Migraine

Migraine is a type of headache caused by abnormal dilation of blood vessels within the skull, leading to stimulation of pain receptors. Although the exact cause of migraines remains unclear, genetics are believed to play a significant role. Migraines often begin during adolescence and are characterized by intense, throbbing pain, typically affecting one side of the head. Some patients experience visual disturbances known as an "aura" before the onset of the headache.

Migraines are chronic and recurrent, with the frequency influenced by exposure to various triggers. In some cases, migraines can occur daily. Migraine attacks can severely impact quality of life, leading to disability, and may contribute to stress, depression, anxiety, menstrual irregularities, menopause symptoms, or even head and neck injuries.

Chronic migraines may lead to complications such as medication overuse headache and increase the risk of stroke. However, many patients experience a decrease in migraine frequency with age.

Patient Advice

1.During a Migraine Attack:

• Rest in a quiet, dark room to ease symptoms.

• Practice deep breathing exercises to relax the body.

• Keep a headache diary to identify potential triggers, such as:
• Foods:tyramine, aspartame, MSG, caffeine, alcohol, nitrates nitrites.
• Environmental triggers:flashing lights, loud noises.

• If migraines are linked to hormonal contraceptive use, consult a doctor to switch to non-hormonal contraception.

2.Cluster Headaches:

• Massage the neck muscles to relieve tension.

• Take warm showers to relax.

• Practice relaxation techniques: meditation, listening to soothing music, or resting in a darkened room.

• Ensure adequate sleep.

• Use pain relievers as needed.

• Avoid smoking and alcohol.

3.Tension-Type Headaches:

• Manage stress, depression, anxiety and maintain a regular sleep and meal schedule.

• Avoid oversleeping.

• Keep a diary to track headache triggers.

• Rest in a dark room during a headache.

• Apply a cold compress to the forehead.

• Perform full-body relaxation, focusing on the eyes, forehead, jaw, and neck.

When to See a Doctor

• Fever, neck stiffness, confusion, seizures, visual disturbances, weakness, numbness, slurred speech, drowsiness, or loss of balance.

• Sudden and severe headache.

• Head trauma followed by a worsening headache.

• Significant change in headache patterns.

• Headaches lasting longer than four hours.

• Suspected drug-related headache.

• Headaches in children under 12 years.

• Severe occipital headaches (back of the head).

• Morning headaches that improve later in the day.

• Frequent and persistent headaches.

• Failure to respond to initial treatments.

Treatment Options

1. Non-Opioid Analgesics and Antipyretics

• Paracetamol is effective for mild-to-moderate migraines when taken early. It can also be used during pregnancy.

• Paracetamol-caffeine combinations should be used cautiously, avoiding excessive caffeine intake.

• Paracetamol combined with metoclopramide may be used for migraine-associated nausea.

2. Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• Examples: aspirin, diclofenac, ibuprofen, naproxen.

• Caution: risk of tinnitus, gastrointestinal irritation, ulcers.

• Contraindications active gastrointestinal ulcers, asthma triggered by NSAIDs, coronary artery bypass graft surgery, severe heart failure, kidney or liver impairment.

• Avoid salicylates in patients under 19 years due to the risk of Reye’s syndrom.

3. Antimigraine Preparations

• Ergot alkaloids (e.g., ergotamine, dihydroergotamine): for prolonged or recurrent migraines.
• Contraindications: pregnancy, breastfeeding, severe hypertension, sepsis, ischemic heart disease, hyperthyroidism, hemiplegic migraine, renal or hepatic failure.

• Triptans (e.g., sumatriptan, rizatriptan, zolmitriptan): act on serotonin receptors and are first-line for moderate-to-severe migraines.
• Avoid within 24 hours of using ergotamines or other triptans.
• Contraindications: history of ischemic stroke, basilar or hemiplegic migraine, uncontrolled hypertension, pregnancy.

• Isometheptene mucate (an indirect sympathomimetic agent): alternative for patients unresponsive to ergot derivatives.

• Antihistamines (e.g., pizotifen, cyproheptadine): preventive therapy, caution in glaucoma, urinary retention, epilepsy.

• Dopamine antagonists (e.g., domperidone): useful for nausea and vomiting.

• Imidazoline agents (e.g., clonidine): potential preventive option, use with caution in cerebrovascular or cardiovascular disease.

• Calcitonin gene-related peptide (CGRP) antagonists (e.g., erenumab, fremanezumab, galcanezumab): injectable drugs for migraine prevention.

Caution : Antimigraine drugs should be avoided during pregnancy and breastfeeding unless clearly necessary.

4. Anticonvulsants

• Topiramate and valproic acid are effective for migraine prevention.

• Phenytoin may also be considered.

• The use of these medications should be under close medical supervision.

5. Beta-Blockers

• Nonselective (e.g., propranolol) and selective (e.g., metoprolol, atenolol) beta-blockers are used for prevention.

• Avoid in uncontrolled heart failure, asthma, and certain arrhythmias.

6. Muscle Relaxants

• Botulinum toxin A injections can help in chronic migraine (≥15 days/month, with ≥8 days of migraine headaches).

7. Peripheral Vasodilators

• Cinnarizine and flunarizine used for migraine prevention.

• Side effects: drowsiness, weight gain, extrapyramidal symptoms, depression.

8. Co-Dergocrine Mesylate

• Used in migraine management, especially in vascular-related headaches.