We can consider two types of Migraine with aura and Migraine without aura.
Patients with migraine experience episodic headaches with moderate to severe intensity, they can last few hours till 3 days and are associated to gastrointestinal symptoms.
When symptoms are present the patients prefer dark and quiet environment and prefer to avoid activity which usually worsen the symptoms.
In the migraine with Aura, the patient also experiences visual symptoms, such as:
- Hemianopsia, which is a reduction or loss of the vision in half the visual field usually on one side
- Spreading scintillating scotoma which patient describes as a scintillating arch or zig zag pattern.
Sometimes can be also present reversible focal neurological disturbances such as:
- Unilateral Paraesthesia of hand, arm or face or leg which means an abnormal sensation describes as pins and needles,tingling,numbness in the mentioned area. In the leg is a seldom occurrence.
- Dysphasia, which is a partial or complete impairment of the ability to communicate, the impairment can be in the understanding or in producing and articulation of the words.
- Can be present weakness in the limb
These symptoms of typical aura are progressive, last from few minutes up to 60 minutes before the headache. Furthermore the symptoms above should not alarm only if there is a clear history of migraine with aura on the other hand the patient should be cleared from the possibility of transient ischaemic attack, mostly in older people.
Between the attacks the patients are symptom free, otherwise if the migraine occurs every day it is a complication and it is classified as Chronic Migraine.
ICHD-II diagnostic criteria for migraine without aura
|A||At least 5 attacks fulfilling criteria B-D|
|B||Headache attacks lasting 4-72 hours*|
(untreated or unsuccessfully treated)
|C|| Headache has at least two of the following characteristics:|
1. unilateral location*
2. pulsating quality (ie, varying with the heartbeat)
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
|D||During headache at least one of the following:|
1. nausea and/or vomiting*
2. photophobia and phonophobia
|E||Not attributed to another disorder (history and examination do not suggest a secondary headache disorder or, if they do, it is ruled out by appropriate investigations or headache attacks do not occur for the first time in close temporal relation to the other disorder)|
*In children, attacks may be shorter-lasting, headache is more commonly bilateral, and gastrointestinal disturbance is more prominent.
Management of migraine
In the Management of migraine we have to main approaches:
- Drug intervention
- Non-Drug intervention
The drug therapy follows a treatment built in different steps, starting with standard analgesic and proceeding towards specific migraine drugs as Triptans which have shown a good efficacy. The final step is to combine different kind of drugs. The collaboration Doctor/Patient is important.
Before to talk about the Non-Drug intervention, we need to talk about the Predisposing and Trigger factors individuated in the migraines:
- Head or neck trauma
- Sleep pattern
- Physical factors. Intense physical activity, mostly if not usual
- Foods And Drinks
Let’s have a look more in depth,how we may reduce them factor:
1)Stress, we have different ways to reduce the amount of stress:
- Lifestyle change, taking a time for yourself and doing what you like
- Relaxation therapy, can be useful to utilise some relaxation techniques such as Breath focus, Body scan or try with yoga and meditation, as well behaviour therapy and hypnosis could have an effect
2)Head or neck trauma: a recent or previous head of neck trauma like Road traffic accident, concussion etc. could lead to cervico-thoracic dysfucntions,
3)Menstruation: migraine are 3 times more likely in women than in men therefore seems that the hormonal and circulatory changes could be related with them. In this case a specific hormonal therapy could be taken in count. Also the use of Visceral technique and exercises with the aim to improve the lombo-pelvic mobility and circulation could be a possible option.
4)Sleep Pattern: too much sleep in the weekend or not enough sleep could trigger a migraine due to the alteration in the system of activation/relaxation and therefore the autonomic nervous system activity.
The first thing to do would be to get a regular sleep pattern, which means get enough sleep and avoid to oversleep. If needed could be associated a drug therapy to help it.
Relaxation techniques might be helpful, as well acupuncture could be a good allied.
5)Depression/anxiety: is not easy to say which one causes the another one, because often they can be interrelated. For example the reduction of the quality life due to the migraine pain could lead to depression and or anxiety, at the same time the presence of these conditions shows a greater risk to develop migraine. Also they could share similar chemical substances in the brain involved in both of them.
The first step would be to try to find the causes of Depression/anxiety since they can be related to abuse, medication, conflict, emotional episodes, major events, genetic, serious illnesses, substance abuse etc. After that should be addressed a specific therapy.
6)Physical factors. Intense physical activity.
Apparently an intense physical activity, mostly unusual could trigger migraines, therefore the first advice would be to avoid any strenuous exercise. On the other hand it could be possible if on the base there is a progressive training with a progression in the intensity of the physical activity.
7)Foods and Drinks:
Aged cheeses, salty foods ,processed foods and foods or drinks containing aspartame may trigger migraines.
The British Association for the study of Headache underlined that a food is considered as trigger when:
- a) migraine onset occurs within 6 hours of intake; b) the effect is reasonably reproducible; c) withdrawal leads to improvement.
Alcohol, among the drinks seems to be one of the more important migraine trigger.
Physiotherapy: has been shown that musculoskeletal problems are contributing factors in migraine and Tension-type headache. For example could be very relevant in the case of head or neck trauma, to restore a normal functionality in the involved area.
Physiotherapy can help to reestablish a normal range of movement in the Cervical spine, bringing back a normal muscle/joint functionality.
Also can help in the case where an Occipital neuralgia in which the Arnold nerve is involved, has been misdiagnosed with a migraine. The role of physiotherapy where possible will be to reduce or eliminate the compression of the Arnold nerve.
Acupuncture: Acupuncture is at least as effective as prophylactic drug therapy for migraine and it is safe, long-lasting and cost-effective. Also acupuncture has shown a role in the prophylaxis(prevention) of headaches/migraine.
Acupuncture in different studies has shown to have a role in the reduction of the intensity and the frequency of migraine.
Recent studies have found that acupuncture was similar in effectiveness to anti-depressant medication, therefore could be a reason more to take into account acupuncture in the treatment of migraine.
Supplements: Riboflavin and coenzyme Q10 seem to decrease the frequency of migraine attack.