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Migraine is
an ailment that affects millions worldwide. It affects people of all
races and gender, and the social and economic implications are
tremendous. It has been estimated that in the USA, US$5 to $17 billion
is lost in productivity per year due to migraine alone. The healthcare
costs for treatment of migraine alone runs to millions in the USA.
Just how
common is migraine? It is estimated that countries such as Norway and
the US have estimated a prevalence of between 11-18%. Migraine is more
common in women - in almost every community-based survey of migraine
prevalence, the ratio of females to males suffering from migraine is
about 1.5 to 1. We have come a long way from the time when headache and
migraine were thought to be due to "evil spirits" trapped within the
head. Exorcism of the spirits was then believed to be achieved by
drilling a hole in the skull to let the spirits out. Naturally, this
drastic treatment proved to be rather unpopular!
We know that
migraine is more complicated than that. There are certain individuals
who are more prone to migraine - it is believe that these individuals
have an altered migrainous threshold that makes them more susceptible to
migraine headache. Genetics may play a role in the migraine threshold.
Persons with a lower threshold may be more prone to environmental
triggers that may set off an attack, such as certain food types, stress
or menstruation in women.
Symptoms
of Migraine
The
International Headache society divides migraine into 2 main groups -
migraine with aura and migraine without aura. Common to both is the
presence of headache, which is often one-sided and of a pulsating
quality. Bilateral headaches, however, are certainly not unknown in
migraine. The headache is usually of moderate to severe intensity, and
may be associated with nausea and vomiting. The headache usually lasts
between 4-72 hours.
Aversion to
light and sound is also a feature of a migraine headache. The patient
often has to lie down and rest for relief. Other features such as
irritability, a sensation of light-headedness and nasal congestion may
also be present. Some migraine patients have migraine with aura. The
aura precedes the headache, and this often lasts 10-20 minutes. The most
common type of aura is the visual aura, which can be varied.
Some people
report seeing flashes or sparks of light, while some others report a
scotoma, or a "hole" in their vision, which may be surrounded by a
shimmering rim or light. Still others report visual hallucinations
shaped like the jagged walls of a fortress, termed "fortification
spectra". Besides the visual aura, other rarer types of aura exist. Some
migraine sufferers report tingling or numbness over one side of their
body, while others report weakness of one side. Speech disturbances are
rare but have been reported. Regardless of the type of aura, the
symptoms almost always resolve completely with time, though in very rare
instances, the neurological abnormality may remain. After 4-72 hours,
the headache gradually resolves. During this resolution phase, patients
often feel tired and may have little appetite.
Can other
diseases simulate migraine ?
Generally,
the most important factor in the diagnosis of migraine is taking a good
history from the patient. There are of course other more serious
conditions, such as bleeding into the brain, brain tumors or infections
of the brain that may superficially resemble migraine. However a closer
examination of the patients symptoms will often yield clues that will
tell the physician that it may not be migraine after all. Some of these
clues are:
a) Sudden severe headache
b) Headaches associated with persistent
fever
c) Headaches accompanied by drowsiness
or confusion
d) Progressively worsening headaches
e) Headaches associated with persistent
neurological signs such as double vision, weakness of limbs, or fits.
These clues
are known as "red flags" as they tell us that there may be a more
sinister and dangerous diseases lurking behind the seemingly innocent
facade of headaches. To put things in perspective however, such sinister
conditions are uncommon. By and large, most patients with headache have
either migraine or tension headaches, and less than 1% have sinister
conditions.
Treatment
of Migraine
However, if
"red flags" are causing the physician to be concerned, then a CT scan of
the head may be done to exclude such potentially dangerous conditions.
It is not feasible nor cost-effective to do a CT scan for every patient
with a headache, as the majority of CT scans will not reveal any major
abnormality. The treatment of migraine does not just depend on drugs
alone. Besides medication, a wellness program should also be
concurrently initiated.
It is
important to modify one's lifestyle to avoid migraine triggers such as
stress, lack of sleep and smoking. Relaxation techniques and biofeedback
may also help to reduce migraine. Food triggers such as alcohol,
chocolate or food containing high levels of MSG may have to be avoided.
However, as each person's trigger varies, this has to be individualized.
Restrictive diets are rarely necessary, and the modifications in food
should not be too drastic.
Migraine is a
common disease that affects a significant percentage of the population.
We are indeed fortunate to have medical insights and new drugs that are
able to treat migraine more effectively. New research is ongoing to
hopefully help us in unlocking the mysteries of migraine, so that we are
better able to lessen the socio-economic and healthcare burden of this
common disease.
How to treat Migraine ?
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