Let’s talk about the M-word.
The explosion of research in a migraine is in stark contrast to way that migraine was treated in the past.
If you have every had a migraine or know someone who has had migraines, it is not your simple headache. It can affect many organ systems (more on this below). This is often a debilitating condition and one that sends people to the ER because of its severe symptoms and sometimes downright scary presentation.
We doctors diagnose migraines clinically, that is; we listen to a patient and base the diagnose almost solely on the symptoms a person has. There is no imaging test or blood test that will confirm the diagnosis of migraine. We often get pictures of the brain and run other tests to make sure that we are not missing something more serious such as a brain aneurysm or tumor.
The clinical criteria for migraine is as follows:
A person has at least 5 painful attacks lasting from 4 hours to 3 days. The pain has 2 of 4 qualities:
- A pulsing or throbbing quality
- One sided
- The pain is moderate to severe T
- The pain is worsened by regular physical activity (i.e. walking up stairs).
During the headache there is either nausea or vomiting and or light or sound sensitivity.
These headaches cannot be explained by anything else, meaning there is no bleeding in the brain or other problems to explain the pain.
Migraines are a significant cause of disability, missed work and emergency room visits. They are much more common in the active working years (ages 15-55). Lost productivity has been estimated at 5.6 billion dollars because of missed work and restricted activity. In one study almost 24 percent of females age 21-30 experienced a migraine in a year. Migraines are more prevalent in woman affecting them two to three times as much and hormones likely play a role in this phenomenon. One third of patients require bed rest during a headache.
What causes migraines?
There is a lot of mystery surrounding the true cause of migraine headaches. Many theories have been proposed regarding migraine headaches, but none have been proven. Migraine tends to run in families and there is clearly a genetic component to them. Some of these theories explain the pain pathways that occur during a migraine but the root cause of why they occur is still unknown.
Some of the pathways involved in migraine include:
-Activation of peripheral trigeminal nerve branches. These branches directly innervate and affect the brain blood vessels and the surrounding covering of the brain that is called the dura mater. Both the dura mater and the blood vessels can “feel” pain and cause pain to be registered as a symptom in the brain. The actual brain substance does not experience pain. These nerve branches also send pain signals into the blood stream including glutamate, substance P, and CGRP. These painful substances can make the head more sensitive to pain and it takes the body time to “clear” out these particles that are involved in inflammation and excitation. An “inflamed” and “excited” brain is primed to feel pain and “wired” to set off a cascade of patterned events. In this case, a migraine. Some medications target these substances. In fact, a novel new drug call Aimovig targets CGRP (more in another blog).
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-Plasma extravasation- This process describes the process by which the nerve receptors in the brain release more painful substances into the blood and circulation, thereby furthering the pain process.
-“Sensitization” describes the process by which nerves become more reactive and can feel pain by something that usually doesn’t cause pain. For example, a gentle touch of the scalp may be painful in a patient that has migraine, but not in a person who doesn’t have migraine. There are many levels to this pain processing. In effect, the pain tends to make more pain!
-Imbalances in brain neurotransmitters such as Serotonin have been seen experimentally in migraine brain pathophysiology. This is the target of some of the medications specifically for migraine.
Overall, a migraine brain is more excitable and affects other parts of the brain that control a variety of functions in the body including balance, wakefulness and sleep, reactions to normal stimuli, thinking processing speeds, mood, and appetite. More on this in future blogs.
Why are migraines often under diagnosed and under treated?
Migraines are less common then tension type headaches but have many more symptoms. These headaches have specific treatments and sometimes can be refractory and not respond to simple treatments that work for some milder types of headaches.
Neurology is a highly specialized field and within that field, headache medicine has grown into a field onto itself. So even some Neurologists are not familiar with the newest treatments for headaches. Headache specialists have spent a long time learning the nuances and art of treating headaches. There is trial and error in finding the right medications for treatment and patients need to be educated carefully about their condition.
Migraine is an episodic condition; meaning it tends to come and go. Patients often go to an emergency room or see their primary care doctor after they have had the symptoms. They might get treatment that puts them to sleep or they are told to see a specialist. The wait times for these types of doctors can be months. Consulting a specialist online such as City Neurology is an appropriate way for a headache specialist to assess symptoms, schedule follow ups and get you on the right track for migraine care.