WHAT IS A MIGRAINE AND HOW COMMON IS IT?
Why do I have a headache? You’re not alone. Worldwide, migraine affects more than 10-12% of the population, with approximately 1 billion migraineurs estimated worldwide. It is estimated that there are 39 million migraineurs in the US, accounting for 12% of the US population. Migraine affects 18% of women and 6% of men. Nearly 25% of U.S. households include someone with migraine.
In 2016, migraine was determined to be the 2nd leading cause of all global disability, and the 2nd leading cause of all neurological disease burden. Migraine is the 2nd most common cause of disability by years lived with disability, following low back pain! Migraine accounts for 50% of all neurologic disability. Furthermore, chronic pain in general is the largest contributor to years lived with disability globally, and is associated with tremendous negative impacts on social, economic, and personal function.
In addition to the attack-related disability, many sufferers live in fear because their migraines disrupt their ability to work, go to school, partake in social activities, or care for their families, and this significantly limits their overall quality of life. More than 90% of migraine sufferers are unable to work or function normally during their attacks. $36 billion dollars are lost each year as a result of 113 million lost workdays and other associated costs due to migraine. So clearly, migraine has significant negative impacts on the lives of patients and on society.
WHAT ARE MIGRAINE SYMPTOMS, WHAT IS MIGRAINE AURA, AND HOW IS MIGRAINE DIAGNOSED?
Migraine is an episodic headache lasting 4 to 72 hours if untreated or unsuccessfully treated. There must be 2 of the following 4 features present: a unilateral (one-sided) headache, pounding/throbbing/pulsating quality, moderate-to-severe pain intensity, and worsening by routine physical activity. There must also be 1 of the following 2 features present: nausea and/or vomiting, or both photophobia (sensitivity to light) and phonophobia (sensitivity to sound).
Approximately 25% of patients with migraine have neurological symptoms (aura) associated with their migraine. Those migraines are called migraine with aura (classic migraine), in contrast to migraine without aura occurring in 75% of patients (common migraine). What causes migraine aura? Aura is caused by a spreading wave of electricity, or neuronal excitation, across the cortex (outside layer of the brain). Depending on where that electrical wave spreads, a variety of migraine aura can occur. If it spreads across the visual cortex, you’ll get visual aura. If it spreads across the sensory cortex, you’ll get sensory aura such as numbness and tingling. If it spreads across the speech areas, you’ll get trouble speaking, getting words out, or slurred speech. As the front of this electrical wave spreads, you get “positive” features of migraine aura (flashing, shapes, tingling, etc.). Immediately following this neuronal excitation wave is a wave of neuronal depression where the neurons are not working properly. This is called spreading neuronal depression and it causes the “negative” migraine aura symptoms (lost area of vision, numbness, etc.).
The aura should last between 5-60 minutes and the headache commonly follows the aura within 1 hour. The most common type is visual aura and includes flashing lights, shimmering lines with areas of lost vision (scintillating scotoma), curved “c” shapes, squiggly lines, zig-zag lines, kaleidoscope colors, fortification spectra, prisms, shapes, or other visual phenomena. Migraines with visual aura are often referred to generically as visual migraines, or ophthalmic migraines, although these are not technically the accurate terminology by criteria. The second most common type of aura is sensory aura and consists of pins and needles or numbness in one area of the body on only one side, especially the face and arm/hand. The third most common type of aura is speech and/or language aura and consists of trouble getting words out, or slurred speech (dysphasia). Some patients get migraine aura with a non-migraine headache, or migraine aura without headache, sometimes referred to as silent migraine, painless migraine, migraine equivalent, or acephalgic migraine.
There are less common types of aura as well. One of the less common types of aura is motor aura. This consists of a migraine with at least 1 of the common auras discussed above, as well as fully reversible motor weakness on 1 side of the body that lasts less than 72 hours. This type of migraine is also called hemiplegic migraine. Brainstem aura is another less common type of aura. It consists of a migraine with at least 1 of the common auras discussed above, and at least 2 features including slurred speech, vertigo, tinnitus (ringing in the ear), hypacusis (hearing difficulty), diplopia (double vision), ataxia (unsteady, imbalanced walking such as an intoxicated appearance), and decreased level of consciousness. This type of migraine is called migraine with brainstem aura, and was formerly called basilar migraine, or basilar artery migraine. Retinal aura is another less common type and consists of any of the visual disturbances mentioned above occurring clearly in only one eye. However, this is often difficult to differentiate between typical migraine with aura, which usually affects both eyes to some extent.
Although vertigo, dizziness, and lightheadedness are common associated features of migraine, there is a distinct form of migraine with pronounced vertigo called vestibular migraine. Since migraine is an electrical neurological event, there are additional unusual symptoms and phenomena that can occur in patients with migraine such as Alice in Wonderland Syndrome. This phenomenon is often felt to be an aura type symptom. It is described by patients as a perception of becoming physically larger or smaller in comparison to their surroundings, or that their surroundings are growing or shrinking rather than them personally. Sometimes it can also be associated additional visual distortions such as the perception that fixed surroundings are moving.
WHAT ARE THE MOST COMMON MIGRAINE TRIGGERS?
Many patients have migraine triggers. However, many patients may not be able to identify triggers. Migraine is an electrical neurological event, and it can just happen without a trigger. This is similar to epilepsy, which is a different type of electrical brain disorder, but the point is that it can also just be triggered for no good reason. So do not feel bad or frustrated if you can not identify migraine triggers. If you can, great, because you can try avoiding them for less migraines.
Common migraine triggers are stress, hormonal such as menstrual, changes in sleep pattern (headache from lack of sleep or too much sleep), missed meals and hunger, certain migraine trigger foods (there are many foods that trigger migraines), or food additives such as MSG, nitrates, tyramine, aspartame, and other artificial sweeteners. Dehydration is also a very common migraine trigger which leads to dehydration headache, as is headache from heat. Abrupt changes in diet are common migraine triggers, although the right changes can also lessen migraines. For example, many patients get headaches on keto diet, while others get less headache on keto.
Barometric pressure changes, atmospheric pressure changes, or air pressure changes (such as storms, weather or season changes, airplane travel, etc.) are common migraine triggers, sometimes referred to as barometric pressure headaches. What is barometric pressure? It is the weight of the atmosphere (air) that surrounds us. Barometric pressure typically drops before bad weather and storms. The subsequent lower air pressure pushes less against the body, allowing tissues to theoretically expand. The thought is that expanded tissues can then put pressure on various areas of the body such as nerves or joints, triggering subsequent pain. The drop in air pressure also creates a pressure difference between the air outside of the body and the air in your sinuses. This is felt to be another potential migraine trigger since the trigeminal nerves (the source of migraine) innervate the sinuses and are stimulated and activated by this pressure change. For some patients, the high barometric pressure is what triggers their migraine for similar pressure gradient reasons as mentioned above, which is especially cruel that a beautiful sunny day may trigger such misery.
WHAT ARE THE BEST HEADACHE REMEDIES?
What helps a headache? The options are detailed at the treatment link at the top of this page, or here. The most important thing about headache treatment and migraine treatment is to first have an abortive treatment plan (what to take as needed for headache). These may include NSAIDs, over the counter pain meds, triptans, one of the new medications such as the gepants such as Nurtec ODT or Ubrelvy, the ditans (Reyvow), or a neuromodulatory device. If the headaches are frequent enough, a preventive daily treatment plan should be initiated as well. These include a daily pill, natural supplements and natural remedies for headache, Botox injections, neuromodulatory device, or a once monthly CGRP monoclonal antibody (Aimovig, Ajovy, Emgality, Vyepti).
WHAT IS CHRONIC MIGRAINE?
Chronic migraine is defined by headaches on 15 or more days per month for 3 or more months, with 8 of those days having more migrainous features (such as throbbing pain, nausea, sensitivity to light, sensitivity to sound). Patients that have a prior or current history of headaches such as migraine or tension-type headaches tend to be much more susceptible to developing medication overuse headache (rebound headache). Medication overuse headache (rebound headache) is one of the most common causes of chronic daily headache (more than 15 days of headache per month) in the form of chronic migraine or chronic tension-type headache. This factor must be eliminated if present, and the headaches will never improve until a weaning detoxification from the overused medications happens. It can take 2-3 months for significant improvement to occur following detoxification, depending on medicine used, duration of use, frequency of use, and quantity of use. Preventive (daily medicines used to lessen the frequency and/or severity of headaches) and abortive (“as-needed” at headache onset) pain medications are also generally less effective in the setting of medication overuse headache. The overused medications are often taken for the headaches. However, these medicines are also commonly being used for some other type of body pain such as back pain, but inadvertently convert an infrequent headache to a frequent or daily headache. This is almost a guarantee to happen if there is a history of migraine headaches. You can read a more detailed discussion on rebound headache and how to break out of the cycle here.
As discussed above, overuse of certain medications will typically convert underlying episodic migraine to chronic migraine over time. Research has shown that medication overuse can transform episodic migraine (less than 15 days of headache per month) to chronic migraine (greater than 15 days of headache per month) if the following medications are used at the following frequencies:
- More than 10 days per month for at least 2-3 consecutive months of over the counter (OTC) pain medications (Tylenol, Excedrin, Acetaminophen, Aleve, Naproxen, Motrin, Advil, Ibuprofen, or other non-steroidal anti-inflammatories (NSAIDs))
- More than 10 days per month for at least 2-3 consecutive months of triptans (Sumatriptan, Rizatriptan, Zolmitriptan, Almotriptan, Frovatriptan, Naratriptan, Eletriptan)
- More than 8 days per month for at least 2-3 months of any narcotic, opioid, or opiate medication (Vicodin, Norco, Hydrocodone, Oxycodone, Oxycontin, Percocet, Tramadol, Ultram, Ultracet, Morphine, Codeine, etc.)
- More than 5 days per month for at least 2-3 months of any butalbital containing medication (Fioricet, Fiorinal, Esgic)
IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!
FIRST, LET’S DECIDE WHERE TO START:
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.
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