General Migraine Article
Migraine is a genetic, inherited condition involving the brain, the trigeminal nerve, and cranial blood vessels which consists of symptoms of episodic headache with intervening periods of normal health. It is familial in occurrence and about 80% of patients who have migraine will have someone in their family with it. Migraine occurs in women about three times as often as men. The American Migraine study found that 18% of women have migraine, while 6% of men have it. Migraine is said to be the most common chronic human health problem for women. Something like 98-99 % of headache is either tension headache (70%) or migraine (30%). People with migraine often have motion sickness (60%) either in childhood or adulthood. They may get a headache after drinking alcohol, especially wine or beer. This may come “at the end of a drink” even though not much has been consumed. They have a sensitive brain and affected individuals may get attacks following exposure to bright sunlight, flashing lights or patterns, heat, nervous excitement, or fasting. Women often begin with headaches at menarche, when they have their first period, and they may keep this pattern until menopause. A popular myth about migraine is that it goes away after menopause for women. For some it does, for others their headaches continue. About 70% of women with migraine get headaches during the monthly estrogen withdrawal which occurs just before they start to bleed. They may have little headache during pregnancy, only to have the attacks return with resumption of the menstrual cycle. These same women may have an increase in frequency, intensity, and type of migraine attacks with the use of birth control pills or estrogen. The other 30% of women with migraine may notice no particular relationship to their menses or estrogen levels. These are likely different genes for migraine. Migraine attacks may be precipitated by relaxation after stress—the weekend, holiday, or vacation headache. Headaches may come from oversleeping, anxiety, or depression. The patients with migraine should consider that they have an over excitable brain and that the attacks follow this over stimulation.
The vasodilator peptides calcitonin gene-related peptides (CGRP), substance P, and neurokinins are found in the cell bodies of trigeminal neurons. CGRP levels increase during migraine. Also sterile neurogenic inflammation can occur in response to the vasoactive peptides substance P and Neurokinins which are released by the trigeminal vascular system. The 5-HT 1D receptors have a prejunctional location at the neurovascular synapse between the trigeminal nerve and the dural vasculature. The Triptans are serotonin receptor specific agonists that abort migraine. There are also 5-HT 1D receptors located centrally at the trigeminal ganglion which when activated inhibit the conduction of pain signals from the site of the neurogenic inflammation and vasodilatation in the meninges to the second order brainstem neurons mediating pain during migraine. 5-HT1D receptors located in the nucleus tractus solitarius of the brainstem inhibit central nausea and vomiting. All Triptans activate both 5-HT1D and 5-HT1B receptors and all Triptans have central and peripheral effects in humans.
The patient with migraine needs to understand that although the condition cannot be cured, since it is part of the genetic makeup, effective treatment exists. Adequate rest of seven to eight hours of sleep a night, a short nap at midday and regular hours for going to sleep and arising, including the weekend, may help set the individual’s internal biologic clock. Fasting, missing meals, oversleeping, alcohol, bright sunlight, and heat should be avoided. Daily caffeine in beverages or medication should be eliminated. Regular aerobic exercise taken three or four times a week may help relieve anxiety and stress and help the headaches. For some patients relaxation training, formal psychological counseling, or learning cognitive behavioral therapy (CBT) may be helpful. Prescribed medication, which is usually a triptan or DHE, should be taken early on in the course of the headache without delay, attempting to “nip the headache in the bud,” before it is fully developed. Migraine should be treated early and when it is mild. Extra supplies of medication should be stashed away at work, in the car, and at home. If a headache comes on at night during sleep, the patient should take his dose of medication, and attempt to return to sleep. In general sleep is one of nature’s best treatments for migraine and the individual who ”changes his life,” stops an activity, goes home from work, takes his medication and lies down in a quiet, dark room will fare well. The idea is to “learn to live” and “give into” the condition rather than ignore it and have the headache win.
Analgesic, pain killer, or narcotic type medications usually fail to treat migraine successfully. Taking hydrocodone and going to sleep for the rest of the day is not successful treatment. A program of outpatient self-management wherein the patient takes his medication and stops the headache is desired. The patient who has to go to the emergency room or the doctor’s office for repeated injections is somewhat of a treatment failure. For patients who experience more than 3-4 migraines a month, chronic preventive therapy may be helpful.