Migraine Headache

General

The difference between a migraine and other headaches is primarily the duration, intensity and frequency of the headache.  Migraine symptoms include severe pain, typically on one side of the head, but can be on both sides or switch from side-to-side.  Other symptoms include sensitivity to light, vision impairment, aversion to noise and smells, numbness and tingling, confusion and nausea.

Women tend to get migraines more often than men, beginning in their teens, which leads researchers to believe there is a hormonal component to migraine headaches. Migraines have a strong genetic predisposition.

Chronic migraines” are defined as migraines that occur 15 times or more during a one month period, each lasting at least four hours – over four consecutive months.  Migraines that occur less often are no less debilitating.  At Novocur, we treat both categories.

Exposure to certain foods, toxins, chemicals, flashing lights or stressors have been known to trigger a migraine headache. Some food allergies triggers are controversial in scientific literature, but alcohol is probably the least controversial of them all. Red wine in particular can be a culprit because of the high levels of the naturally occurring chemical Tyramine. Tyramine is also found in aged cheeses, certain processed meats and nuts. Caffeine in excessive amounts can also be a trigger. Food additives and sweeteners are often to blame, such as MSG and Aspartame.

Phases of Migraine

There are 4 possible phases to a migraine headache, although not every Migraineur will experience all 4 phases:

Phase 1 - Prodrome: Sometimes called the “Preheadache” phase. Will occur in about 40% of sufferers. The symptoms that occur in this phase may onset hours or up to 3 days prior to the actual pain of the headache. These symptoms can act as an alert that migraine pain is on the way.

Possible prodromes include:
  • aphasia: difficulty finding words and/or speaking (can mimic stroke)
  • constipation or diarrhea
  • difficulty concentrating
  • excessive yawning
  • fatigue
  • food cravings
  • hyperactivity
  • increased frequency of urination
  • mood changes — feeling depressed, irritable, etc.
  • neck pain
  • sleepiness

Phase 2 – Aura: The Aura phase accompanies a migraine only about 25% of the time. The Aura phase also gives notice that the pain of the headache is quickly approaching, which gives the sufferer time to take action in an effort to stop the migraine from progressing.

The visual disturbances that are iconic of this phase are not the only symptoms however, and can include the following:

  • Alice in Wonderland Syndrome: a rare form of Migraine aura in which the distinctive symptom is a type of metamorphopsia, a distortion of body image and perspective, which Migraineurs know, while it’s occurring is not real. “Alice in Wonderland” syndrome can occur at any age, but it is more commonly experienced by children.
  • allodynia: hypersensitivity to feel and touch to the point that what would be “normal” is painful
  • aphasia
  • auditory hallucinations: hearing sounds that aren’t actually present
  • confusion
  • decrease in or loss of hearing
  • dizziness
  • hemiplegia: one-sided paralysis (occurs in hemiplegic Migraine only)
  • olfactory hallucinations: smelling odors that aren’t actually present
  • one-sided motor weakness (occurs in hemiplegic Migraine only)
  • paresthesia: prickling, stinging, burning, numbness, and / or tingling, usually of the extremities or face
  • vertigo: sensation of whirling or spinning, not to be confused with dizziness
  • visual: wavy lines (sometimes described as “looking like heat rising from pavement”)
  • “blank” or tiny blind spots
  • blurry vision
  • partial loss of sight
  • phosphenes: brief flashes of light that streak across the visual field
  • scotoma: an area of decreased or lost vision. Some people describe scotomata as being like having tiny blank spots in their vision. Some compare it to tiny snowflakes.
  • unilateral (one-sided) scotoma: occurs in retinal Migraine only
  • pulsating or throbbing headache that is worsened by physical activity. Duration of 4 to 72 hours in adults, 1 to 72 hours in children
  • Because the trigeminal nerve becomes inflamed during a Migraine, and because of its location, pain may occur around eyes, in the sinus area, and the teeth and jaw.>/span>
  • confusion
  • dehydration
  • depression, anxiety, panic
  • diarrhea or constipation
  • fluid retention
  • hot flashes and / or chills
  • nasal congestion and / or runny nose
  • nausea and / or vomiting
  • neck pain
  • osmophobia (heightened sensitivity to odors)
  • phonophobia (heightened sensitivity to sound)
  • photophobia (heightened sensitivity to light)

Phase 3 – Headache: The symptoms typical of the headache phase are usually the most debilitating of all the phases, but this is not always the case. Sometimes you can experience a headache without the headache phase, which is called “acephalgic” or “silent”.

Phase 4 – Postdrome: Some migraine sufferers report feeling “hung over” after an episode. This is often the last phase of the migraine and can last for hours and even up to 3 days after the headache stops.

Postdrome symptoms may include:>

  • fatigue
  • lowered intellect levels
  • lowered mood levels, especially depression, or feelings of well-being and euphoria
  • poor concentration and comprehension

Migraine Treatments: Migraine headaches can be treated with Pharmacological Interventions (medications) or through Procedural Interventions.

Pharmacological Intervention: Having a specialist who understands the nuances of the prescription medications available for migraines is important. Often, the drugs utilized to manage migraines were not first developed for migraine pain, but since their initial development research on several drugs has shown them to powerful tools in the fight against migraine headaches. Medications to manage migraine headaches generally fall into two categories: Pain Relieving Medications and Preventative Medications.

Pain Relieving Medications: Sometimes called abortive medications, these drugs are designed to stop a headache already in progress. It helps to take the medication early in the onset of the headache and usually lying down in a dark and quiet area after taking them is best.

Types of Pain Relieving Medications:

  1. NSAIDS: (non-steroidal anti-inflammatory drugs), such as Aspirin or Ibupfrofen (Advil, Motrin and others) can sometimes be effective for mild migraine pain. Pain relieving drugs such as Tylenol can also help with mild migraine pain. Many patients find Excedrin Migraine, which is a combination of acetaminophen, aspirin and caffeine to be the most effective over-the-counter medication for migraine pain up to moderate pain levels.
  2. Triptans: Many people with migraine attacks use triptans to treat their migraines. Triptans work by promoting constriction of blood vessels and blocking pain pathways in the brain. The carotid artery blood flow seems to be the target of triptan drugs. Vasoconstriction seems to be accomplished without affecting cerebral blood flow in the brain. Vasodilation causing increase blood flow to the brain is a suspected cause of migraine pain. Pain signals from the trigeminal nerve complex also seem to be inhibited by triptan drugs helping to reduce pain. Triptan medications include sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax). Some triptans are available as nasal sprays and injections, in addition to tablets. Side effects of triptans include nausea, dizziness, drowsiness and muscle weakness. They aren't recommended for people at risk of strokes and heart attacks. A single-tablet combination of sumatriptan and naproxen sodium (Treximet) has proved to be more effective in relieving migraine symptoms than either medication on its own.
  3. Ergots: Ergotamine and caffeine combination drugs (Migergot, Cafergot) are less effective than triptans. Ergots seem most effective in those whose pain lasts for more than 48 hours. Ergots work by narrowing blood vessels, in the head and throughout the body. Ergots can cause the undesirable side effect of “rebound headache”. This is a headache that returns after a period of remission following treatment with some medications. When the headache returns it is sometimes increased in intensity; worse than before taking the medication. Ergotamine may cause worsened nausea and vomiting related to your migraines and other side effects, and it may also lead to medication-overuse headaches. Other side effects may include anxiety, flushing, gastric upset and restlessness. There are more potential side effects with those patients who have vascular or cardiac disease because of the ergot mechanism of action, which narrows vessels throughout the body. Dihydroergotamine (D.H.E. 45, Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine. It's available as a nasal spray and in injection form. This medication may cause fewer side effects than ergotamine and is less likely to lead to medication-overuse headaches. You should not be taking ergots if you are over 60 years old or are taking beta-blocking medication. Those suffering from hyperthyroidism, bradycardia, peripheral vascular disease, coronary artery disease, hypertension, liver disease, or thrombophlebitis or clots should not take ergot alkaloid medications.
  4. Opioid MedicationsOpioid drugs work by binding to opioid receptors in the brain, spinal cord, and other areas of the body and reduce the transmission of pain messages to the brain. Opioid medications containing narcotics, particularly codeine, are sometimes used to treat migraine headache pain for people who can't take triptans or ergot. Narcotics are habit-forming and are usually used only as a last resort.
  5. Glucocorticoids (GC’s) i.e. prednisone, dexamethasone:  GC’s are steroids that reduce inflammation throughout the body. Cortisol is a naturally occurring GC that is made by your adrenal glands, and works to regulate inflammation and other processes in your body. However, sometimes your levels of cortisol are not enough to counter sudden, chronic, or severe inflammation. Synthetic GCs are drugs including prednisone, dexamethasone, and hydrocortisone. Synthetic GCs act in a similar way to stop inflammation, and can be even more potent than naturally occurring chemicals. A glucocorticoid may be used in conjunction with other medications to improve pain relief. Because of the risk of steroid toxicity, glucocorticoids shouldn't be used frequently.

Types of Preventative Medications: You may be a candidate for preventive therapy if you have four or more debilitating attacks a month, if attacks last more than 12 hours, if pain-relieving medications aren't helping, or if your migraine signs and symptoms include a prolonged aura or numbness and weakness. Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks. Your doctor may recommend that you take preventive medications daily, or only when a predictable trigger, such as menstruation, is approaching. In most cases, preventive medications don't stop headaches completely, and some drugs cause serious side effects. If you have had good results from preventive medicine and your migraines are well controlled, your doctor may recommend tapering off the medication to see if your migraines return without it.

The following types of medications are commonly utilized as preventive migraine measures:

      1. Cardiovascular drugs. Beta blockers, which are commonly used to treat high blood pressure and coronary artery disease, may reduce the frequency and severity of migraines.The beta blockers propranolol (Inderal LA, Innopran XL, others), metoprolol tartrate (Lopressor) and timolol (Betimol) have proved effective for preventing migraines. Other beta blockers are also sometimes used for treatment of migraines. You may not notice improvement in symptoms for several weeks after taking these medications.If you're older than age 60, use tobacco, or have certain heart, lung or blood vessel conditions, doctors may recommend you take alternate medications instead of beta blockers.Another class of cardiovascular medications (calcium channel blockers) used to treat high blood pressure and keep blood vessels from becoming narrow or wide, also may be helpful in preventing migraines and relieving symptoms from migraines. Verapamil (Calan, Verelan, others) is a calcium channel blocker that may help you.In addition, the angiotensin-converting enzyme (commonly referred to as ACE) inhibitor, lisinopril (Zestril), may be useful in reducing the length and severity of migraines.Researchers don't understand exactly why these cardiovascular medications prevent migraine attacks.
      2. Antidepressants. Certain antidepressants help to prevent some types of headaches and other chronic pain syndromes, including migraines. Tricyclic antidepressants may be effective in preventing migraines. You don't have to have depression to benefit from these drugs. When an antidepressant is used for pain the dosage will be smaller than when used to treat depression.  A minimum of 1-3 weeks will be required to begin to see improvements after beginning to take an antidepressant for pain, but 6-8 weeks is likely required to evaluate complete effectiveness.Tricyclic antidepressants may reduce the frequency of migraine headaches by affecting the level of serotonin and other brain chemicals. Serotonin is a very important neuro-signaling chemical found in the brain, gut and other nerve tissues. Low levels of serotonin correlate with chronic headache sufferers, particularly migraine sufferers, but also in those suffering from Irritable Bowel Syndrome and other chronic pain disorders. During a headache episode the levels of serotonin diminish even further. In theory, elevating the baseline level of serotonin in the brain should make triggering a headache more difficult. Amitriptyline is the only tricyclic antidepressant proven to effectively prevent migraine headaches. Other tricyclic antidepressants are sometimes used because they may have fewer side effects than amitriptyline. These medications can cause dryness of mouth, constipation, weight gain and other side effects. Another class of antidepressants called selective serotonin reuptake inhibitors (SSRIs) has not proved to be effective for migraine headache prevention. However, research suggests that one serotonin and norepinephrine reuptake inhibitor (SNRIs), venlafaxine (Effexor XR), may be helpful in preventing migraines. Never abruptly stop taking an antidepressant medication.  Instead, taper off the drug under the supervision of a doctor.)   Severe side-effects will be encountered without tapering off an antidepressant medication, including the reappearance of the original condition.
      3. Anti-seizure/Neuropathic Pain Medications. Some anti-seizure drugs, such as valproate sodium (Depacon), topiramate (Topamax), gabapentin (Neurontin), and pregabalin (Lyrica) seem to reduce the frequency of migraine headaches. There are indications that newer Neuropathic Pain medications, such as carbamezepine, may also be effective in preventing trigeminal nerve pain with fewer side-effects than older Anti-seizure medications or Tricyclic Antidepressants. An increasing relationship between neuropathic pain and migraine seems to be developing in the scientific literature, which increases the interest and utilization of newer Neuropathic Pain Medications by pain doctors.In high doses, anti-seizure drugs may cause side effects. Valproate sodium may cause nausea, tremor, weight gain, hair loss and dizziness. Valproate products should not be used in pregnant women for prevention of migraine headaches. Topiramate may cause diarrhea, nausea, weight loss, memory difficulties and concentration problems.
      4. OnabotulinumtoxinA (Botox). Botox has been shown to be helpful in treating chronic migraine headaches in adults.During this procedure, injections are made in muscles of the forehead and neck. When this is effective, the treatment usually needs to be repeated every 12 weeks. Botox appears to affect the transmission of pain from pain receptors associated with the trigeminal nerve.
Procedural Interventions for Migraine Headache:

Occipital Nerve Block:

Many migraine sufferers are sometimes unable to control their pain through dietary changes, over the counter medications, or through prescription abortive/preventative medications. Migraine sufferers are often surprised how easily the frequency, duration and intensity of their headaches can be reduced following minimally invasive injectable treatments at Novocur.

Occipital Nerve Blocks are one of the most common treatments that often dramatically help the sufferer of migraine, tension or cluster headaches achieve relief. There is one greater occipital nerve on either side of the back of the head. The Occipital Nerves emerge at the base of the head and travel toward the top of the head where they terminate. These nerves communicate pain signals in the head to the brain.

Irritation of these nerves (Occipital Neuralgia) often contributes to different types of headache pain, including the pain from migraine, cluster and/or tension type headache. The occipital nerves of the head are indirectly connected to the trigeminal nerve, which is more responsible for pain in the front of the head and face. Occipital neuritis appears to lower the pain threshold of the trigeminal nerve, which is responsible for more Cluster type headaches.

A small amount of anesthetic and anti-inflammatory medication is injected on the back of the head near these nerves to reduce inflammation and pressure around the nerve tissue and to reset the threshold by which these nerves fire pain signals.

Greater and Lesser Occipital Nerve Radiofrequency Ablation(RFA):

Occasionally, a patient will experience tremendous relief from an Occipital Nerve Block, but the relief is very temporary. In this case, the relief experienced tells the doctor he has treated the correct the nerve tissue responsible for the pain, but a more long lasting treatment will be required. The same nerve tissue can then be treated using Radiofrequency technology to provide anywhere from 6-12 months of relief.

Radiofrequency Ablation is performed very similarly to an injection type procedure, but the doctor inserts a fine electrode through the center of the needle. This electrode extends beyond the end of the needle by just a couple of millimeters and through this electrode, using a sophisticated radiofrequency generator, the doctor can pass a very controlled type of heat energy into the tissue near the occipital nerve. This heat energy is designed to heat the occipital nerve tissue just enough to prevent communication of pain signals from the head to the brain. This communication jam effectively breaks the pain cycle and pain communication.

Peripheral Nerve (Occipital) Stimulation:

Certain migraine and cluster headaches are resistant to all medications and cannot be controlled through more conservative interventional procedures, such as Occipital Nerve Blocks or Occipital Nerve RFA. These refractory cases may be candidates for Peripheral Nerve Stimulation.

Peripheral Nerve Stimulation utilizes equipment from FDA-approved Spinal Cord Stimulation usages. A thin electrode is placed over the occipital nerves in the scalp. The electrode emits small amounts of electricity from its pacemaker-like generator to the branches of nerve tissue that form the greater and lesser occipital nerves. A successful implant will leave the patient feeling a pleasant vibratory sensation in the back of the head, which provides a very long term nerve blocking effect to greatly diminish intensity, duration and frequency of migraine and cluster type headaches.

Novocur will temporarily place these electrodes so the patient can sample the effectiveness before deciding to go forward with a permanent implantation of the electrodes and generator.  If the patient and Novocur physician determine the trial to be a success, then a referral will be coordinated to achieve a permanent implantation of the device.

Migraine Cause Theories:

Vascular Theory –

Migraines typically occur when blood vessels in the head begin to contract and expand in an abnormal manner. The arteries in the back of the head have been shown to go into spasm, causing a reduced blood flow to the back part of the brain or the occipital lobe. This is thought to trigger aura that are followed by migraine. The vascular theory is falling out of favor with current researchers who now focus their attention on a neural explanation.

An interesting study in 2012 showed a relationship between “brain freeze” and migraines, which illustrates a possible mechanism of pain production in migraine sufferers. The study showed those people who suffer more easily from “brain freeze”, after eating ice cream or cold drinks, have a higher tendency to suffer from migraine. Blood vessels just above the roof of the mouth, which are at the base of the brain, become constricted from the cold in the mouth. The brain responds to this diminished blood pressure in the brain by dilating the same vessels, which causes an increased in blood flow. This increased blood flow is accompanied by the pain of the “brain freeze”.  Researchers suspect a similar mechanism of vasodilation in the brain or by vessels leading to the brain may be a cause of migraine headache. A vascular mechanism for the cause of migraine has been suspected for centuries, but evidence to link a vascular cause has been meager in scientific research.

Neural Theory/Brainstem Origin

Although the resolution of PET scans is pushed to the limit in pinpointing precisely where in the brainstem this takes place, there is certainly some increased activity seen in PET scans in an area of the dorsolateral brainstem during acute migraine attacks.

Neural structures implicated include one or both of:

      • periaqueductal grey matter – involved in neurological pain inhibition/suppression
      •  locus coeruleus – known to modulate response to sensory neural transmission in critically regulating cortical function.

Dysfunction of the above brainstem structures and networks could account not only for the headache component, but also for the auditory, olfactory and visual components. Plus locus coeruleus dysfunction also could account for the symptoms of anxiety and distractibility which people with migraine can experience.

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