Migraine

A migraine is characterized by throbbing pain on one side of the head, it is a moderate to severe headache. The attacks frequently last from several hours to several days. Without an aura, migraines are encountered, which is a pain disorder. This means that there is a disorder in the brain and spinal cord, involving the nerves and blood vessels, which results in the pain and the neurologic symptoms associated with a migraine headache.

 
Migraines without aura:

Migraine without aura is the commonest type of migraine, also it has a higher attack frequency and is more disabling than migraine with aura. 

Migraine Recurrent disorders are characterized by attacks of reversible focal neurological symptoms that usually develop gradually over 5-20 minutes and last for less than 60 minutes. Headaches with the features of a migraine without aura usually follow the aura symptoms, less commonly, a headache is completely absent or lacks migrainous features.

 

Migraine with aura:

Migraine with headaches is characterized by depression, irritability, loss of appetite, paraesthesia, and visual symptoms. Paraesthesia of the hand and face are the most common, specifically the tongue, which can help differentiate from a TIA.  Speech difficulty during an aura shows the involvement of the dominant hemisphere.  Dizziness and vertigo may be related to the changes in the blood flow around the vestibular mechanism or the brainstem activity.

 

Aura without Headache

Sometimes aura symptoms are not followed by headache.

 

Sporadic and familial hemiplegic Migraine

This type of migraine with aura includes motor weakness and impaired coordination. Prodromal symptoms include numbness of the face and arm that may spread to one side of the body. Basilar symptoms may be present with dysphasia or aphasia causing difficulty in speech. Pain may be present rarely on the ipsilateral or contralateral sides of the symptoms, there may also be loss of consciousness.

 

Basilar type of Migraine

Basilar migraine symptoms suggest posterior fossa involvement localizing to the vascular territory of the basilar artery- the brainstem, cerebellum, and occipital lobes.  The prodromal symptoms indicate brainstem dysfunction i.e dysarthria, ataxia, tinnitus, diplopia, altered level of consciousness, symptoms in both the temporal and nasal fields of both the eyes, and peripheral dysesthesias, followed by occipital headache

 

Vestibular Migraine

When dizziness is the primary complaint of the patient then it may be considered a vestibular migraine. Vertigo occurring as an aura may arise from the same transient inhibition of neuronal function that is responsible for the visual aura. Episodic vertigo from vestibular migraine can be a subset of basilar migraine. Vomiting, nausea, hypersensitivity to motion, and postural instability are cardinal signs. Dizziness can also be associated with (BPPV) benign paroxysmal positional vertigo.

 

Retinal Migraine

Retinal migraine is repeated attacks of monocular visual disturbance, like scotoma, scintillations, or blindness, associated with migraine headaches. Visual changes are unilateral, result in pain around the eye and paralysis of the third, fourth, and sixth cranial nerves, and can produce double vision. The headache always precedes the oculomotor deficit for several days, paralysis can progress from being transient to last several days, and in some cases it becomes permanent.

There are also many causes of migraine, a few of them are mentioned below:

• Dehydration.
• Hormonal changes.
• Excess stress.
• Intense physical activity.
• Severe heat and other extreme weather.
• Bright lights
• Barometric pressure changes.
• Loud sounds
• Skipping meals.
• Certain medications.
• Changes in sleep patterns.
• Certain foods.
• Traveling.
• Smoking.
• Alcohol use.

Symptoms of migraine headache without aura are:

• Recurrent headache disorder attacks last from 4-72 hours,
• Headaches at unilateral locations,
• Pulsating quality,
• Moderate or severe intensity,
• Aggravation by routine physical activity,
• Associated with nausea and/or photophobia.

 

Migraine headaches with aura:

The symptom usually includes:

• Gradual development is over 5-20 minutes and lasts for less than 60 minutes.
• Depression,
• Irritability,
• Loss of appetite,
• Paresthesia,
• Visual symptoms,
• Vertigo,
• Dizziness,
• Speech difficulty.

 

Pathology:

Activation of the hypothalamus, and neuropeptides involved in homeostatic functions, may contribute to symptoms that occur during the prodrome phase. Hypothalamus is involved in many physiologic processes, like nociceptive processing, feeding, control of the sleep–wake cycle, thirst, autonomic and endocrine regulation, and arousal. Hypothalamic neurons that regulate homeostasis may underlie non-pain symptoms that occur during the prodrome phase and in other migraine phases, these include nausea and vomiting, fatigue, and changes in appetite. Cortical spreading depression is considered to be the primary pathophysiology behind the aura phase. An initial wave of neuronal depolarization inhibits cortical activity and reduces blood flow.

Several neuropeptides implicate in the sensitization of the central and peripheral trigeminovascular system, which creates a state of hypersensitivity and contributes to both pain and non-pain symptoms during the headache phase. Several neuropeptides, including calcitonin gene-related peptide (CGRP), implicate head pain and other symptoms. Trigeminal and retinal nociceptive input converge in the thalamus. There are several similarities in the symptoms experienced during the prodrome and postdrome phases such as fatigue, food cravings, and cognitive symptoms that may endure well into the aura, headache, and also postdrome phases of a migraine attack. After the headache cessation, some regions of the brain remain abnormally activated, including the olfactory regions, the midbrain, and the hypothalamus.

Diagnostic criteria for migraine without aura:

A. At least 5 attacks fulfilling the criteria given in B-D.

B. Headache attacks lasting 4-72 hr.

C. Headache has at least 2 of the following 4 symptoms:

1. Unilateral location:

Pulsating quality.

Moderate or severe pain intensity.

Aggravates or causes avoidance of routine physical activity like walking or climbing stairs.

2. During a headache at least 1 of the following symptoms:

Nausea or vomiting

Photophobia and phonophobia.

D. Not attributed to another disorder.

 

Diagnostic criteria for migraine with aura:

A. At least 2 attacks fulfilling the criteria given in B and C.

B. One or more of the following symptoms which are fully reversible aura symptoms:

1.  Visual.

2.  Sensory.

3.  Speech and/or language.

4.  Motor.

5.  Brainstem.

6.  Retinal.

C. At least 3 of the following 6 symptoms:

1.  at least one aura symptom gradually spreads over ≥5 minutes.

2.  2 or more aura symptoms occur one after the other.

3.  each aura symptom lasts for 5-60 minutes.

4.  at least 1 aura symptom occurs unilaterally.

5.  at least 1 positive aura symptom.

6.  the aura is followed by a headache within 60 minutes.

D. Not better accounted by another international classification of headache disorders -3 diagnosis.

 

CT scan and MRI:



CT scan or MRI is recommended to look for hemorrhage, increased intracranial pressure, and other structural causes of headaches.

Medication: Analgesics, Anti-inflammatory Agents, Anti-Convulsant, etc,

Note: Medication should not be taken without the doctor's prescription.

Relaxation:

Physiotherapists can give self-relaxation tips to lessen pain during a migraine. Relaxation can be used as an adjunct treatment to the patient's medical management for headaches.

 
Cryotherapy:

Cryotherapy can help temporarily lessen the pain during a migraine attack. Frozen neck wrap can be applied for migraine headaches targeting the carotid arteries at the neck, this significantly reduces pain associated with migraine headaches. These techniques are helpful if the patient if uses them during the beginning of a migraine.

 
Thermotherapy:

The physiotherapist can teach how to use thermotherapy or heat to ease the symptoms

 
Massage therapy:

The physiotherapist can teach the family members, how to perform certain massages to ease the migraine symptoms. Massage therapy reduces migraine frequency both during the 6 weeks of massage as well as during the 3 weeks following the end of the massage therapy.

 
Manual cervical traction:

Manual cervical traction is a non-invasive procedure that can ease neck pain from migraines. It can help separate the bones, joints, and disks in the neck. Cervical traction can help relieve tension from the nerves and stretch the neck muscles.

 

Acupuncture:

Acupuncture has similar efficacy compared with continuous treatment with standard drug therapy and also is effective for long-lasting effects and also decreases the intake of medication.

 

Stretching Exercises:


Certain stretches can help the patient feel better during a migraine. The therapist recommends some movements to help with specific pain areas in the body. Instructions are given for doing exercises and performing the movements correctly.

Some patients with this condition have exercise-triggered migraine attacks. For this reason, physiotherapy may make certain people's symptoms worse. It's important to know if physiotherapy could be a trigger rather than a treatment for migraine pain. Physiotherapy as a migraine treatment might not be effective if the patient has rare migraines i.e. they happen once a month and if there are classic symptoms like neurologic signs such as aura with clear triggers.