A migraine is a primary headache disorder characterised by recurrent headaches that are moderate to severe. It is the most common complaint with which patients present to a clinician.
Migraine was first comprehensively classified in 1988, which was updated by “The International Headache Society” in 2018 which is widely used by pain physicians now.
The six-subclasses of Migraine:
Most common type of migraine headache, which doesn’t have an early symptom called an aura before headache begins.
Aetiology and pathogenesis:
According to theory several chemical mediators play a role in migraine. A wave of nerve cell activity spread across the brain and triggers trigeminal neuralgia.
There is release of variety of neurotransmitters causing inflammatory process and pain.
It often runs in family, so there might be genetic link according to researchers.
There can be triggering factors like certain foods, smells, stress, loss of sleep, etc.
Often begin in childhood and gets worsened by adolescence.
Interesting fact “more boys than girls” have migraine but “more adult women than men” have migraine.
A migraine without aura is “not life-threatening”.
Throbbing or steady headache in the front. • One or both sides
Last for 4-72 hours
Can be associated with nausea, vomiting, dizziness
Can get aggravated with routine activity, light and sound.
The International headache society recommend the 5-4-3-2-1 criteria to diagnose migraine. This number series stands for
Occurring on one side; Pulsating; Causing moderate to severe pain aggravated by activity
Nausea, Vomiting, Sensitivity to light, Sensitivity to sound
Clinical history: to rule out other causes of headaches.
History of at least 5 attacks fulfilling the above criteria.
Imaging studies- CT, MRI
Management of acute attacks
First line of medicines:
Goals: Reduce the attack frequency, severity, and disability. Avoid acute headache medication overuse. Improve the quality of life. Reduce headache-related distress and psychological symptoms.
Recurring migraines significantly interfere with their daily routines, despite acute treatment
Failure or overuse of acute therapies.
Uncommon migraine conditions, such as hemiplegic migraine, basilar migraine, migraine with prolonged aura.
Medicines for prophylaxis:
The prophylactic medicines have been placed to 5 different classes based on efficacy and safety. Different class of medicines are medicine of choice depending on the co-morbidities. Single medicine or medicine combinations can be tried but a beta blocker and flunarizine combination should be avoided.
In Indian set up the medicine dosage required are much lesser compared to western population.
Non pharmacologic interventions:
Article written by:
Dr. Hamsa Jayasheel.
MBBS, DA, DNB Anaesthesiology
Pain fellow @ Daradia Pain Hospital