Migraines

Happy Monday, and welcome to Medical Mondays!

I generally try not to take medications for anything, unless I find it absolutely necessary. (I bought a tiny bottle of Ibuprofen back in 2009 when I messed up my back, and let’s just say…I still have it, and it’s still pretty full.)

However, last Sunday, I woke up with a dull, throbbing headache that kept me company all through my drive back to Kentucky. It stuck around all through the day as I tried to study, so I was all sorts of annoyed (and miserable) because I’d been hoping to catch up/get ahead, but with the accompanying nausea, dry heaves, and complete lack of appetite, I was a pretty pathetic sight by evening (aka curled up under a pile of blankets in my very-darkened room).

I managed to make it over to Isaac + Sean’s, and they gave me unexpired Ibuprofen, a glass of water, and covered me with a blanket.

M: (grabs my blanket from me)
F: Why would you do that!? ;_;
M: I asked you a question and you were ignoring me! :[
F: I never even heard your question!
M: Why are you being so pathetic? What’s going on?
I: Be nice to her! She has a bad headache!
M: …Oh. Oops. Sorry! (tucks me back in)

I can recall a handful of other times in my life where this has happened (e.g. DR beach day last year, although thankfully, it set in later in the day), but had always written it off and/or attributed it to stress or dehydration. But…maybe they’re not. My mom gets them too.

This whole back story is really just to introduce this week’s topic to you…Migraines!

Migraines are a complex and recurrent headache disorder, and are one of the most common complaints in medicine. It is currently thought to be due to a neurogenic process with secondary changes in cerebral perfusion associated with sterile neurogenic inflammation.

In the U.S., >30 million people have 1+ migraine headaches per year. ~75% of those who experience migraines are female, and about 70% patients have a first-degree relative with a history of migraine.

Signs & Symptoms

• Throbbing or pulsatile headache, with moderate to severe pain that intensifies with movement or physical activity
• Unilateral + localized pain in the frontotemporal + ocular area, but pain can be felt anywhere around head or neck
• Pain builds up over period of 1-2 hours, progressing posteriorly + becoming diffuse
• Headache lasts 4-72 hours
• Nausea (80%), vomiting (50%), including anorexia + food intolerance, and lightheadedness
• Sensitivity to light + sound
• Migraine aura may precede or accompany the headache phase, or may occur on its own
  • Usually develops over 5-20 minutes + lasts < 60 min
  • Most common visual phenomenon is the “scintillating scotoma” (arc or band of absent vision with shimmering or glittering zigzag border)

Physical Findings

• Cranial/cervical muscle tenderness
• Tachycardia (HR > 100) or bradycardia (HR < 60)
• Hypertension or hypotension

Diagnosis

The diagnosis of migraines is based on patient history. Symptoms must not have been attributable to another disorder, and patients must have had at least 5 headache attacks that lasted 4-72 hours (untreated or unsuccessfully treated). The headache must have had at least 2 of the following characteristics:

• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by or causing avoidance of routine physical activity

The patient must also have had at least 1 of the following:

• Nausea and/or vomiting
• Photophobia + phonophobia

Treatment/Management

• Acute/Abortive Medications
  • SSRIs or triptans
  • Ergot alkaloids (e.g. ergotamine, dihydroergotamine)
  • Analgesics
  • NSAIDs
  • Antiemetics
• Preventive/Prophylactic Medications
  • Antiepileptic drugs
  • Beta blockers
  • Tricyclic antidepressants
  • Calcium channel blockers
  • SSRIs
  • NSAIDs
  • Serotonin antagonists
  • Botulinum toxin

These can be considered if the patient has any of the following:

• Frequency of attacks >2/month
• Duration of individual attacks >24 hrs
• Headaches cause major disruptions in patient’s lifestyle, with significant disability that lasts 3+ days
• Abortive therapy fails or is overused
• Symptomatic medications contraindicated or ineffective
• Use of abortive medications >2/week

Other treatments that may be helpful include:

• Reduction of migraine triggers (e.g. lack of sleep, fatigue, stress, certain foods)
• Nonpharmacologic therapy (e.g. biofeedback, cognitive-behavioral therapy)
• Integrative medicine (e.g. butterbur, riboflavin, magnesium, feverfew, coenzyme Q10)

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Disclaimer: This is where I reiterate that I am merely a medical student struggling through the world that is her clinical rotations. The statements made on this blog should not be taken as medical advice to treat, cure or prevent any disease. Please contact your own physician or health care provider before starting a health or fitness/wellness program. (See full disclaimer here.)