Migraine attacks can vary greatly. A migraine attack is usually divided into certain phases. These last for different lengths of time and not all of them necessarily have to occur.
Several hours to two days beforehand, a migraine headache can be announced with one of the following symptoms:
This can be followed by perceptual disturbances (migraine aura). These usually affect vision (visual aura). For example, a migraine aura can cause flickering vision or the seeing of zigzag lines, loss of visual field (scotomas) or those affected see objects partially distorted, blurred, enlarged or reduced in size (metamorphopsia). The second most common aura symptom is sensory disturbances with a tingling sensation that slowly spreads from the hand over the arm to the head. The ability to speak can also be impaired (aphasia). Very rarely, disorientation and paralysis (paresis) occur. The migraine aura is sometimes accompanied by balance disorders. In contrast to a stroke, the symptoms of a migraine aura typically set in slowly and subside just as slowly.
Almost every migraine attack causes headaches and sometimes nausea with vomiting. The affected person is sensitive to light (photophobia), noise (phonophobia) and smells (osmophobia). The headaches, which are usually severe, occur in the majority of cases on one side of the head (hemicrania), but can also affect the entire head. The pain is pulsating or stabbing and is particularly localized in the forehead, temples and eyes. The symptoms are intensified by movement; they are relieved by rest and darkness.
In adults, the headache phase of a migraine attack lasts at least four hours if left untreated and can last up to three days.
Even when the headache and other symptoms of the migraine have completely subsided, many patients still complain of tiredness and exhaustion for hours to one or two days.
Children and adolescents typically have shorter migraine attacks. They usually feel the headache on both sides in the forehead and temple area. They also often have balance problems.
Genetic factors also play a significant role, as migraines tend to run in families. Certain genetic mutations may affect how the brain processes pain and responds to environmental triggers. Additionally, environmental factors such as stress, hormonal changes, certain foods, and sensory stimuli can act as triggers for migraine attacks.
1. Cortical Spreading Depression (CSD): The cascade often begins with a phenomenon called cortical spreading depression, which is a wave of electrical activity that spreads across the brain’s cortex. This wave can lead to changes in blood flow and the release of inflammatory substances.
2. Release of Neurotransmitters: As CSD occurs, neurotransmitters like serotonin and calcitonin gene-related peptide (CGRP) are released. These substances play a crucial role in pain signaling and can lead to inflammation and vasodilation (widening of blood vessels).
3. Vasodilation and Inflammation: The release of CGRP and other inflammatory mediators causes blood vessels in the brain to dilate, which contributes to the throbbing pain characteristic of migraines. This inflammation can also affect surrounding tissues and nerves.
4. Activation of Pain Pathways: The changes in blood flow and the release of inflammatory substances activate the trigeminal nerve system, which is responsible for facial sensation and pain. This activation sends pain signals to the brain, intensifying the headache.
5. Central Sensitization: Over time, repeated migraine attacks can lead to central sensitization, where the brain becomes more sensitive to pain stimuli. This can result in increased frequency and severity of migraines.
6. Symptoms Manifest: As the cascade progresses, individuals may experience not only headache pain but also associated symptoms such as nausea, vomiting, and sensitivity to light and sound.
Understanding this cascade helps in developing targeted treatments and preventive strategies for managing migraines effectively.
It is best to have your family doctor refer you to a neurologist in a pain center who specializes in migraines. Never try to solve the problem yourself by taking painkillers in the long run, as this can lead to medication dependency, worsening of migraine, gastric perforations and kidney failure are among other unintended side effects.
Many patients are dissatisfied with the way the appointment with the doctor goes. This can be because they feel misunderstood, for example, or because they were unable to ask all of their questions because the doctor was under time pressure. But there are a few things you can do yourself to make the most of your time.
Good preparation for the appointment and a cooperative and trusting doctor-patient dialogue are important foundations on which decisions about examinations and treatments are based.
If you make a note of important points before the appointment – which you might otherwise forget when you are nervous or often short on time in the doctor’s office – and have all the necessary documents ready, it will be easier for the doctor to get a comprehensive overview of the illness.
By providing detailed information about the course of the headaches, you can help the migraine doctor to get a comprehensive picture of the symptoms and make a reliable diagnosis. For example, before your doctor’s appointment, write down as precisely as possible:
In order to document the course of your migraines, it can be very useful to keep a migraine diary. In addition to the duration and intensity of the pain and the nature of the pain, you also write down individual influencing factors such as lack of sleep, stress or irregular daily routines. This will help you to better avoid these migraine triggers in the future.
To diagnose a migraine, the doctor first asks about the symptoms. Among other things, he will ask about the frequency and duration of the attacks, the type and severity of the headaches and accompanying symptoms. A headache diary can help answer these questions. In this way, the doctor can usually already diagnose migraine and differentiate it from other types of headaches and other illnesses.
Diagnosis also includes a physical neurological examination. Typically, there are no abnormalities in migraines. If there are abnormalities that cannot be explained in any other way, additional tests must be carried out. Even if the symptoms do not clearly indicate migraines, further tests may be necessary to rule out other illnesses that also cause headaches. Depending on the suspected diagnosis, these include examination of the cerebrospinal fluid (lumbar puncture), a blood sample, an ultrasound examination (Doppler sonography), imaging procedures such as computer tomography (CCT) or magnetic resonance imaging (MRI) and an electroencephalogram (EEG).
There are several types of migraine that the doctor can differentiate during diagnosis.
The most common type is migraine without aura. Headaches and other symptoms occur without an aura preceding them. In women, migraine without aura is often associated with the menstrual cycle and occurs particularly frequently before and during menstruation.
In about one in ten cases, a migraine is associated with an aura. It tends to occur more frequently in men. In rare cases, a migraine-typical aura can occur without a headache phase following.
In addition to the common types of migraine, other types are known.
In familial hemiplegic migraine, in addition to the migraine symptoms, there is paralysis on one side of the body, which goes away again after the attack. This type of migraine usually affects several members of a family and the susceptibility to it is inherited in an autosomal dominant manner.
In the so-called retinal migraine, in addition to the headache in one eye, there is a slowly progressive loss of visual field, which then completely disappears over time. In rare cases, sufferers go blind in one eye for several minutes.
Migraine with brainstem aura is very rare and occurs somewhat more frequently in young women. It is accompanied by pain in the back of the head, impaired consciousness (dizziness to coma), spinning vertigo, visual disturbances such as double vision and abnormal sensations in the hands and face.
Complications are also possible. In the rare case of status migraenosus, the migraine lasts for more than three days. In some cases, the aura phase can last longer than an hour. In very rare cases, a stroke can also occur during the migraine attack (migrainous infarction). In the case of these complications and if the migraine symptoms appear differently than usual, the patient should be examined by a doctor to make sure that it is a migraine attack and to avoid long-term effects.
If the aura lasts for more than a week, it is a persistent aura. Migralepsy is a form of migraine in which the aura turns into an epileptic seizure. A normal migraine can develop into a chronic migraine. In this case, the symptoms occur on more than 15 days a month.
Unfortunately, there is still no single solution for all types of migraines available. As always, it is important that the specialist asks the right questions and that you answer them fully and honestly (Anamnesis before the diagnosis). The neurologist will then offer you various treatment suggestions.
As soon as you have decided on the most promising option, you then have to put it into practice. Your doctor will suggest a treatment strategy for both the prevention phase and the acute migraine treatment.
It is then important that you take the medication at the right time in the right dose and follow the doctor’s instructions 100%. This is the only way the doctor can provide you with the best possible support as your partner in treating migraines. Statistics show that only around 30% of all patients take their medication at the right time and in the right dose. Unfortunately, patients are misleading so their doctors. It is up to patients to improve these statistics.
A range of medications are helpful in an acute migraine attack. For mild to moderate symptoms, taking painkillers (non-opioid analgesics, non-steroidal anti-inflammatory drugs) in the right dosage early on helps. Your doctor or pharmacist can give you information about this. Ibuprofen, naproxen, paracetamol, acetylsalicylic acid (ASA) or diclofenac are particularly suitable for adults. Chewable or effervescent tablets are absorbed by the body the fastest. Paracetamol works best as a suppository (rectal). If a migraine attack is accompanied by vomiting, anti-nausea medications (antiemetics) can help. They stimulate stomach movement, which is slowed down by the migraine. This also improves the absorption of the painkillers into the blood. Painkillers should not be used more than ten days a month, otherwise permanent headaches can be a side effect.
For more severe migraine symptoms, migraine-specific medications, so-called triptans, are recommended. They block neurovascular inflammation, constrict the dilated blood vessels and thus work against the headaches and the other accompanying symptoms of migraines, such as nausea and vomiting. Triptans also help best when taken early, but they can be used at any time during a migraine attack. If no effect is achieved, it is not advisable to continue taking them during the attack. Triptans must not be used in the case of untreated high blood pressure, coronary heart disease or other vascular diseases. Regular use of triptans on more than ten days per month can lead to chronic headaches that can only be stopped by withdrawing from the triptans.
Ergot alkaloids (so-called ergotamines) were also used in the past to treat migraines. They are still available, but are a second-line drug due to their side effects. Ergotamines must never be taken together with triptans.
Migraine prophylaxis is advisable for frequent and severe migraine attacks. Your doctor will select the active ingredient that is suitable for you. Substances that were originally developed for other diseases but have proven their migraine-preventing effect in targeted studies are often used as the first choice. These are beta-receptor blockers (e.g. metoprolol), anticonvulsants (e.g. topiramate) or antidepressants (e.g. amitriptyline). But there are also many other medications. In addition, from November 2018, newly developed medications, so-called antibodies, will be available that block the effect of the messenger substance CGRP. CGRP plays an important role in the development of migraine attacks.
The effect of drug-based migraine prophylaxis only sets in after six to eight weeks and is particularly effective when the medication is also combined with other non-drug therapies to prevent migraines. Relaxation methods (such as progressive muscle relaxation according to Jacobson), endurance sports, biofeedback techniques, acupuncture and, if necessary, behavioral therapy, for example with stress management training, can reduce the susceptibility to migraines. For many patients, drug prophylaxis is only required temporarily for six months or a whole year. Once the monthly number of migraine attacks has decreased, non-drug measures are often sufficient for further prevention.
There is little scientific research and little scientific proof into the positive effects of Traditional Thai Massage on migraines. It has been proven that Traditional Thai Massage, as practiced at Hattha Thai Spa, can have a positive effect on some migraine trigger factors (stress, sleep disorders, migraine-related musculoskeletal problems) and thus have a positive influence on the course of therapy. Traditional Thai Massage can be useful both as a preventative measure and in acute treatment. However, you should only add TTM to your treatment plan when a doctor has ruled out an underlying and serious illness for your headaches, such as a stroke or meningitis (inflammation of the meninges). Afterwards decide on a joint treatment plan with your doctor and your Thai Massage therapist. Write to us if you would like to contact one of our migraine patients.
If the chosen strategy does not lead to significant improvement in either the prevention or treatment of acute migraine, the specialist will suggest the next treatment regime. He will continue this approach until you have exhausted all treatment options.
Yes, especially for women, it may be that during or after pregnancy the migraines are gone forever. Good news is also that pharmaceutical companies are still researching new medicines for the benefit of those who suffer.
Sources:
https://www.sciencedirect.com/science/article/pii/S0753332221003425 (picture)
https://www.bmj.com/content/386/bmj-2024-080107 Meta analysis concerning migraine medications
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