Symptoms And Treatment of Migraine Headache :

Vascular headaches include migraine, cluster headache, toxic headache, exertional headache and some types of post-traumatic headache. Vascular headaches affect at least one-fifth of the population at some time during their lives. Common to all these headaches is a tendency towards extracranial vascular dilatation manifested by the throbbing headache phase of a particular attack. Vasoconstriction may also be evident and responsible for the painless sensory phenomena prior to the onset of head pain.

Vascular headaches usually begin early in life, often at puberty or in the second decade. There may be a familial tendency (50%). The headache usually begins early in the morning and reaches high intensity within 2 hours. It may last for a number of hours. Headaches usually resolve within a day but can recur daily or several times a week. There may be an increased frequency of occurrence in certain seasons, especially during spring.

Migraine

Migraine with and without aura, that is, vascular headache occurring with and without neurological symptoms respectively, present a difficult management problem, particularly in athletes who develop migraine headaches after exercise. Although most people think of migraine as headache alone, the true migraine sufferer usually notices a spectrum of symptoms, including nausea, vomiting, diarrhea and weight gain.

They may notice a prodromal period with evidence of endocrine disturbance (e.g. fluid retention). In the typical migraine attack with aura, painless sensory neurological symptoms such as visual disturbances (e.g. scotomas), paresthesia, vertigo, hemiplegia and ophthalmoplegia may precede the headache.

The types of neurological symptoms that develop vary depending on which part of the intracranial vascular tree is affected by the disturbance. In migraine with aura, occipital branches of the vascular tree may be affected and visual symptoms such as flashing lights and scotoma predominate. In a rare form of migraine seen in children known as vertebrobasilar migraine, brain stem abnormalities such as behavioral disturbances and even death have been described.

The IHS criteria for the diagnosis of migraine without aura.

Clinical Features

Patients describe migraine headache pain as sharp and intense. It is often throbbing, beating or pulsing, although occasionally the pain is steady. Commonly, it begins in the temple or forehead on both sides. When it starts on one side, it may spread to the other side. If the headache is intense, it may spread to the occiput and even change to a muscle contraction type of headache. Occasionally, the vascular headache begins at the back of the head and moves forward.

Signs and Symptoms

Many patients do not spontaneously volunteer their visual or sensory symptoms, either because they fail to link them with their headache or because they are hesitant to share the hallucinatory experiences.

1. Occasionally, patients may suffer the sensory phenomena without the headache developing.
2. The common neurological accompaniments to migraine with aura are visual. Patients speak of bright colored or white objects (stars, edges, angles, balls) often to one side of the visual field.
3. These objects may shine or flicker and may move across the visual field, leaving in their wake darkness or a scotoma.
4. The visual symptoms usually last about 20 minutes and most often clear before the sensory, cognitive or headache symptoms begin.
5. Sensory symptoms are usually described as tingling, pricking or pins and needles.
6. These commonly commence in the face or fingers and gradually spread up the limb or over the same side of the body.
7. Vertigo, dysphasia, diplopia, confusion and amnesia are less commonly reported.
8. Headache most often follows the neurological symptoms but may precede or accompany them.
9. Nausea, vomiting and dizziness are common during or after the attack.
10. After the headache, dieresis, diarrhea, euphoria or a surge of energy are commonly described.

The typical features associated with migraine are:

• Precipitating factors, such as tiredness, stress or release from stress (e.g. weekend migraine)
• Character and location of headache
• Periodicity
• Presence of migraine accompaniments (e.g. visual, gastrointestinal symptoms)
• Relief with anti-migraine therapy (e.g. sumatriptan).

Precipitating Factors in Migraine

A number of precipitating factors are commonly found in association with migraine headaches.

These are:

• Endocrine changes (e.g. premenstrual or
• Menstrual, oral contraceptive pills, pregnancy,
• Puberty, menopause, hyperthyroidism)
• Metabolic changes (e.g. fever, anemia)
• Rhinitis
• Change in temperature or altitude
• Change in activity
• Alcohol, especially red wine
• Foods (e.g. chocolates, cheese, nuts, `hot dogs')
• Drugs (e.g. glyceryl trinitrate [nitroglycerin],
• Nitrates, indomethacin)
• Blood pressure changes
• Sleep-too much or too little.

Treatment

The primary method of active treatment is pharmacological.

• Most patients choose to lie quietly in a dark room during a migraine attack. Sleep often terminates the attack.
• High-dose aspirin (ASA) (900-1200 mg) is the drug of choice for the acute treatment of migraine.
• Other acute agents such as sumatriptan (intramuscular or intranasal2) or ergot preparations may be used as second-line therapy.
• Frequent sufferers of migraine may find prophylactic drug therapy necessary and reasonably effective.
• An important part of the management of the migraine sufferer is to identify and avoid precipitating factors.
• Traditional herbal remedies such as feverfew may be helpful.
• It is critical in the management of migraine and other forms of headache that the use of repeated doses of simple analgesia alone be avoided.
• One of the consequences of the overuse of analgesic medication is the so-called analgesic rebound headache which becomes a self-generating headache requiring increasing doses of analgesia.
• Analgesic rebound headache, once established, is extremely difficult to treat and usually requires a specialist headache neurological clinic.

For this reason, the use of simple analgesics in headache treatment should be limited to a maximum of three days per week. Treatment of the headache should be directed at the cause of the problem not simply pain management.