THE WORD “MIGRAINE” IS KNOWN TO EVERYONE FROM CHILD, from books, but for some reason it is often considered a synonym for severe headache. Despite the prevalence of this disease, which occurs in 12-18% of women and 6% of men, awareness of it remains surprisingly low. Together with a neurologist Denis Korobko, we understand what a migraine is, how it differs from an ordinary headache, and why it is useless to treat it with antispasmodics.
How does a migraine progress and what is an aura?
Migraine is a chronic illness, the main symptom of which is, indeed, a severe headache. Very often there is nausea, up to vomiting, so that the first migraine attack can easily be mistaken for poisoning. Headache and nausea can be accompanied by a fear of light and sound, when any external stimulus instantly worsens the condition. According to the WHO, in the UK alone, migraines are responsible for the loss of 25 million hours of work and school each year; this is one of the most important causes of disability. The fact is that an attack of headache, nausea, photophobia can last for several days; at this time, almost the only thing the patient is capable of is lying in a dark room under a blanket, trying to fall asleep in the hope that the attack will eventually end.
In about a quarter of patients, a migraine attack is preceded by a so-called aura, that is, additional symptoms from the nervous system. The visual aura is the appearance of “blind spots”, narrowing of the field of vision, the appearance of luminous zigzags before the eyes; most often the aura is described as an iridescent zigzag at the periphery of the field of view of one of the eyes, which gradually expands. Sometimes the so-called Alice in Wonderland syndrome develops , when the dimensions of the surrounding objects and even their own body parts are distorted. It may seem that one’s own legs or arms have become gigantic, and the furniture around has shrunk to a toy; it is believed that Lewis Carroll suffered from migraines and reflected an aura in Alice’s adventures. Aura can include auditory effects, dizziness, skin numbness or tingling sensation, confusion, and memory impairment.
Why is this happening?
Migraine is a neurological process that is only partially understood. It is already known that the aura is associated with a reversible, temporary, disruption of electrical activity in the cerebral cortex. At the chemical level, these disorders are caused by shifts in the ionic composition, when potassium ions leave the cells into the extracellular space, and calcium and sodium, on the contrary, move into the cells. This process is called cortical spreading depression (or depolarization); this means that suppression of electrical activity occurs in the cerebral cortex, which expands in waves to larger and larger areas. The term “depression” in this case is used as a synonym for oppression, suppression, and has no psychological relationship to depression. Now neurologists from different countries have come to a common opinion that this process is the main mechanism of migraine, and not just auras, as was previously thought; most likely, a migraine without an aura develops in the same way.
Scientists have been able to identify certain triggers that provoke migraine attacks in some (but not all) patients. Frequent triggers include stress, lack of sleep and changes in regimen, caffeine, hunger and associated hypoglycemia, and mild dehydration. Exercise can both prevent and provoke migraines. Triggers have traditionally included certain foods (such as chocolate, cheese, and red wine), although recent studies have disproved the association of migraines with chocolate consumption, and only 10% of patients with migraines reported alcohol as a trigger for migraines . Unfortunately, not so much is known about migraine so far, and it is impractical to recommend all patients to refuse the same products; journaling can help identify personal triggers (if any).
Is migraine related to hormones or lifestyle?
Migraine has a significant hormonal component and is two to three times more common in women than in men. About half of women with migraines clearly associate attacks with the menstrual cycle. There is also a separate condition called menstrual migraine , which is associated with cyclical declines in estrogen levels. At the same time, there is no specific analysis, the results of which would allow the patient to say: “Your level of such and such hormone is low, and this is the cause of migraine.” In such cases, stabilizing estrogen levels can help; estrogens can be prescribed alone or as part of combined oral contraceptives. The problem is that if some women are helped by COCs to get rid of migraines, then they become the trigger for others. Unfortunately, migraines with aura that occur while taking COCs are a direct indication for their cancellation due to an increased risk of stroke; combined contraceptives in this case can be replaced with progestin.
Periods of hormonal changes, such as pregnancy or menopause, can also affect the course of migraine, and unpredictably: from complete disappearance or at least a decrease in the frequency and severity of attacks until they appear for the first time in life. The fact that hormone replacement therapy after menopause can help get rid of migraines in one woman, but provoke it in another does not improve the situation. In the same patient, different drugs may have the opposite effect. Lifestyle also does not affect the risk of migraine unequivocally. Previously, migraines were called a disease of aristocrats, implying that only those who are not engaged in physical labor have free time to listen to themselves and complain about headaches. But in the early 2000s, Russian scientists conducted a large epidemiological study, and it turned out that the prevalence of migraine is the same among people with different levels of education, engaged in different types of work. So far, the only proven risk factor for migraine is genetics: in more than 70% of patients with migraine, it is also noted in relatives.
How is migraine treated?
So far, no drug has been created that could affect the alleged cause of migraine, that is, an imbalance in electrolytes (potassium, sodium and calcium) and a change in the electrical activity of the brain. But the mechanism of development of migraine involves the expansion of blood vessels, which can be affected. For this, drugs of the triptan group are used; the most studied and widespread of these is sumatriptan. In addition to him, zolmitriptan, naratriptan, eletriptan and frovatriptan are registered in Russia. The newest triptan, rizatriptan, is not yet sold in Russia, but many patients bring it from Europe. Sumatriptan is available as a tablet and as a nasal spray (and is also available for intramuscular injection in the US). You need to take the dose as soon as possible after the onset of the headache. At the same time, triptans do not prevent an attack, therefore it is useless to take them during the aura.
In difficult cases, when seizures occur very often or are especially difficult, and triptans do not give the desired effect, another treatment may be selected. Ergotamine (an ergot alkaloid) and opioid analgesics are used to treat severe migraines. Both in Russia are dispensed strictly according to the prescription; these are unsafe drugs, and treatment with them should be carefully coordinated with your doctor. With migraines with a hormonal component, COCs or hormone replacement therapy can be prescribed or canceled, as described above. Migraine prophylaxis is usually not done if the attacks occur no more than twice a month. For frequent migraines, low-dose antidepressants, anticonvulsants, or beta-blockers may be prescribed for prophylaxis; selection of treatment depends on concomitant diseases.
Antispasmodics like spazmalgon or noshpa are ineffective for migraines and can even worsen the condition by further dilating the vessels. For mild attacks, common NSAIDs, such as aspirin, paracetamol, or ibuprofen, sometimes help. Recently, evidence has emerged that infantile colic, which is commonly associated with abdominal pain, is nothing more than a migraine. The new recommendation includes treating colic with paracetamol and eliminating stimulants (i.e. staying in darkness and silence). It is also important for adults to find an opportunity to lie down, and it is better to sleep, in a dark, quiet and warm room, taking medication. Various new treatments for migraine are being studied, including electrical stimulation of the occipital nerve and Botox injections, but it is too early to talk about their effectiveness.
Which doctor should I go to?
Neurologists are involved in the diagnosis and treatment of migraines. Usually the diagnosis is made on the basis of the clinical picture, that is, a description of how the headache attacks proceed, what the aura looks like (if any), how often these conditions occur and how long they last. Primary migraine is also called idiopathic; this means that it is not caused by any other medical condition. The efficacy of triptans is considered an indirect diagnostic feature of primary migraine; if sumatriptan helps to relieve the attack, then the migraine can be considered confirmed, and additional diagnostics are not required. If a migraine is associated with the menstrual cycle, pregnancy, menopause, or taking COCs, you should also tell your gynecologist about this.
In typical cases of migraine, according to the accepted diagnostic protocol, computed tomography or magnetic resonance imaging of the brain is not needed; however, many patients insist on MRI and are ready to do this procedure at their own expense for the sake of their own peace of mind. Tomography is needed if the migraine is atypical, first appeared after forty years, if the nature of the pain suddenly changed, if the patient once had malignant tumors. In such cases, CT or MRI is performed to exclude or confirm tumor processes, aneurysms, multiple sclerosis, which may be the cause of a secondary headache.
Migraine seriously impairs the quality of life and must be dealt with thoroughly. It is important that science does not stand still, the understanding of the mechanisms of the disease becomes deeper, new diagnostic methods and innovative medicines often appear. Headache should not be tolerated or treated with grandmother’s methods; it is better to contact a specialist who will determine what is the matter and select an effective treatment.