cephalalgia January 2011 31: 6-12, first published on April 7, 2010 doi:10.1177/0333102410365108
This article is part of the July 2016 Ultimate Blog Challenge