Migraine

Migraine is a severe, sudden, pulsating or throbbing headache, often accompanied by nausea and vomiting. In most cases, the headache only occurs on one side of the head. The length of a migraine attack can vary from four hours to three days.

Migraines are the most common type of headache, along with tension-type headaches. Women (about 14%) are affected almost twice as often as men (7%). Almost one in four women will suffer from a migraine at least once in their lifetime.

About five percent of children of prepubertal age also suffer from migraine attacks. People between the ages of 35 and 45 are most frequently affected. Furthermore, it can be observed that children of sufferers have an increased risk of also suffering from migraine.

The exact causes of migraine attacks are not yet fully known today. It is assumed that genetic factors play a major role, as migraine is more common in families with a parent with the disease. This assumption is also supported by various studies on twin siblings. In hemiplegic migraine - a special form of migraine - the disease-causing gene has been identified on chromosome 19.

Although the exact causes and triggers of migraine are not known, there are some theories on how the characteristic pain develops:

• It is assumed that various neurotransmitters (for example serotonin) play an important role in the development mechanism of migraine. These neurotransmitters are brain messengers that are stored in nerve cells and released in response to certain stimuli. Their function is to transmit inhibitory or activating signals to organs such as muscles, blood vessels, the heart or the digestive tract. A disturbance of the serotonin balance in the brain could lead to the development of migraine.
• Another theory is that a migraine is triggered by the activation of a so-called "migraine generator" in the brain stem. In migraine, there is a hyperexcitability of certain brain regions (especially the trigeminal nucleus) and a local inflammation of the nerve fibres that regulate the blood vessels at the base of the brain. The inflammatory process makes the vascular wall more permeable, allowing various substances to leak from the blood vessels and irritate the surrounding tissue. This also irritates the pain receptors of the trigeminal nerve as well as the trigeminal nucleus, intensifying the whole process itself and increasing the intensity of the migraine attack.

There are different factors (called triggers) from person to person that can trigger a migraine attack:

• Lack of sleep
• stress
• Very bright, glaring light
• hormonal fluctuations during menstruation, taking hormonal contraceptives or pregnancy
• nicotine (both active and passive smoking)
• alcohol
• heavy physical exertion
• in rare cases, foods such as red wine, chocolate and certain types of cheese

Different forms of migraine can be distinguished on the basis of the symptoms. The international classification defines two main forms: Migraine with aura and migraine without aura.

Migraine without a ura is the more common form. It is characterised by a slowly increasing, pulsating headache that usually affects only one side of the head and lasts between four and 72 hours. Migraines are often accompanied by nausea and vomiting. During the migraine attack, sufferers are particularly sensitive to noise and light - quiet and darkened places of retreat are therefore preferred. Everyday physical exertion, such as climbing stairs or walking quickly, can make the headache worse.

About one in ten sufferers also experience neurological symptoms called migraine with aura. The symptoms usually last no longer than 40 minutes and precede a headache attack. The following symptoms may occur singly or in combination:

• Speech difficulties
• visual disturbances such as visual field loss (black holes in the visual field), colored flashes of light, or zigzag lines across the visual field (called fortifications)
• tingling sensation or weakness in the arms or legs
• balance problems

Several studies show that the presence of migraine with aura in women before the age of 40 may increase the risk of stroke. However, this is only the case if other risk factors such as smoking, being overweight or taking the contraceptive pill are also present.

A migraine usually progresses in four phases:

• Prodromal phase (preliminary phase): Hours to days before a migraine attack occurs, it is heralded by various symptoms such as cravings, loss of appetite, increased irritability or euphoria.
• Aura phase: In about 10% of sufferers, the neurological symptoms (auras) described above occur shortly before the pain phase.
• Headache phase: This phase is manifested by the occurrence of the characteristic unilateral, pulsating headache for four to 72 hours, as well as hypersensitivity to noise and light.
• Regression phase: Here the symptoms slowly subside, but the sufferer still feels tired and fatigued. It can take another 12 to 24 hours to fully recover.

Migraine attacks may occur regularly at short intervals or may not occur for a long period of time, from several weeks to years. If a migraine attack directly follows the previous one, this is called status migraenosus.

As there are no specific laboratory tests to detect migraine, a detailed medical history in combination with a neurological examination is crucial. In certain cases, additional tests such as electroencephalography (EEG) or Doppler sonography may be useful to rule out the presence of other conditions.

Magnetic resonance imaging (MRI) of the head is recommended if the following factors are present:

• abnormalities on neurological examination
• First occurrence of migraine after 40 years of age
• Increase in frequency and intensity of migraine attacks
• Occurrence of many auras (neurological symptoms) at short intervals
• Sudden change in accompanying symptoms

When diagnosing migraine, it is also important to distinguish it from other forms of headache, such as tension headache, medication-induced headache or cluster headache. Furthermore, other diseases such as tumours, inflammations or head injuries must be excluded.

Since the causes of migraine are only insufficiently known, drug therapy primarily focuses on treating the symptoms. A distinction is made between therapy of the acute migraine attack and prophylaxis (prevention) before the attacks.

Depending on the severity of the migraine, different first-line medications are available:

• If the migraine attacks are mild to moderate, the early use of high doses of analgesics (painkillers) and non-steroidal anti-inflammatory painkillers such as acetylsalicylic acid, paracetamol, ibuprofen or diclofenac is recommended. Combination preparations of acetylsalicylic acid, paracetamol and caffeine are more effective than taking the individual substances, according to various studies.
• In severe migraine attacks, it is usually necessary to take so-called triptans (serotonin receptor agonists). These substances act on the serotonin receptors, thereby reducing the headache and combating migraine side effects such as nausea and vomiting. Triptans are most effective when taken early during acute migraine attacks. Many triptans are available in pharmacies in different forms, such as tablets, nasal sprays, suppositories and subcutaneous injections. Triptans can also be taken at the same time as other painkillers. Triptans must not be taken in the presence of coronary heart disease (CHD), Raynaud's syndrome, untreated hypertension (high blood pressure), severe liver and kidney dysfunction, after strokes and during pregnancy and breastfeeding.

The painkillers must never be taken in an uncontrolled manner. It is important to note that the medication must not be taken more than ten times a month and not for longer than three consecutive days, as otherwise drug-induced headaches may develop. If headaches occur frequently, a doctor should be consulted in any case.

In addition, other medications are available for treatment, but they cause more severe side effects:

• Ergotamines (ergot alkaloids): these are also used to control attacks in acute migraine attacks, but they cause side effects (for example, drowsiness, weakness) more frequently than triptans. Ergotamines are therefore only used as a replacement medication for very long migraine attacks or when first-line migraine medications (NSAIDs, triptans) are ineffective.
• Antiemetics: These medications are helpful for the severe nausea and vomiting associated with migraine attacks. Recommended agents such as metoclopramide (approved for adults only) or domperidone (also approved for children) have been shown to improve symptoms.
• Opioids (drugs containing opiates): As the effect of these painkilling drugs on migraine has not been proven and they are highly addictive, opioids should not be used.

Apart from drug therapy, special attention should be paid to getting enough rest and recuperation during a migraine attack. Staying in a quiet, darkened room will alleviate symptoms. Sleep, cold compresses or relaxation exercises can also be helpful.

As migraine is a chronic disease, the cause of which is poorly known and cannot be treated, migraine attacks cannot be completely prevented. However, with adequate therapy and lifestyle, the frequency and intensity of attacks can be reduced. If more than three migraine attacks occur per month, migraine prophylaxis with medication is recommended.

In some cases, migraine attacks occur less frequently after the age of 40. The reasons for this are not known at present. However, there is also the possibility that headaches increase in intensity over time. This may be the result of medication-induced headaches - this type of headache is triggered by taking painkillers or triptans too often.

Migraine prophylaxis with medication and lifestyle changes can have a positive effect on the frequency and intensity of migraine attacks. Behavioural stress management, relaxation exercises (such as Jacobson's progressive muscle relaxation or biofeedback) and cognitive behavioural therapy are effective methods of migraine prophylaxis without medication. Many patients also report the effectiveness of acupuncture treatment.

As migraine attacks are often preceded by certain triggers, such as lack of sleep, stress or nicotine, these triggering factors should be avoided if possible. A headache calendar can be used to analyse lifestyle habits and filter out personal triggers. The headache calendar records the timing, duration and intensity of headaches as well as accompanying symptoms, medication, lifestyle (eating and sleeping habits) and menstrual cycle.

In addition, eating and drinking large quantities in the evening should be avoided if possible. Alcohol consumption should be greatly reduced; at best, alcohol should be avoided altogether. Attention should also be paid to regular sleep patterns and sufficient sleep duration. Endurance sports such as jogging, cycling or swimming have also proved to be effective as a migraine prophylaxis. Regular physical activity increases well-being and counteracts migraine attacks.

If lifestyle changes are not enough to prevent migraine attacks, migraine prophylaxis with medication can be considered. This is recommended if the following factors apply:

• Occurrence of three or more migraine attacks per month.
• Persistence of migraine attacks for longer than 72 hours.
• Significant interference with quality of life, work or school attendance due to migraine attacks. F
• f medications have no effect during an acute migraine attack or cannot be taken due to intolerance.
• If a migranous infarction (persistence of aura symptoms for longer than 60 minutes, possibly in conjunction with reduced blood flow to the brain) has already occurred in the past.

The following agents are available for drug prophylaxis:

• Migraine prophylactics 1st choice: Here, for example, cardiovascular drugs such as beta blockers (propranolol, metoprolol), calcium channel blockers (flunarizine) or antiepileptic agents (topiramate, valproic acid) are available. In some cases, painkillers (naproxen) or antidepressants (amitriptyline) are also suitable for preventing migraine attacks.
• Migraine prophylactics of the 2nd choice: Here, for example, active substances such as gabapentin, venlafaxine, acetylsalicylic acid, magnesium and riboflavin (vitamin B2) are used. However, the migraine-prophylactic effect of these drugs has not been scientifically proven for all substances.

Prophylaxis can reduce the frequency, intensity and duration of migraine attacks by up to 50 percent. In addition, continuous headaches triggered by drug use (drug-induced headaches) can be prevented. It is recommended to combine drug prophylaxis with behavioural therapy measures such as biofeedback procedures or progressive muscle relaxation.