Migraine

migraine summary

Migraine is a disease characterized by severe and repeated headaches. It may or may not be accompanied by an aura and is divided into several types. About 20% of the population suffers from the disease, and the number of women is greater than that of men. In Brazil, this rate reaches 15.2% and the Southeast region has the highest number of cases.
The causes are still not fully known, however, it is believed that genetic factors and external causes (such as hormonal and sleep changes, consumption of certain foods, etc.), trigger the disease.

Risk groups for the disease include women, pregnant women, people under 40 and people with a family history of migraines. Symptoms include severe headaches, sensitivity to light, nausea and vomiting, and may or may not be preceded by an aura. Diagnostic tests include computed tomography, magnetic resonance imaging and lumbar puncture. Some complications come from the use of pain control medications.

Current migraine treatments include analgesics, oral triptans, ergotamine, or opioids. Preventative medications include antidepressants, anti-epileptics and beta-blockers.

Medicinal plants such as feverfew , chamomile and mint can help in the treatment, as well as homeopathic products such as Iris versicolor, Thea and Sanguinaria.
For patients with migraines, it is important that they know which factors trigger attacks so that they can avoid them. Keeping a headache diary helps to establish prevention criteria. Other tips include playing sports, avoiding certain medications and foods, and controlling hormone fluctuations.

Definition

Migraine is a disease characterized by repetitive attacks of headaches that are generally very violent and throbbing. In most cases it is accompanied by other symptoms such as nausea, vomiting and hypersensitivity to light.

Some types of migraines are preceded by sensory symptoms that alert the person that they are going to have a headache. These signs are known as aura.

There are several types of migraines, each varying in terms of symptoms. Some examples are:

– Menstrual (or catamenial) migraine;

– Migraine with or without aura;

– Ophthalmoplegic migraine: when associated with paralysis of the 3rd, 4th or 6th cranial nerves;

– Familial hemiplegic migraine: when there is motor weakness during the aura;

– Retinal migraine: with momentary loss of vision;

– Transformed migraine: also known as Chronic Daily Headache and can happen daily or almost every day (more than 5 times a week);

– Migraine status: long-lasting migraine attacks, which can last from 4 to 72 hours and is also called chronic migraine.

Epidemiology

– Migraines can affect adults and children of both sexes. Data show that of the 20% of the world’s population who have the disease, about 6% are men and 14% are women. Some figures show that the incidence is 3-4 times higher in women than in men. In children up to 12 years old, the incidence of migraine is equal in boys and girls.

– In the United States, an estimated 36 million Americans suffer from migraines, according to the Wall Street Journal of November 30, 2017.
According to a 2018 article in Prevention magazine , 2 to 3 million Americans suffer from chronic migraines . People with chronic migraines suffer for at least 15 days with a migraine attack and its consequences every month.

– Of the total number of patients who have migraines, 15-20% have symptoms with aura. Migraine symptoms are more frequent in patients under 40 years of age, with the highest incidence occurring between 30-39 years.

– A study carried out in Brazil for 1 year by the Federal University of São Paulo (Unifesp) with 3848 people between 18 and 79 years of age showed that the general prevalence of migraine in the population is 15.2%. According to a study carried out, the region with the most cases of migraine in the country is the Southeast, with 20.5% of prevalence, followed by the South region, with 16.4%, Northeast with 13.6%, Midwest with 9, 5% and North with 8.5%. Another interesting data from this study is that individuals who do not practice sports or regular physical activities are 43% more likely to have migraines when compared to those who do.

Causes

One of the causes of migraine is the genetic constitution of each individual. First, there is a genetic predisposition in approximately 70% of cases.

Genetic influence: 
Several studies have shown the influence of genes on the development of migraine. A Finnish study published on May 3, 2018 in the scientific journal Neuron(DOI: 10.1016 / j.neuron.2018.04.014) took into account more than 1,500 families and 8,300 Finnish people suffering from migraine. Comparing this cohort of families with another general cohort of 15,000 participants (called FINRISK), including 1,100 people with migraines, the researchers observed an overall increase in the genetic risk score in familial migraine cases compared with migraine in the general population. In other words, genetic or hereditary influence is obvious. In this study, the scientists also found that hemiplegic migraine was mainly caused by genetic variations, likely caused by rare pathogenic variants in three different genes.

However, other factors (in 30% of cases) external or non-genetic can also trigger migraines. These different factors can be:

– physical and psychological stress

– lack of sleep ( insomnia )

– dehydration (lack of water). In this case, it is recommended to drink at least 2 liters of water a day

– climatic variations, due to air pressure (in about 50% of cases)

– Hormonal fluctuations in women, particularly estrogen levels. Thus, many women report migraines during their menstrual period or during pregnancy. The use of contraceptive drugs can also trigger symptoms, however, in some cases, their use can be beneficial.

– use of hormone replacement drugs during menopause . A recent study by the Nashville Neuroscience Group revealed that of the hormones used, estrogen seems to be the biggest villain.

– alcohol consumption

– smoking (act of smoking)

– change in sleep pattern, such as sleeping too much or not being able to sleep

– physical factors, such as strenuous physical practices

– use of certain medications

– depression (there is a controversial debate between doctors and scientists who believe that depression can cause migraines and those who believe the opposite: that it is migraines that can favor the development of depression, due to the almost psychic difficulties resulting from it. No However, it is proven that there is indeed a relationship between the two diseases)

In addition to the factors mentioned above, diet plays a very important factor in the causes of migraines. Foods that can trigger the disease are:

 

Foods high in salt and processed foods, as well as those that contain sweeteners and preservatives, can also increase the risk of migraines.

The list of foods that can cause migraines is long, but it varies from person to person.

Importantly, migraines occur due to a combination of genetic factors and external causes.

Interesting observation:
A study carried out in England in 2010 showed that the synapses of people who suffered from migraines were hyperexcitable to neurotransmitters, so new drugs could block these neurotransmitters, and in the future improve migraine therapy.

Groups of risk

Some risk groups have a higher incidence of developing migraines, including:

– Patients with a family history of migraine;

– Persons under 40 years of age;

– Women;

– Patients with hormonal variations, such as pregnant women;

– Women undergoing hormone replacement therapy for menopause.

It is important to remember that these risk groups are more predisposed to the disease, but will not necessarily develop it.

Symptoms

The most typical migraine symptoms are:

– violent headaches (which practically incapacitate the sufferer)

– nausea with or without vomiting

– photophobia (sensitivity to light) and sensitivity to sound

– pain that worsens with physical activity

These symptoms occur frequently and can last for a long time (from 4 to 75 hours) and are sometimes preceded by an “aura”. Aura symptoms can include changes in vision, such as seeing flashes of light, or other sensory changes, such as pins and needles in the limbs.

With or without aura, patients may experience some premonitory symptoms of migraine, such as:

– Intense energy and feeling of joy;

– Compulsion for sweets;

– Site;

– Dizziness ;

– Irritability or depression.

Vestibular migraine
Some people with migraine may suffer from vestibular migraine (in English, vestibular migraine ) with a presence of dizziness . These episodes of dizziness can last for hours or even days. Headaches may be present, but not always.

Difference between migraine and headache

According to the International Headache Society, we speak of migraine (instead of headaches or headache, for example), when:

AThere are at least 5 migraine attacks that meet criteria B, C and D.
BThe duration of the crisis is from 4 to 72 hours.
CA “headache” (migraine) has at least two of the following characteristics: 

– location on only one side of the head (unilateral).

– throbbing pain (feeling of pressure or tightness in the head).

– medium to strong intensity, which prevents or makes daily tasks difficult.

– worsening of migraine with everyday tasks, such as climbing stairs.

DAt least one associated symptom:
– nausea and/or vomiting.
– great sensitivity to noise and light.

If you have any concerns, talk to a doctor or pharmacist.

Diagnosis

The exact diagnosis of migraine is generally difficult to make, as specific tests are not available to identify it. However, the doctor may use additional tests to verify the disease.

First, the patient’s clinical history, that is, the symptoms presented by the individual, are of fundamental importance for the medical diagnosis. The intensity and duration of the headaches are important to verify if it really is a migraine. Based on this, the doctor may request additional tests to find out what causes the pain. They include:

– Computed tomography;

– Nuclear Magnetic Resonance Imaging;

– Lumbar puncture, especially if meningitis is suspected as the cause of the migraine.

Complications

Migraine complications can include:

– Vertigo

– Nausea

– Vascular headache

– Dor ocular

– vision loss

migraine complicationsOther migraine complications may come from the patient’s attempt to control the pain with the use of some medications. These can be:

– Gastrointestinal problems from the use of non-steroidal anti-inflammatory drugs such as ibuprofen and aspirin.

– Serotoninergic syndrome: this syndrome is serious and can be triggered by the use of some migraine medications, such as zolmitriptan and sumatriptan and drugs from the classes of selective serotonin reuptake inhibitors, such as paroxetine and fluoxetine. Serotonin syndrome is rare.

– Rebound migraine: this condition occurs when using analgesics to control the headache for a prolonged period of time. The drug, in addition to not causing pain relief, triggers migraine attacks.

– Sabemos, como indica a sociedade acadêmica americana de cardiologia American Heart Association (AHA) em um comunicado divulgado em fevereiro de 2014, que as mulheres com enxaqueca com aura devem parar de fumar para evitar o risco elevado de acidente vascular cerebral (AVC).

Jaw Disorders and Migraines
A Brazilian study published in 2017 found that migraine attacks were more common in cases of certain serious jaw disorders, such as  temporomandibular disorder  (TMD). According to Lidiane Florencio, lead author of this study, patients with chronic migraine (ie, more than 15 attacks per month) are three times more likely to report more severe symptoms of TMD than patients with episodic migraine. This study from the School of Medicine of the University of São Paulo (FMRP-USP) in Brazil was published April 6, 2017 in the scientific journal   Journal of Manipulative and Physiological Therapeutics (DOI: 10.1016 / j.jmpt.2017.02 0.006).

Treatments

There are two types of migraine treatment:

A. Crisis treatments (symptomatic and causal)

1. FIRST OPTION IN CASE OF MODERATE MIGRAINE ATTACK

Analgesics
– acetylsalicylic acid (ASA) from 500 mg to 1 g in tablet.

– ibuprofen : 200 mg to 600 mg in tablet form. Note: Ibuprofen would be particularly effective.

– paracetamol : 500 mg to 1 g in tablet or suppository.

Antiemetics
– metoclopramide (proven in a study in December 2004 as a medicine that has a beneficial role in the treatment of migraine attacks).

– domperidone (as a tablet or suppository).

2. SECOND OPTION, IF THE FIRST DOESN’T WORK

If there is a medium attack, bearable (moderate) nausea and if there is no vomiting at first:

– Oral triptans (in tablet form), contraindicated in case of heart failure.

– Ergotamine, which is cheaper than triptans and has similar efficacy. It is estimated that ergot derivatives may be more effective in patients with pain lasting more than 48 hours.

– Drug combination of butalbital with paracetamol.

– Opioids, such as codeine. In the United States especially, certain morphine derivatives (such as opioids) may be prescribed by the physician during severe migraine attacks and when the patient cannot take other medications. Beware the serious risk of addiction to opioids.

In case of severe crisis, nausea and vomiting at the beginning:

– Subcutaneous (injection), nasal or rectal triptans in case of serious crisis and early vomiting. Contraindicated in case of heart failure.

In case of severe crises, it can also be used:

– Aspirin® 500 mg to 1 g intravascularly – Derived from rye ergot, attention, do not abuse these remedies.

3. NEW CLASS OF DRUG (SINCE 2018) – ANTI-CGRP:

Erenumab e
Since May 17, 2018, a new drug has been available in the United States, belonging to a new class of drugs against painful migraines, in particular those refractory to conventional treatments. This drug, erenumab (Aimovig™), FDA registered on May 17, 2018, was developed by pharmaceutical companies Amgen and Novartis. Aimovig™, a monoclonal antibody, is given by injection once a month. Aimovig ™ blocks the peptide receptor linked to the calcitonin gene (CGRP-R). Calcitonin gene-related peptide (CGRP) is a molecule produced in nerve cells in the brain and spinal cord that plays a key role in people with migraines. Over the years of research, Scientists have found that CGRP helps transmit pain signals to the brain and that migraine sufferers often have a high amount of CGRP. At the cellular or physiological level, erenumab (Aimovig™) blocks the CGRP receptor, called CGRP-R, which lessens the harmful effect of CGRP on the cell.

According to a press release [readable May 18, 2018] from Novartis published in English in May 2018, Aimovig™ has been consistently shown to reduce the number of migraine days per month, including in more difficult populations to treat. treat, many patients achieved a reduction of at least 50%. An editorial in the journal JAMA considers this new drug to be progress, but not a panacea.

There are several other anti-CGRP drugs on the market, particularly in the United States, or in advanced development.

B. Drug treatments that prevent migraine attacks

The medicines mentioned below must be prescribed by a doctor, here we are just informing you of the therapies that are available, just for knowledge and not to create surprise in case your doctor prescribes you, for example, an antidepressant, as this is common.

1. Beta blockers : eg propranolol

2. Calcium antagonists : e.g. ex. the flunarizine

3. Antidepressants : eg. amitriptyline _

4. Two serotonin 5-HT-2 receptor antagonists: e.g. pizotifen, methylsergide

5. Anti-epileptic drugs : eg. topiramate, gabapentin, valproic acid

6. Cyproheptadine

It should be mentioned that you should never prolong a treatment if it is not effective, as it can aggravate the pathology and cause side effects.

To finish this subject, know that there are drug treatments such as acupuncture, which are also effective in the treatment of migraines.

Another possibility is the Chinese self-massage technique known as do-in. Do-in has shown satisfactory results in curing migraine symptoms and is similar to acupuncture because it is considered a traditional Chinese medicine technique.

– For specialists: reaction mechanism of triptans: Triptans act on serotonin 5-HT1D receptors, they are quite selective (compared to rye ergot derivatives, with effects on blood vessels, risk of ergotism = gangrene) and exert a constricting effect.

Risks of using certain migraine medications

Rye ergot derivatives (or rye ergot alkaloids) can cause gangrene, vomiting, and migraines themselves.
Therefore, if possible, it is advised to avoid them or consume very little. Prefer analgesics or triptans.

Excessive use of analgesics (aspirin,…) can also trigger migraines or headaches, and this can create a vicious circle. Talk to your doctor if you notice that this is happening to you, he will definitely find a good solution for your case.

Other basic treatments (in migraine prevention):

To fight migraines, there are other methods such as:
– Transcutaneous electrical stimulation. This method can be effective for some people.
– Botox. In the form of injections into the skull, especially indicated during chronic migraine.
– Ketamine, possible effect on very strong migraines, further studies are needed to confirm or deny its effectiveness. Ketamine is increasingly used to treat severe cases of depression.
– Methods against stress: ex. yoga, mindfulness meditation, self-hypnosis, etc.
– Surgery. Surgery is a rarely used method against migraine, mainly due to the lack of consensus in scientific terms. The surgery acts on certain nerves. Ask your doctor or neurologist for more information about this.

Herbal medicine

The medicinal plants mentioned below have demonstrated effectiveness in the treatment of migraines, however, these natural medicines should not be considered as the first choice of treatment (in the case of triptans, etc.) but rather as an alternative or complement.

– coffee ,  to be consumed as a beverage. It can act positively on migraine.

– Butterbur (Petasites hybridus) , to be taken in tablet form.

– mint (menta piperita), to be used as an infusion or essential oil.

– feverfew (feverfew), to be used as an infusion or capsule.

– Roman chamomile , to be used as an infusion or essential oil.

Tips

– Know the causes or triggers of migraine well. Have an agenda/diary where you can write down when you had your last migraines, as well as your diet and the weather that preceded them. It is good to take all possible precautions to prevent the causes (triggering factors) of migraines and to make them identifiable. Avoid consuming too much caffeine (more than 3 cups of coffee a day) or caffeine-based medications. Drinking a maximum of one or two coffees a day can do you good.

– Avoid consuming triptans and other ergotamines in excess, as all these compounds can favor migraines and headaches.

– Use medication to prevent migraines (under medical prescription). In certain cases, the consumption of vitamin B2  (riboflavin) in high doses can have a preventive effect against migraines. Other non-drug techniques such as acupuncture can also be effective.

– Use a hat in winter, as the cold can trigger migraines.

– When you have a migraine attack, relax and rest. You may need to rest in a dark room with little or no noise. The use of gel packs and light massages on the head can help relieve pain.

– Look for alternative treatments for migraine, such as do-in and acupuncture. Many of them have shown satisfactory results in improving symptoms and quality of life.

– With exceptions, avoid going to the emergency room for a migraine, because the emergency department is not a suitable place, often with a lot of light and noise (risk factors for migraine).

Prevention

– Play sports (report of scientific studies). According to a study by a Turkish university, the practice of sports has a prophylactic effect on migraine attacks. The German Migraine and Headache Societies endorsed this finding. From a scientific point of view, it is believed that aerobic physical activity (with oxygen), such as running, soccer and tennis, can reduce the frequency of headaches, as the level of beta-endorphins – substances naturally secreted by the brain as an anti-pain – would increase during the regular practice of these sports. However, further studies are still needed to evaluate the role of endorphins in the onset of migraine attacks, but sport is assuredly beneficial in the prevention of cardiovascular diseases and does not cause any harm.

– Avoid, for example, the intake of very fatty and bulky foods and excess liquid at night.

– Avoid stress and large mood swings. Relaxation therapies, acupuncture, tai chi, and do-in help with this.

– Seek treatment for depression.

– Control alcohol consumption.

– Avoid smoking.

– Regulate sleep. Sleep well, but not too much. For this, you can turn to melatonin .

– Avoid consuming too much caffeine or caffeine-based medications.

– Avoid eating foods that you know trigger migraines, such as tyramine-containing foods, sausages and chocolate. Establish a migraine diet.

– Reduce hormonal effects. For women, it may be interesting to reduce the effect of drugs that alter estrogen levels, such as birth control pills or hormone replacement therapy.

– Consume vitamin B2 and magnesium supplements .

Jeanne Kenney
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I’m a stylist trainer, a content creator, and an entrepreneur passion. Virgo sign and Pisces ascendant, I move easily between my dreams, the crazy world I want, and my feet on the ground to carry out my projects.

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