Chronic Migraines: Is the relief possible?

This disorder isn't caused by the frequent use of painkillers as some people think. The word migraine comes from the Greek word- hemicrania, which means literally, “half of the head" because the pain is often localized in one side of the head only. Chronic migraines may occur from overuse of migraine medications (rebound headache) or may develop over time (transformed migraine).

Signs and symptoms of migraine

Although the signs and symptoms of migraine vary among patients, there are four common characteristic phases in most patients:

1. The prodrome, which occurs hours or days before the headache
2. The aura, which immediately precedes the headache
3. The headache phase
4. The postdrome

The prodrome phase

Prodromal symptoms occur in 40% to 60% of patients that suffer from migraines. What are the characteristic symptoms of this phase? It is mostly characterized with:

• altered mood,
• irritability,
• depression or euphoria,
• fatigue,
• yawning,
• excessive sleepiness,
• craving for certain food and
• other vegetative symptoms

A typical patient is experiencing these symptoms about several hours or days before the real headache, so he or she can tell that the migraine attack is near.

The aura

This phase appears gradually over 5 to 20 minutes before the headache and usually subsides just before the headache begins. Symptoms of migraine aura can be different:

Visual aura

It is the most common and it is accompanied by the disturbance in vision consisting usually of unformed flashes of white or rarely multicolored lights. Some patients complain about blurred or cloudy vision, as though they were looking through thick or smoked glass.

The Somato-sensory aura

The most common symptom of Somato-sensory aura is a feeling of pins-and-needles experienced in the hands and arms as well as in the nose-mouth area. These sensations migrate up the arm and then extend to involve the face, lips and tongue.

The headache

The headache is often very characteristic. The typical migraine headache is unilateral, throbbing, with moderate to severe pain and can be aggravated by physical activity, but patient must realize that not all of these features are necessary. The pain may be bilateral at the onset, or start on one side and become generalized, usually alternating the sides from one attack to the next. The onset is usually gradual. The pain peaks and then subsides, and usually lasts between 4 and 72 hours in adults and 1 to 48 hours in children. The intensity of pain can also vary. There are some conditions that may accompany migraine. Anorexia is common, and nausea occurs in almost 90 percent of patients, while vomiting occurs in about one third of patients.

Many patients experience sensory disorders such as:

• photophobia,
• phonophobia,
• osmophobia

That’s why they seek a dark and quiet room. Beside the strong headache patients often experience

• blurred vision,
• nasal stuffiness,
• diarrhea,
• polyuria,
• sweating,
• edema of the scalp or face,
• scalp tenderness,
• prominence of a vein or artery in the temple,
• stiffness and tenderness of the neck.

The postdrome phase

After this strong headache, the patient often feels tired, irritable, and listless and may have impaired concentration, scalp tenderness or mood changes. 

Pathophysiology of the condition

The truth is that scientists are unclear about the precise cause of migraine headaches. However, most of them are sure that a key element is blood flow changes in the brain. The most famous theory is theory which explains these blood flow changes and also certain biochemical changes that may be involved in the headache process. According to this theory, the nervous system responds to some triggers by causing a spasm of the nerve-rich arteries at the base of the brain. The spasm constricts several arteries supplying blood to the brain, including the scalp artery and the carotid or neck arteries. As these arteries constrict, the flow of blood to the brain is reduced and at the same time, blood-clotting particles clump together. Some believe that all this is regulated by a substance called serotonin. It is logical to assume that reduced blood flow decreases the brain's supply of oxygen which is causing several neurological symptoms such as a headache, distorted vision or speech impairment similar to symptoms of a stroke.
The next part is well studied. When the oxygen supply is reduced, arteries in the brain open wider to meet the brain's energy needs. That’s the key point because the dilation of these arteries triggers the release of pain-producing substances called prostaglandins from various tissues and blood cells.

The most common migraine triggers

What exactly is a migraine trigger? A migraine trigger is any factor that leads to the development of an acute migraine headache.

Triggers may be categorized as:

• behavioral
• environmental
• infectious
• dietary
• chemical
• hormonal

The  triggers that are the most commonly reported include stress, over-illumination or glare, alcohol, foods, too much or too little sleep, and weather.
The good thing is that migraine patients can identify personal headache triggers and then try to avoid headache by avoiding factors they identify as triggers.

Food

Many studies have discovered that alcohol, caffeine withdrawal, and missing meals are the most important dietary migraine precipitants. Most of the people are not aware that the experts found little or no evidence that notorious suspected triggers such as chocolate and cheese, or specific substances such as nitrites which are normally present in foods as well as histamine or tyramine trigger headaches.

On the other hand, most of the experts recommend eliminating the following common headache triggers from the diet:

• Aged Cheese,
• Monosodium Glutamate,
• Processed fish and
• Meats containing nitrates,
• Dark chocolate,
• Aspartame,
• Certain alcoholic beverages (red wine),
• Citrus fruits
• Caffeine

Weather

Several studies have found that migraines can be triggered by the changes in weather.  Most likely to trigger a migraine were, in the following order:

• Temperature mixed with humidity. High humidity plus high or low temperature was the biggest cause.
• Significant changes in weather
• Changes in barometric pressure

Winds were also a topic of interest for many studies. The number of people reporting migraine episodes during the winds was much higher then in winds-free days.

Treatment of migraine

Trigger avoidance

Probably the best possible treatment for a chronic migraine is trigger avoidance! Patients can attempt to identify and avoid factors that promote or precipitate migraine episodes. In most cases, a general dietary restriction has not showed to be an effective approach to treating migraine.

Symptomatic control

Migraine sufferers have noticed that a cold or hot shower, a wet washcloth, or less often a warm bath and resting in a dark and silent room may be as helpful as medication for them, but both should be used when needed. Pain killers are recommended by most of the experts. The problem is that many patients avoid taking the medications when the attack is beginning, hoping that it will go away. This is wrong because treating the attack at the onset can often abort it before it becomes serious, and can reduce the frequency of subsequent attacks in the near-term.

Over-the-counter abortive medications

The first line of treatment should be over-the-counter abortive medication.
Doctors often recommend simple analgesics, such as paracetamol, Aspirin and caffeine. They may provide some relief, although they are not effective for most sufferers.

Narcotic pain killers

Narcotic pain killers, codeine, morphine or other opiates are proven to provide variable relief. However they have several possible side effects, such as the possibility of causing rebound headaches or analgesic overuse headache, and the risk of addiction.

Selective serotonin receptor agonists

Selective serotonin receptor agonists are becoming the therapy of choice for severe migraine attacks that cannot be controlled by other means. They are highly effective, reducing the symptoms or aborting the attack within 30 to 90 minutes in 70-80% of patients. They have few side effects if used in correct dosage and frequency.

Some members of this family of drugs are:

• Sumatriptan (Imitrex®, Imigran®)
• Zolmitriptan (Zomig®)
• Naratriptan (Amerge®, Naramig®)

Preventive drugs

Patients who have more than two headache days per week are usually recommended to use preventatives and avoid overuse of acute pain medications. The most effective prescription medications include several classes of medications such as beta blockers, antidepressants and anticonvulsants.

Physical therapy

According to many physicians, exercising for 15-20 minutes per day is helpful in reducing the frequency of migraines. Massage therapy and physical therapy are often also very effective forms of treatment in reducing the frequency and intensity of migraines. Patients should also be aware of the fact that deep massage can trigger a migraine attack in a person who is not used to such treatments.

Herbal supplements

• Butterbur (Petasites hybridus) rhizome extract
• Cannabis
• Supplementation of coenzyme Q10
• The plant feverfew (Tanacetum parthenium)
• Magnesium citrate
• Kudzu root (Pueraria lobata)