What is a migraine?

Worldwide, a migraine is a prevalent neurological condition casing uncomfortable headache that affects individuals and society alike. In fact, migraines affect 15% of people in the united states leading to a detrimental effect on their quality of life and their ability to carry out work, family, and social activities. To clarify, migraine causes severe pain on one side of the head, usually accompanied by nausea, vomiting, phonophobia and photophobia.

Episodic and chronic migraine:

It is common for migraine headaches to last for many years or over the course of a person's life life. By definition, episodic migraine headaches occur on fewer than 15 consecutive days each month. Meanwhile, Symptoms of chronic migraine are defined by the recently revised beta diagnostic criteria for International Classification of Headache Disorders (third revision). Actually, they defined it as headaches at least 15 days a month for at least 3 months, with migraine symptoms at least 8 days a month. Besides, the frequency or intensity of episodic migraine can revoke, remain constant, or progress over time to high-frequency episodes or chronic migraines.

What causes migraine?

Genes and inheritance play a big role in migraines, as well as CADASIL, MELAS, HIHRATL, RVCL, HERNS, and numerous other triggers.

Genes and inheritance: Genetic factors are strongly implicated in migraine. For instance, near relatives of affected individuals have a three-fold higher risk for migraines than those of non-affected relatives. However, there may be multiple genetics sources acting in synergy environmental factors to produce migraine rather than a single gene at a specific loci. Therefore, these genes could help predict the type of migraine treatment a patient would benefit from.

Familial Hemiplegic Migraine: It is possible to develop hemiplegic migraine sporadically or in families. Without doubt, mutations in the CACNA1A gene, the ATP1A2 gene, and the SCN1A gene are all caused by channelopathies. Moreover, other familial causes are a mutation in PRRT2 gene and mutations in the SLC4A4 gene.

CADASIL: It stands for cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. Furthermore, it's a form of autosomal dominant inheritance that manifests as migraine with aura (prodrome in 80% of carriers) caused by NOTCH3 gene mutation on chromosome 19.

MELAS: A recurrent migraine headache can be present in MELAS syndrome because of mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes. Indeed, it's a maternally inherited multisystem disorder.

HIHRATL: Hereditary endotheliopathy with retinopathy, nephropathy, and stroke.

Other triggers: 

A survey found that almost two out of three patients reported triggers that contributed to migraine headaches. Some of the triggers are probable while others are only likely or unproven.

• Stress plays a significant role in 80% of cases
• Hormonal (menstruation, ovulation and pregnancy) changes play a role in 65% of cases
• Skipped meals account for 57 percent of cases
• Weather has an impact on 53% of cases
• Insufficient sleep could be a cause 50% of cases
• Odors play a role in 40% of cases
• Exercise contribute to 22%
• Pain in the neck seems to be a factor in 38.8 percent of cases
•  Light exposure in 38% 
• Alcohol consumption in 38%
• Smoking in 36% of cases
• Late sleeping was present in 32% of cases
• Heat causes 30% of the disease
•  food causes 27% of cases (aspartame and tyramine considered potential factors)

Migraine symptoms:

Migraines are a neurological condition that affects both children and adults at different stages. While not everyone experience these stages, they are prodrome, aura, headache and post-drome.

• Prodrome is characterized by premonitory symptoms where a headache usually begins 24 to 48 hours of experiencing symptoms. To illustrate, some of the symptoms that people experience frequently include yawning, mood changes, feeling cold, lethargy, neck symptoms, light sensitivity (photophobia), restlessness, difficulty focusing vision, craving, sound sensitivity, sweating, overactive energy, thirst, and edema.
• Aura where around 25% of patients experience cortical dysfunction, changes in blood circulation and neurovascular integration. Further, they usually occur prior to headache onset, and they are gradual. In addition, aura last less than 60 minutes, and are more often visual in nature. Evidently, patients have positive and negative symptoms. While the first is caused by the release of active neurotransmitters in the central nervous system, negative symptoms suggest that the body isn't functioning as it should. In addition, to visual auras, sensory auras are also common, and they can occur alongside or without visual symptoms. Also, language auras are not common, and they consist of temporal dysphasia. Finally, rare motor auras are mostly associated with hemiplegia. 

• Headache where more modifications affect the blood flow. The function of the brainstem, thalamus, hypothalamus, and cortex are also affected. In most cases, it is unilateral, characterized by a pulsatile or throbbing sensation, and then becomes increasingly intense over hours or even days. Symptoms of the condition include nausea, vomiting, lachrymation, allodynia, photophobia, phonophobia, rhinorrhea, and osmophobia.
• Postdrome is a pain that persists despite termination of a headache, often linked to symptoms such as headache, exhaustion, dizziness, difficulty concentrating, and euphoria.

Migraine treatment:

There are typically three primary objectives to get rid of migraines: relief of pain, restoring function, and reducing headache frequency; preventing migraine progression may also be an an objective. As a matter of fact, injections of onabotulinumtoxinA are prescribed for chronic migraine, but five US Food and Drug Association strategies are approved for episodic migraine. To illustrate, treatment can vary significantly according to the patient's condition and symptoms.

Abortive or acute treatment:

Treatment of an acute headache involves treating it rapidly, and with one large dosage. In patients with migraine-induced gastric stasis leading to nausea and vomiting, oral agents may not be effective. Thus, parenteral medications may be essential.

• NSAIDs for mild to moderate attacks with no nausea and vomiting.
• Triptans to treat moderate to severe attacks. Do not use if you are pregnant, or suffer from ischemic stroke or heart disease, hypertension, angina, hemiplegic or basilar migraine.
• Antiemetics to decrease vomiting or nausea.
• If conventional treatment is not working, or if a patient suffers from coronary artery disease, calcium-gene-related peptide antagonists could be considered.
• Blocking of the peripheral nerve.
• There are no medications that can be prescribed for acute attacks as parental medicines, but ergot can be inhaled as a bridge therapy for migraines caused by overuse of medication or status migrainosus.
• In the short term, dexamethasone has been shown to reduce the occurrence of headaches in the early stages, but it does not alleviate headaches immediately.
• It's possible to reduce the intensity of pain by transcutaneous stimulation of the supraorbital nerve.
• In patients with epilepsy, transcranial magnetic stimulation is not safe. However, transcranial magnetic stimulation is an effective second-line treatment without serious side effects, and works against chronic migraines.
• Some might benefit from nonpainful remote electric neuro-stimulation.

Preventive or prophylactic treatment:

Promotes a reduction in migraine frequency, improves reactivity to acute attacks' severity and duration, and reduces disability. Treatments used are beta-blockers, antidepressants, calcium channel blockers, anticonvulsants and Calcitonin gene-related peptide antagonists.

Other or alternative treatment: 

Such as yoga, exercising, relaxation, lifestyle change, detoxification, melatonin, etc...

Complications:

• Work disabilities
• Symptoms of seizures
• Brain infarctions
• Lost wages

References:

-Peters GL. Migraine overview and summary of current and emerging treatment options. Am J Manag Care. 2019 Jan;25(2 Suppl):S23-S34. PMID: 30681821.

-Lipton RB, Silberstein SD. Episodic and chronic migraine headache: breaking down barriers to optimal treatment and prevention. Headache. 2015 Mar;55 Suppl 2:103-22; quiz 123-6. doi: 10.1111/head.12505_2. PMID: 25662743.

-Gallagher RM, Cutrer FM. Migraine: diagnosis, management, and new treatment options. Am J Manag Care. 2002 Feb;8(3 Suppl):S58-73. PMID: 11859906.

-Pescador Ruschel MA, De Jesus O. Migraine Headache. [Updated 2021 Aug 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-