Face / Head / Neck

Migraine

Definition

Migraine is the most common type of headache after tension headache. It is a chronic paroxysmal disorder in which the headache, which is almost always present, is accompanied by general and neurological symptoms.

Aetiology

The exact cause of migraine is unclear and is probably polygenetic and multi-factorial. However, a genetic base has not yet been confirmed, except in familiar hemiplegic migraine, for which a defective gene has been discovered.

Sometimes a direct reason for the migraine attack can be found, such as too much or too little sleep, shift work, certain foods and stress. There is no hypothesis to explain all the phenomena of migraine, but it is thought that a response in the trigeminal vascular area could be involved. A sterile inflammatory reaction occurs around the nerve endings near the meningeal blood vessels.

Aura is thought to be due to 'cortical spreading depression', in which a wave of depolarization moves across the cortex. In this way, a temporary loss of neuron function occurs, resulting in neurological deficit.

Signs and symptoms

The signs and symptoms of migraine can vary per patient. In the most typical form, occurring in 60-70% of patients, sudden unilateral violent attacks usually occur, accompanied by a throbbing headache. The symptoms usually occur early in the early morning, but can present at any time. Patients may wake up in the middle of the night. The headache generally increases continuously and becomes more intense, and then slowly declines again. Exercise can aggravate the headache.

As well as headache, nausea, vomiting, diarrhoea, photophobia and phonophobia can occur. Untreated, an average attack lasts from four to 72 hours. So-called prodromal symptoms, which may include fatigue, difficulty concentrating, stiff neck, sensitivity to light and sound, nausea and visual disturbances, may occur from several hours to two days before the headache manifests itself.. Combinations of these symptoms are frequently seen.

An aura, a mixture of neurological symptoms associated with migraine headaches, may also occur. An aura is usually a black or grey spot that increases progressively (scotomes). There may also be co-existent unilateral ascending numbness or motor weakness. An aura usually lasts no longer than one hour.

Diagnostics

Physical Examination

The neurological examination in migraine patients usually is normal. In the migraine aura, transient neurological symptoms, consisting of loss of sight (90%), speech disorders and unilateral tingling can be observed.

Additional Somatic Diagnostics

The diagnosis of migraine is made based on the typical history and the exclusion of other causes of headache. An MRI scan is only indicated in certain atypical cases.

Additional Psycho-cognitive Diagnostics

  • RAND-36 (quality of life)
  • VAS-Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis.  Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

The treatment of migraine consists of episode-related and preventive treatment and is primarily carried out with analgesics (paracetamol, ibuprofen, naproxen) and special anti-migraine drugs. Painkillers can be taken when a patient feels an attack coming on.

With regard to anti-migraine drugs, there is a distinction between medication to stop the attacks (sumatriptan) and medication to prevent the attacks (propanolol).

Preventive treatment should be considered when a patient experiences more than two migraine attacks per month.

Episodic therapy

  • General analgesics
  • Paracetamol, NSAID, possibly in combination with anti-emetics
  • Specific anti-migraine medication
  • Sumatriptan

Preventive treatment

  • Beta-blockers
  • Propanolol